ANATOMI HATI

T.D. 2 LOBUS : KANAN & KIRI.

LOBUS KIRI

SEG. LATERAL .

SEG. MEDIAL .
BATAS LIG . FALSIFORMIS.

LOBUS KANAN SEG. ANTERIOR . SEG. POSTERIOR.

This is the external surface of a normal liver. The color is brown and the surface is smooth. A normal liver is about 1200 to 1600 grams.

Surgical Treatment of HCC

Budi Irwan

METABOLISME GARAM EMPEDU,PIGMEN EMPEDU METABOLISME KARBOHIDRAT PEMBENTUKAN UREA,PENYIMPANAN PROTEIN(ASAMAMINO),METABOLISME LEMAK,KETOGENESIS SINTESIS KOLESTEROL,DAN PENIMBUNAN LEMAK PENIMBUNAN VITAMIN DAN MINERAL METABOLISME STEROID DETOKSIFIKASI GUDANG DARAH DAN FILTRASI

KHS (KARSINOMA HEPATOSELULAR),HEPATOMA PRIMER DR SEL HEPATOSIT KARSINOMA KOLANGIOSELULAR,HEPATOMA PRIMER YANG BERASAL DARI EPITEL SALURAN EMPEDU INTRAHEPATIK KARSINOMA CAMPURA HEPATOSELULAR DAN KOLANGIOSELULAR

TIPE MASSIF,PD SATU LOBUS DAN HANYA SATU NODUL SAJA TIPE NODULER,PALING SERING DIJUMPAI,HATI MEMBESAR,NODUL YG BANYAK (IRREGULER) TIPE DIFFUS,UMUMNYA SEL HATI MASIH DALAM BATAS NORMAL TETAPI TERISI OLEH SEL KARSINOMA YG DIFFUS

TUMOR HATI PRIMER ( HEPATO CELLULAR CARCINOMA ) AS, JARANG DISTRIBUSI DENGAN ANGKA KEJADIAN TERTINGGI DI ASIA TIMUR,SUB SAHARA AFRIKA DAN MELANESIA, JARANG DITEMUKAN PADA USIA MUDA

INSIDENS MENINGKAT PADA USIS TUA

Hepatocellular carcinoma (HCC) a primary malignancy of the liver, hepatocellular origin HCC is a major cause of death from cancer in Eastern Asia and sub-Saharan Africa HCC causes 662,000 deaths per year, about half of them in China. Males >> females Age of 30 to 50.

HBV 70-90% of chronic cases in cirrhosis Treatment decrease risk HCV 1-3% of HCV develop HCC Treatment decrease risk Co-infection Aflatoxins (Aspergillus fumigatus) 4 fold increased risk HCC Alcohol >50-70g/day Synergist with HCV and HBV Nonalcoholic Steatohepatitis?

El-Serag, H.B. and K.L. Rudolph, Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology, 2007. 132(7): p. 2557-76. Brunetto M.R., O.F., Koehler M., et al., Effect of interferon-alpha on progression of cirrhosis to hepatocellular carcinoma: a retrospective cohort study. International Interferon-alpha Hepatocellular Carcinoma Study Group. Lancet, 1998. 351(9115): p. 1535-9.

Obesity Diabetes Mellitus Hemochromatosis Alpha-1 antitrypsin deficiency Autoimmune hepatitis 15-50% of HCC in the US have no established risk factors

Thorgeirsson, S.S. and J.W. Grisham, Molecular pathogenesis of human hepatocellular carcinoma. Nat Genet, 2002. 31(

HCC with cholangiolar features, moderately differentiated

Healthy Liver

Hepatic Fibrosis

Cirrhosis

Liver Cancer

Healthy Liver

Hepatic Fibrosis

Cirrhosis

Liver Cancer

KANKER HATI

20% infeksi kronis 80% Infeksi HCV: kronis berakhir dengan sirosis 25% sirosis berakhir dengan kanker hati atau gagal hati

Kelompok Risiko Tinggi HCV:

Pengguna Narkoba Suntik Penerima Transfusi

Pasien terpapar alat medis

yang tak steril

Here is another example of macronodular cirrhosis. Viral hepatitis (B or C) is the most common cause for macronodular cirrhosis. Wilson's disease and alpha-1-antitrypsin deficiency also can produce a macronodular cirrhosis.

METASTASE TUMOR HATI

PARU - PARU TULANG ADRENAL OTAK DIAFRAGMA PERI PORTAL LIMPH NODE

D/ SUBKLINIS HEPATOMA,STAD.DINI,TANPA GEJALA DAN TANDA FISIK YG JELAS D/NON INVASIF

D/PATOLOGIS

1.

2.
3. 4.

Clinis Imaging Blood level of alphafetoprotein Needle biopsy

RIWAYAT ALKOHOL ATAU SIROSIS RASA SAKIT ATAU TIDAK ENAK TERABA MASSA BERAT BADAN MENURUN ASITES JAUNDICE ANOREKSIA,PERUT GEMBUNG LETIH,BERAT BADAN MENURUN,

PERDARAHAN

DIAGNOSA
AFP MENINGGI 50 90 % . TUMOR KECIL BISA NORMAL / SDKT .

AFP JUGA BISA ME PADA SIROSIS HATI .

TIDAK BERMAKNA.

AFP

MONITOR KEBERHASILAN RESEKSI

KURATIF.

PARA NEOPLASTIC COMPLIKASI :

HIPOGLISEMIA

HIPERKALSEMIA
ERITROSITOSIS

HIPERTROFI PULMONARI
OSTEOARTROPATI

CT Scan MRI USG Nuclear Medicine Angiography Plain film

Preferred Less usefull

BIOPSI
USG .
STAGING .

STAGING SYSTEM HCC ( AJCC ) KLASIFIKASI TNM

TNM SISTEM,OKUDA,MORPHOLOGY,MET,VI OKUDA SISTEM, BILLIRUBIN,ALB,ASC CLIP (CANCER OF THE LIVER ITALIAN PROGRAM),CHILD PUGH JIS SCORE (JAPAN INTEGRATED STAGING) BCLC(BARCELONA CLINIC LIVER CANCER) ,CHILD PUGH,PH,BILLIRUBIN

STAGE GROUP
- STAGE I - STAGE II - STAGE III - STAGE IVa - STAGE IVb T1 T2 T3 T 1-3 T4 Any T N0 N0 N0 N1 Any N Any N M0 M0 M0 M0 M0 M1

PENATALAKSANAAN :
TERAPI DEFINITIF OPERASI HANYA 10 30 % MASIH OPERABLE HANYA 50 70 % YANG CURATIVE

KRITERIA NON OPERATIF :

ADA PENYAKIT EKTRA HEPATIK GANGGUAN FUNGSI HATI BERAT MASA TUMOR YANG MASIF V. PORTA ATAU V. CAVA SUDAH TERLIBAT KONTRA INDIKASI RELATIF

HEMANGIOMA ABSESS HEPAR TUMOR METASTASE

TERAPI OPERASI RESEKSI TRANSPLANTASI HATI TERAPI NON OPERATIP RFA (RADIO FREKWENSI ABALATIO)

INJ.ETANOL MRNI (95%),INTRA TUMOR PERKUTANTAS

KEMOEMBOLISASI ARTERI HEPATIK PERKUTANERAPI OPERASI KEMOTERAPI SISTEMIK

RADIOTERAPI
TAMOXIPEN INJ.ASAM ASETAT PERKUTAN SORAFENIF (95%)

Treatment modality 1. Livertransplantation

2. Hepatic resection 3. Thermal ablation (Radiofrequency,microwave,la ser) 4. Cryotherapy

Limitations 1.Donor avaibility, Three or fewer lesions, none > 3 cm , Solitary lesion < 5 cm 2.Minimal or no cirrhosis, three or fewer lesions 3.Three or fewer lesions, each < 5 cm 4.Small lesions, rarely done percutaneously

5. Conformal radiation 6. Proton beam therapy 7. Intra-arterial radiotherapy 8. Intralesional ethanol

9. Chemoembolization 10.Systemic or intra arterial chemothrapy

5. Solitary lession 6. Radiation-induced liver disease 7. Radiation hepatitis, renal/pancreatic damage 8. Few, small lesions, difficulty viewing during injections, requires multiple sessions 9. Adequate hepatic function, patent portal vein, considerable local toxicity 10.Toxicity, lack of efficacy

Liver transplant / Resection (< 5% of cases) 5 yr survival , 41-93% Radiofrequency ablation (RFA) 5 yr survival , 33-40% Solitary tumors, max 3-5 cm Percutaneous ethanol injection. 5 yr survival , 29-71% Solitary tumors, max 3-5cm

Transarterial chemoembolization (TACE) 2 yr survival 24-63% No vascular invasion, preserved liver function, no extrahepatic spread Radiation therapy

Systemic chemotherapy

Five-year survival rates, based upon the newer staging system are as follows, Stage I 55 percent Stage II 37 percent Stage III 16 percent Stage IV- 0 percent

75% of HCCs present when stage III/IV Most patients with advanced HCC die within 1 year of diagnosis, with <10% of patients surviving after 5 years Main challenge in treating advanced HCC is the underlying liver dysfunction

Usaha difokuskan kepada pencegahan. Bisa dilakukan beberapa tindaka prevention antara lain, Vaksinasi anak-anak pada usia dini terhadap hepatitis B, Mengurangi risiko untuk tertular hepatitis C Menggurangi atau menghindarkan konsumsi minuman beralkohol yang berlebihan. Makan makanan bergizi seperti buah dan sayuran. Modifikasi gaya hidup.

TUMOR HATI SEKUNDER

- GASTROINTESTINAL TUMOR KOLON & REKTUM

GEJALA KLINIS :
- SERING SUDAH LANJUT ASITES, JAUNDICE, SAKIT PERUT KANAN ATAS, FAAL HATI , AFP SEDIKIT MENINGGI. PROGNOSA JELEK DIAGNOSA USG CT SCAN / CTAP