WALES LIVER DELIVERY PLAN - WAGE



WALES LIVER DELIVERY PLANPRIMARY LIVER CANCER (HCC)Diagnosis of HCCMost HCC patients present with symptoms of liver decompensation, often due to HCC complicating previously undiagnosed cirrhosisIt is to be hoped that an increasing proportion of HCC will be surveillance-detected. Such patients are more likely to be candidates for treatment and have a better prognosis than symptomatic HCC.HCC normally has characteristic appearances on contrast-enhanced CT or MRI scan. Liver MRI is increasingly used to confirm the diagnosis.Liver biopsy is only appropriate for lesions greater than 1 cm that are visible by ultrasound and do not have characteristic appearances of HCC on cross-sectional imaging and whose alpha-fetoprotein is not elevated above 200 or a rising trend.Patients whose abnormalities are less than 1 cm in diameter (and/or indeterminate of any size) should undergo enhanced surveillance by CT or MRI every 4 months. If a lesion is indeterminate and the patient is a candidate for TACE or Sorafenib a biopsy should be considered.All patients with HCC should have undergone a liver screen, in particular to exclude chronic viral hepatitis.Treatment of HCCPartial liver resection for HCC is only indicated in patients with disease limited to one or two segments who have Childs A cirrhosis in the absence of portal hypertension or portal vein thrombosis. If there is uncertainty about portal hypertension hepatic venous wedge pressure measurement may be necessary.Liver transplantation may be indicated in patients with HCC who fulfil other transplantation criteria and have good performance status of 0-1 once any treatable cause for encephalopathy has been reversed. Tumour-related contraindications include rupture, alpha-fetoprotein greater than 1,000 iu/l, macroscopic vascular invasion or extra hepatic spread. Criteria for selecting patients with HCC for liver transplantation are ad follows:Single tumour no greater than 5 cm orUp to five tumours each less than 3 cm in diameter or Single tumour 5 and 7 cm in diameter without evidence of tumour progression (volume increase by 20% and no extra-hepatic spread or new nodule formation over the preceding six months. Locoregional therapy should be considered during this time. Waiting list place will be considered from the time of first staging scan.Liver transplantation is never indicated in patients whose anticipated five-year post-transplant survival is less than 50%. Microwave ablation is typically offered to patients with single lesions up to 4 cm in diameter (or 2-3 lesions up to 3cm in diameter) that are situated relatively peripherally in the liverTrans-arterial Catheter Embolisation (TACE) is offered to patients with larger or multifocal lesions and more centrally-lying lesions. Patients should be Child Pugh A-B with WHO Performance Status no worse than 2. TACE is sometimes the treatment of choice in patients with extrahepatic disease whose major tumour burden is concentrated within the liver.Sorafenib – this can be offered to patients with a performance status of 0-1 who are Childs Pugh A. It is logical to choose Sorafenib in patients who have extra-hepatic disease. Treatment may be poorly tolerated and back up needs to be available via the Oncology Clinical Nurse Specialist team. It is reasonable to offer TACE to patients with intrahepatic portal vein thrombosis and/or a hepatoma arterial embolisation prognostic score (HAP) of up to 2. Other treatments such as selective internal radiotherapy or SBRT can be considered for individual patients by the HCC regional MDT. Follow-up Following TreatmentThe Cardiff Liver Unit Protocol is as follows: a CT thorax and upper abdomen every six months for two years then annually until Year 5 when the patient can be discharged. It may be indicated to juxtapose ultrasound surveillance every year in between the yearly CTs in these patients because ultrasound may be more sensitive in surveillance for new disease whereas CT is the better modality to exclude disease recurrence and compare with historic CTs.. After Year 5 patients should be returned to their local hepatology services with a view to six-monthly ultrasound surveillance if their performance status remains good. Surveillance after ablational surgery requires cross-sectional imaging at least annually for five years. After TACE a CT or MRI scan is undertaken at six weeks and then three-monthly. Such scans should be undertaken at hospitals that are used to performing and interpreting these scans.What a HCC MDM Should Look LikeEach HCC patient should have a named key professional cancer nurse specialist who attends or video-links into the regional HCC MDM. The need for such a key professional is part of the Welsh Cancer Standards.There needs to be a consultant in each health board with designated responsibility for HCC who links into the regional MDM as part of their job plan. This consultant hepatologist should be responsible for keeping a local database of patients with cirrhosis undergoing surveillance and patients found to have HCC and their subsequent treatment. Equally the time between first referral and discussion at the regional HCC MDM should be recorded. There is a potential database to be funded by commerce that could allow audit and scrutiny. Patients from South Wales nearly all travel to Birmingham or the Royal Free for transplantation. Proper service commissioning will reduce variations and delays in management. ................
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