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Discrepância entre os guidelines EASL, AASLD E APASL. Como lidar? Profa. Dra. Ilka FSF Boin Unidade de Transplante Hepático HC - Unicamp
Discrepância entre os guidelines EASL, AASLD E APASL. Como lidar?
Profa. Dra. Ilka FSF Boin
Unidade de Transplante Hepático
HC - Unicamp
AASLD 2018
Main risk factors for primary liver cancer worldwide*
Alcohol (%) HBV (%) HCV (%) Others (%)
Europe
Western 32 13 44 10
Central 46 15 29 10
Eastern 53 15 24 8
North America 37 9 31 23
Andean Latin America 23 45 12 20
Asia
East Asia 32 41 9 18
Asia-Pacific 18 22 55 6
South-East Asia 31 26 22 21
Africa
North Africa, Middle East 13 27 44 16
Southern (sub-Saharan) 40 29 20 11
Western (sub-Saharan) 29 45 11 15
• ~90% of HCCs are of known underlying aetiology1
– Most frequently HCV, HBV, alcohol and aflatoxin exposure
AASLD 2018
Comparison of international guidelines for noninvasive diagnosis of hepatocellular carcinoma: 2018 update. Kim TH, et al. Clin Mol Hepatol. 2019
APASL 2017 AASLD 2018 EASL 2018
• (HBV, HCV, NASH, genetic
hemochromatosis, PBC, alpha-1
antitrypsin )
• (HBV, HVC, PBC, genetic
hemochromatosis, alpha-1-
antitrypsin)
• Child-Pugh A/B
• Cirrhotic patients, Child- Pugh
C awaiting OLT
• Non-cirrhotic HBV
(Asian men > 40 y,
Asian women > 50 y,
Africans > 20 y;
family history of HCC)
• Hepatitis B carriers
(Asian men >40 y,
Asian women > 50 y,
all cirrhotic HBV carriers,
family history of HCC,
African/North American blacks)
• Non-cirrhotic HBV at
intermediate/ high risk of HCC
• Non-cirrhotic patients with F3
fibrosis, regardless of etiology
on individual risk assessment
Target Population for Surveillance (Cirrhotic)
Comparison of international guidelines for noninvasive diagnosis of hepatocellular carcinoma: 2018 update. Kim TH, et al. Clin Mol Hepatol. 2019
APASL 2017 AASLD 2018 EASL 2018
Ultrasound and AFP
every 6 mo
• Ultrasound with/without
AFP every 6 mo
• Ultrasound every 6 mo
• CT or MRI in select
patients with a high
likelihood of having
an inadequate US
• CT or MRI for patients on
waiting list for LT and when
obesity, intestinal gas, and
chest wall with inadequate
ultrasound assessment
• Ultrasound <4 mo interval
when a nodule of <1 cm has
been detected during
surveillance
Screening and Surveillance Test
Target population risk for HCC with positive
screening/surveillance test
risk for HCC with abnormal
results on screening test
risk for HCC with ≥1 cm
nodule on US
1st imaging modality CT, MRI/ ECCM or HBA CT, MRI/ ECCM or HBA CT, MRI/ECCM or HBA
2nd imaging modality CEUS (Sonazoid) None CEUS
Phases for washout ECA: PVP or DP ECA: PVP or DP ECA: PVP or DP
HBA: PVP HBA: PVP HBA: PVP
Imaging criteria for arterial
phase hyperE HCC
Regardless of size: LI-RADS 5 Nodule >1 cm
APHE and washout APHE
or hypointensity on HBP Washout
Imaging criteria for arterial
phase hypo or isoE HCC
Yes None None
Imaging criteria for arterial
phase hypo or isoE
PROBABLE HCC
None (but definite HCC
diagnosis is possible)
Yes None
Diagnostic and Staging for HCC (Kim TH, 2019)APASL (2017) AASLD (2018) EASL (2018)
Imaging criteria for
subcentimeter size HCC
Yes None None
Exclusion criteria None None None
Imaging criteria for HCC
tumor in vein
None None None
Ancialliary features None Yes None
Categories • Arterial hyperE HCC • Definitely benign (LR-1) Arterial hyperE HCC
• Probably benign (LR-2)
• Arterial hypo- isoE HCC • Intermediate (LR-3)
• Probably HCC (LR-4)
• Definitely HCC (LR-5)
• Malignant, not HCC (LR-M)
Staging (multidisciplinary team) BCLC BCLC
Diagnostic and Staging for HCCAPASL (2017) AASLD (2018) EASL (2018)
Non-invasive diagnosis
• Non-invasive diagnostic criteria for patients with cirrhosis require particular imaging techniques
Recommendations
Non-invasive criteria* can only be applied to cirrhotic
patients for nodule(s) ≥1 cm, in light of the high pre-test
probability, and are based on imaging techniques obtained by
multiphasic CT, dynamic contrast-enhanced MRI…
High Strong
…or CEUS Moderate Weak
Because of their higher sensitivity and the analysis of the
whole liver, CT or MRI should be used first High Strong
FDG PET scan is not recommended for early diagnosis of
HCC because of the high false-negative rate Low Strong
Level of evidence Grade of recommendation
AASLD 2018
Resection and Liver Tx
CTP A/B A Liver function / PH
Size > 1cm (HK, Jp, Ko) (T1/T2) > 2cm
Number < 3 2-3 2-3 (Milan)
Macro VI None ( ???) None None (trials)
Liver Resection for HCCAPASL (2017) AASLD (2018) EASL (2018)
Recommendations EASL 2018
Surgical resection is the treatment of choice in HCC arising on a non-cirrhotic Low Strong
Indications for resection of HCC in cirrhosis should be based on:
• Multi-parametric composite assessment of liver function• Portal hypertension ( < 10 mmHg)• Extent of hepatectomy and expected volume of future liver remnant• Performance status• Patient co-morbidities• Paleteles > 100.000 ; BT < 2; (AASLD / APASL)
High Strong
Peri-resection mortality in cirrhotic patients should be <3% High Strong
Criterios Cirúrgicos para Ressecção BCLC B• Ressecção de > 2 segmentos ?
• Ressecções não anatômicas ?
• Margem > 2cm e F3/F4
• Preservação de volume remanescente > 40%
• Não mobilização hepatica (anterior approach)
• Uso de IOUS (localizar trombos ou novas lesões
• Uso de pouco tempo de clamp vascular
• Uso de PVC baixa
• Cirurgia aberta x laparoscópica
• Acompanhamento a cada 6 meses
Shindoh J. et al J Hepatol 2016
- Liver Transplantation- Child-Pugh B / C --> decompensated cirrhosis and other diseases
- Without distant metastasis
- Standard criteria --> Milan
- LDLT --> depends on institutional or case-by-case
- Each center developed institutional expansion criteria
- Taiwan and Hong Kong --> UCSF
- China --> satisfactory outcomes
- Korea --> UCSF or Milan
- Japan --> Milan (National Insurance)
- Caution --> recurrence and survival rateAvailable via license: CC BY-NC-ND 4.0
AASLD 2018
UCSFAFP < 500
Milan : Yes
DWS: Yes
MVI: No
Marginal graft: Yes
AFP : study
LDLT: Yes (selected)
Percutaneous ablation
Nault J-C, et al. J Hepatol 2018;68:783–97
EASL CPG HCC. J Hepatol 2018; doi: 10.1016/j.jhep.2018.03.019
• Thermal injury of adjacent
structure
• Heat sink effect (near major
vessels)
• Multibipolar mode is less
sensitive to heat sink effect
Advantages Limitations
• Well-evaluated treatment
(reference)
• Multibipolar mode: increases
volume and
predictability (margin) of
ablation zone
• No reliable endpoint to set the
amount of energy deposition
• Higher and faster temperature
picks reached than with RFA
(less sensitive to heat sink
effect than monopolar RFA)
• Limited risk of thermal injury to
neighbouring critical structures
• Unsensitive to heat sink effect
• Advantage of multibipolar mode
(no touch technique,
predictability of margins)
• Cryoshock with first device
• Limited clinical data available
with new devices
• Easy monitoring with imaging of
ice ball progression
• Only preliminary clinical data
• General anaesthesia using
curare and major analgesic
drugs is mandatory
Radiofrequency ablation Microwave ablation Cryoablation Irreversible electroporation
Monopolar RFA
Multibipolar
No touch RFA
Active energy
deposition: few mm
Active energy
deposition: ~1 cm Ice ball: ~1–3 cm
Heat
diffusion
Heat
diffusion
Cold
diffusion
Cell
membrane
