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TABLE 1
Diagnosis work-up in HCC 11
Diagnosis by imaging
Multiphasic contrast enhanced CT or MRI of typical vascular hallmarks of HCC in a nodule of more than 1 cm diameter
Multiphasic MRI is more sensitive than multiple detector CT
Diagnosis by pathology
Histopathological diagnosis of tumour biopsies relies on haematoxylin and eosin staining and may be supplemented with immunohistochemistry
Required to diagnose HCC in non-cirrhotic liver
MRI with diffusion-weighted imaging and hepatobiliary contrast agents might identify risk nodules .
Table 2 shows the scoring system and parameters . The Child-Pugh score is calculated by adding the scores of the five factors and can range from 5 to 15 . Child-Pugh class can be A ( score of 5 – 6 ), B ( 7 – 9 ), or C ( 10 or above ). Decompensation indicates cirrhosis with a Child-Pugh score of > 7 ( Class B ). This level is the accepted criterion for listing liver transplantation .
BCLC staging 12 There are five stages in the BCLC system : Stage 0 – Very early Stage A – Early Stage B – Intermediate Stage C – Advanced Stage D – Severe / end stage
Table 3 shows the stages / corresponding Child-Pugh stages . The BCLC system uses the Eastern Cooperative Oncology
Group ( ECOG ) performance status . 14 This assesses disease progression and how the disease is affecting the daily living abilities of the patient Table 4 summarises the grades .
ALBI score Albumin-Bilirubin ( ALBI ) is a useful score to evaluate liver function objectively and uses objective parameters and stratifies patients into grades . In combination with other liver cancer scores , the prognosis and survival of patients can be evaluated with more accuracy . The ALBI grade has emerged as an alternative , reproducible and objective measure of liver functional reserve in patients with HCC , defining worsening liver impairment across 3 grades ( I to III ). 15 The ALBI score is calculated as :
ALBI score = −0.085 × ( albumin g / l ) + 0.66 × l g ( TBil μmol / l )
Management of early and intermediate HCC The management of HCC can be complex and requires treatment of not only HCC but the underlying liver disease , as well as a consideration of the tumour extent and any patient
TABLE 2
Child-Pugh scoring system and parameters
Parameter Assign 1 point Assign 2 points Assign 3 points
Ascites Absent Slight Moderate
Bilirubin ( mg / dl ) < 2 2 – 3 > 3
Prothrombin time ( seconds over control or International normalised ratio
< 4
< 1.7
4 – 6
1.7 – 2.3
> 6
> 2.3
Encephalopathy None Grade 1 – 2 ( mild-moderate ) Grade 3 – 4 ( severe )
TABLE 3
BCLC staging
Stage 0 ( Child-Pugh A ) Stage B ( Child-Pugh A or B ) Stage C ( Child-Pugh A or B ) Stage D ( Child-Pugh C )
• Single tumour of any size or up to 3 nodules ≤3 cm .
• Preserved liver function
• Eastern Cooperative Oncology Group ( ECOG ) performance status ( PS ) 0
• Multinodular
• Preserved liver function
• ECOG PS 0
• Portal invasion
• Extrahepatic spread
• Preserved liver function
• ECOG PS 0 – 2
• End-stage liver function
• ECOG PS 3 – 4
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