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  • 8/6/2019 Cc Hepatic

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    Cancerul hepaticCancerul hepatic

    HoriaHoria--Alexandru PlesaAlexandru Plesa

    Mg 5, Seria 3, Grupa 26Mg 5, Seria 3, Grupa 26

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    EpidemiologieEpidemiologie

    Primul loc in AsiaPrimul loc in Asia

    Incidenta:Incidenta:

    JaponiaJaponia:: 120120 lala 100100..000000 dede locuitorilocuitori (locul(locul III)III)

    MareaMarea BritanieBritanie:: 11--55 lala 100100..000000 dede locuitorilocuitori.. B/F=B/F= 66//11

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    EtiopatogenezaEtiopatogeneza

    Virusul hepatic BVirusul hepatic B (Ag HBs(Ag HBs ciroza,ciroza,AHC, varsta, sex, cofactori, durataAHC, varsta, sex, cofactori, duratainfectiei).infectiei).

    Ciroza hepaticaCiroza hepatica

    Virusul hepatic CVirusul hepatic C

    AflatoxineAflatoxine ((Aspergillus sp.)Aspergillus sp.)

    Alti factori: contraceptive orale, mutatiiAlti factori: contraceptive orale, mutatiigenetice, toxine, deficitul degenetice, toxine, deficitul de --11--AT, boliAT, boliconcomitente.concomitente.

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    Tipuri histopatologiceTipuri histopatologice

    1. Hepatocarcinomul1. Hepatocarcinomul-- unicentricunicentricmasivmasiv

    -- multicentric (nodular)multicentric (nodular)

    -- difuz (ciroza!)difuz (ciroza!)2. Carcinomul sclerozant (fibrozant)2. Carcinomul sclerozant (fibrozant)

    3. Carcinomul fibrolamelar3. Carcinomul fibrolamelar:: --tineri!tineri!

    -- prognostic maiprognostic maibun.bun.

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    Diagnostic diferentialDiagnostic diferential

    1.1. Metastaze hepaticeMetastaze hepatice

    2.2. Colangiocarcinom (Colangiocarcinom ( ciroza!) ciroza!)

    3.3. Adenom al ductelor biliareAdenom al ductelor biliare4.4. HNFHNF

    5.5. Tumori hepatice benigne(adenom,Tumori hepatice benigne(adenom,

    chistadenom)chistadenom)

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    Istorie naturalaIstorie naturala

    Boala limitata (20%).Boala limitata (20%). Deces:Deces:-- evolutie locala (invazie vena porta,evolutie locala (invazie vena porta,

    suprahepatice, VCI, AD, organe abdominalesuprahepatice, VCI, AD, organe abdominalevecine)vecine)

    --insuficienta hepaticainsuficienta hepatica

    Diseminare si expansiune:Diseminare si expansiune:1.1. crestere centrifugalacrestere centrifugalacompresiunecompresiune2.2. parasinusoidparasinusoidparenchimul inconjuratorparenchimul inconjurator3.3. venos: anterograd/retrogradvenos: anterograd/retrograd4.4. limfatica: adenopatiilimfatica: adenopatii5.5. invazie diafragmaticainvazie diafragmatica

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    StadializareStadializare

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    Tablou clinicTablou clinic

    Durere hipcondru drept (frecvent!)Durere hipcondru drept (frecvent!) GG

    Astenie, fatigabilitateAstenie, fatigabilitate

    FebraFebra AnorexieAnorexie

    Obiectiv:Obiectiv: -- hepatomegaliehepatomegalie-- dura, neregulatadura, neregulata-- splenomegaliesplenomegalie

    --ictericter-- edeme, ascitaedeme, ascita

    --casexiecasexie

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    Diagnostic si bilant preterapeuticDiagnostic si bilant preterapeutic

    Hemoleucograma, VSHHemoleucograma, VSH

    Teste functionale hepatice:Teste functionale hepatice: NN////(evol!)(evol!)1.1. Bilirubina, LDH, Albumine Bilirubina, LDH, Albumine --prognostic!!!prognostic!!!

    2.2. GGT(confirma!!!)GGT(confirma!!!)3.3. AFP (>400 ng/mlAFP (>400 ng/ml--PROGNOSTIC.PROGNOSTIC.

    Ecografie abdominalaEcografie abdominala

    PBHPBH--confirmare (confirmare (EFECTE ADVERSE!!!)EFECTE ADVERSE!!!)

    CT/RMNCT/RMN extensie locala si la distantaextensie locala si la distanta Alte: angiografie, scintigrafie hepatica, osoasa,Alte: angiografie, scintigrafie hepatica, osoasa,

    rgr. Pulmonarargr. Pulmonara

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    PrognosticPrognostic

    TNMTNM

    CLIP:CLIP:

    1.1. ChildChild--PughPugh2.2. AscitaAscita

    3.3. Invazia venei porteInvazia venei porte

    4.4. Caracter unicentric/multicentric/masivCaracter unicentric/multicentric/masiv

    5.5. AFPAFP

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    Factori de prognosticFactori de prognostic

    1.1. Numar (unic/multiplu)Numar (unic/multiplu)

    2.2. Dimensiune(Dimensiune())

    3.3. Interesare venoasaInteresare venoasa4.4. LocalizareLocalizare

    5.5. Rezectie curativa/paliativaRezectie curativa/paliativa

    6.6. Rezerva functionala hepaticaRezerva functionala hepatica

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    ScreeningScreening

    Indicatii:Indicatii:

    Pacienti cu infectie cronica cu virus B/C.Pacienti cu infectie cronica cu virus B/C.

    Ecografie hepaticaEcografie hepatica

    Dozare AFPDozare AFP

    La 3La 3--6 luni6 luni

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    ProfilaxieProfilaxie

    1.1. Vaccin anti HBVVaccin anti HBV

    2.2. Tratament cuTratament cu --interferon la pacienti cuinterferon la pacienti cu

    infectie cronica si cirozainfectie cronica si ciroza3.3. Reducerea contaminarii alimentelor cuReducerea contaminarii alimentelor cu

    aflatoxineaflatoxine

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    TratamentTratament

    Chirurgical:Chirurgical:

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    TratamentTratament

    Chimioterapie:Chimioterapie: Chimioembolizare lipiodolata intraarterialaChimioembolizare lipiodolata intraarteriala

    hepaticahepatica

    Neoadjuvanta: Adriamicina, 5Neoadjuvanta: Adriamicina, 5--FUFUchirurgiechirurgie Exclusiva: Fluoxuridina +RadioterapieExclusiva: Fluoxuridina +Radioterapie

    Alte procedee:Alte procedee:

    1.1. Ablatie cu radiofrecventaAblatie cu radiofrecventa2.2. Alcoolizare percutanaAlcoolizare percutana

    3.3. CriochirurgieCriochirurgie

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    Complicatii ale tratamentuluiComplicatii ale tratamentului

    Chirurgie: abces subfrenic, subhepatic,Chirurgie: abces subfrenic, subhepatic,infectii, pneumotoraceinfectii, pneumotorace

    Chimioembolizare:Chimioembolizare:1.1. Sindrom postembolizareSindrom postembolizare

    2.2. Abces hepaticAbces hepatic

    3.3. IHIH

    4.4. Ulceratii GDUlceratii GD

    Radioterapia: hepatita radica.Radioterapia: hepatita radica.

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    Rezultate si prognosticRezultate si prognostic

    Supravietuirea mediana la 5 ani: 29%Supravietuirea mediana la 5 ani: 29%

    Supraveghere:Supraveghere:

    1.1. La 3 luni in primii 2 ani de la dg.La 3 luni in primii 2 ani de la dg.2.2. Anamneza+ E.O.Anamneza+ E.O.

    3.3. Biologic: HLG, transaminaze, FA, bilirubina,Biologic: HLG, transaminaze, FA, bilirubina,albumine, AFP.albumine, AFP.

    4.4. Rgr. ToracicaRgr. Toracica

    5.5. Eco + CT abdominalEco + CT abdominal