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Protocols

Towards An Egyptian Guideline From Screening to Treatment of Hepatocellular Carcinoma

I- Screening Prof.
Dr. Ashraf Omer
Prof. Dr. Wafaa El-Metanawy

II- Diagnosis:
Prof. Dr. Ahmed El-Dorry
Prof. Dr. Gamal Esmat
Prof. Dr. Mohamed Tawfik

III- Staging:
Prof. Dr. EmamWaked
Prof. Dr. Mohsen Salama

IV- Treatment:
Locoregional TTT:
Prof. Dr. Ahmed El-Dorry
Prof. Dr. Mohamed Kamal Shaker
Surgical TTT:
Prof. Dr. Amr Helmy
Prof. Dr. Mahmoud El-Meteny
Prof. Dr. Refaat Refaat Kamel
Medical TTT:
Prof. Dr. Emad Hamada
Prof. Dr. Heba El-Zawahry

Our protocol will clarify the main points for early HCC management

I- Screening

For early detection of cases with hepatic nodule or elevated AFP

Who??
1- Cirrhotic
2- All HBV patients*
3- Chronic active HCV (except those with biopsy<3 Metavair score).

When??
Every 4 months

How??
AFP & Abdominal U|S

* Even those who are PCR –ve candidate after treatment

II- Diagnosis

For early diagnosis of cases with HCC (malignant nodule).

* hypervascularity in arterial phase & washout in the early or delayed venous phase)

Further Evaluation

  • Kidney Function tests
  • ECG
  • Chest X-ray
  • Pelvic-abdominal CT.
  • Chest CT.
  • Bone scan.

III- Staging

For detection of specific category of treatment according the patient's general condition.

Performance Status Scale

Status Definition
0 Normal activity
1 Symptoms but ambulatory
2 In bed <50% of time
3 In bed >50% of time
4 100% bed ridden

 

IV- Treatment

Selection of type of treatment according to the patient's stage.

In Cirrhotic

Stage A
(Single tumor)
>> A1 >> LTx- resection- RFA| PEI
>> A2 >> LTx- RFA| PEI
>> A3 >> LTx- RFA| PEI
Multiple (all ≤3cm)
>>A4 >> LTx- RFA| PEI

Stage B
(Child A & B)
Large size >> Sorafenib (if possible as supportive TTT)
If less than 10 cm >> TACE ± RFA| PEI
If more than 10 cm in child A >> Resection

Stage C
(Child A & B)
Vascular invasion >> Sorafenib (if possible as supportive TTT)
>> Conservative

Stage D
(Child C)
>> within Milan criteria >> LTx
>> Outside >> Conservative TTT

* Staging according to table 1

A- Locoregional TTT

If the size of the lesion:
> PEI=RF
3-5cm >> RFA
except difficult sites >> PEI
>> surgical access
5-7cm >> TACE followed by RFA| PEI
7-10cm >> palliative repeated TACE

B- Surgical TTT

In cirrhotic

LTX is preferable if available according to Milan criteria:

  • Single lesion ≤ 5cm
  • or up to 3nodules <3cm
  • Absence of LNs metastases or vascular invasion

Resection in stage A1 (normal bil. & no PH)

Post-treatment follow-up:

  • Laboratory Investigations:
    • Liver function tests (SGOT, SGPT, T.bil., D.bil., Alb, PT|INR)
    • Kidney function tests (Cr., Urea, Na, K)
    • AFP
  • Radiology: Triphasic Helical CT (Multislice if available)
    • Done 1 month after end of therapy
    • During 1st year of follow up:
      • repeat every 3 month
    • During 2nd year of follow up:
      • repeat CT every 6 month
      • repeat other investigations every 3month
    • After 2 years:
      • repeat CT once|year
      • repeat other investigations every 3 months as long as no other new lesions are developed.

Best of care:

  • Nutrition
  • Psychological support
  • TTT of ascites.
  • TTT of Portal hypertension.

It must be multidisplenary decision

  • Hepatology
  • Hepatic surgery
  • Interventional radiology
  • Oncology

Table 1

BCLC Practical Staging of HCC

BCLC; Barcelona clinic liver cancer staging system (Bruix et al., 2004)