Page 174 - Read Online

first letters of the following indications of the TPN, and the for a further investigation in ECOG > 2 patients who are
result is a phrase that can be much more easily remembered: symptomatic and in bed > 50% of the day.
Major visceral injury, Inflammatory bowel disease, Sepsis,
Ileus, Post-operative, Paralysis, Intestinal fistulas, and Burns. Extra-hepatic disease
These mnemonics are being used with increasing frequency Here, the extra-hepatic dissemination of the HCCs are
in the medical education due to the need to learn, memorize, evaluated, which is an important finding in the advanced
remember, and recall a lot of things. [9,10] stage HCC diagnosis (BCLC Stage C) and helps in the
differential diagnosis of the intermediate stage HCCs (BCLC
A MNEMONIC ACRONYM TO DECIDE AND CHOOSE Stage B). The portal vein invasion, lymph node positivity (N1),
THE RESECTABLE HCC: “PERISH” and distant metastasis (M1) are the pathognomonic findings
of the advanced stage HCCs. These HCCs tend to be mostly
This phrase “PERISH” is designed to help practically and locally advanced cancers that have a high affinity to make
easily the surgeons in choosing the HCCs to be resected in lymph node metastasis (30%). The distant metastasis are
an algorithm while evaluating a patient. It is a mnemonic seen less frequently (13.5%); most commonly to lungs,
acronym designed for: Performance of patient, Extra-hepatic bones, peritoneum, and the adrenal glands. [11-13] There are
disease, Reserve of the liver, Intra-hepatic distribution, some authors suggesting surgical resection for the distant
Stratifying risk factors, Hepatectomy size. All these factors metastasis to lungs or adrenal glands for a better prognosis
[14]
have a great importance in the patient selection that will be in HCCs with up to three pulmonary lesions. However, this
eligible for the surgery. is not generally accepted. The major vascular invasion that
cannot be reconstructed also leads to the HCCs advanced
Performance of patient stage. The vessel invasion is more common in extra-hepatic
These patients with HCC, if eligible for a resection will be disseminated HCCs. [12,13] In these situations, only sorafenib
candidates for one of the major surgeries in the general treatment, and even in some, only the supportive treatment
surgery practice. This may be a small size resection or a modalities can be used.
major hepatectomy, if the HCC and the patient are suitable.
Hence, even if there is a chance of surgical resection as a Reserve of liver
cure for the disease, there are patient factors that are as Since 80% of these HCCs originate from the cirrhotic livers,
important as the HCCs status when the surgeon is making resection of these tumors is a much more complicated issue.
a surgery decision. The age of the patient, debilitating, and The pitfalls of liver surgery in these patients are inadequate
co-morbid diseases (cardiovascular, renal, pulmonary, etc.) functional remnant, decrease in liver regeneration capacity,
are the important factors that help the surgeon in making and increase the probability of hemorrhage due to portal
the evaluation. hypertension. When inadequate liver remnant is left behind,
this may lead to hepatic insufficiency and failure, which is the
The age of the patients is an important factor affecting the most common cause of death in this group. Calculation of
outcomes of the surgical interventions. During the years liver reserve should be the third step of the evaluation. There
1991-1995, in USA, the HCC incidence increased significantly are several staging methods to determine the hepatic reserve,
in 40-60 years old patients up to 2.4 per 100,000 from such as Model for the End-Stage Liver Disease, Indo-cyanine
1.4 per 100,000. Furthermore, a more objective criteria, Green (ICG) Retention Test, Metabolism of Lidocaine to the
[11]
[15]
the ECOG classification for the health status is used in the Metabolite, and Arterial Body Ketone Ratio. However,
BCLC staging of the HCCs [Table 1]. Here, the patient’s the most widely accepted staging system is Child-Pugh
[5]
performance in doing their daily routines and taking care classification as A, B, and C [Table 2]. Previous studies clearly
of their own needs are taken into consideration. The ECOG demonstrated that liver resection in cirrhotic patients
Class 0, Class 1, and sometimes the Class 2 can tolerate accompanied with exacerbated transient hepatic dysfunction,
the surgical treatment. However, ECOG Class 3 and Class 4,
due to their debilities cannot be candidates for surgical Table 1: ECOG performance scoring system
intervention whatever the HCC status is. The end stage HCC Performance Defi nition
(BCLC Stage D) accounting for the 20% of HCCs also includes status
ECOG Class > 2 and/or Child-Pugh Class C patients. These are 1 No symptoms; normal activity level
directly classified as the terminal stage patients that are only 2 Symptomatic, but able to carry out normal daily activities
candidates for supportive treatments with a survival period 3 Symptomatic; in bed less than half of the day; needs
some assistance with daily activities
of < 3 months [Figure 1]. Poor patient performance is an 4 Symptomatic; in bed more than half of the day
[4]
early indicator for the treatment decision without a need ECOG: Eastern Cooperative Oncology Group

Hepatoma Research | Volume 1 | Issue 3 | October 15, 2015 167