Hepatocellular Carcinoma

INTRODUCTION:
  • Hepatocellular Carcinoma is a primary cancer meaning it originated in the Liver(as opposed to Liver metastases,or secondary Liver Cancers which have spread to Liver from other organs)
  • It is commonly associated with Cirrhosis and Hepatitis.
  • Male to Female ratio is 4:1 for HCC.
  • High incidence in East Africa and South east Asia
  • Its worldwide incidence parallels the prevalence of hepatitis B
  • Fibrolameller type is having good prognosis
ETIOLOGY:
  • Common Cause:
  1. Cirrhosis from any cause
  2. Hepatitis B or C chronic infection
  3. Ethanol chronic consumption.
  4. Aflatoxin B1 or other mycotoxins
  • Unusual Cause:
  1. Primary Biliary Cirrhosis
  2. Hemochromatosis
  3. Alpha 1 Antitrypsin deficiency
  4. Hemochromatosis
  5. Wilson’s Disease
SYMPTOMS:
  • Abdominal Pain
  • Weight Loss
  • Weakness
  • Abdominal Fullness and swelling
  • Jaundice
  • Nausea
SIGNS:
  • Hepatomegaly (50 to 90% of patients)
  • Ascites(30 to 60%)
  • Abdominal Bruits
  • Splenomegaly
  • Spider Angioma
  • Obstructive Jaundice
  • Paraneoplastic Syndromes
PARANEOPLASTIC SYNDROME:
  • Erythrocytosis
  • Persistent fever
  • Hypoglycemia
  • Hypercalcemia
  • Hypercholesterolemia
DIAGNOSIS:
  • Diagnosis of HCC should be bases on followings:
  1. History & P/E
  2. IMAGING(CT,MRI)
  3. LIVER BIOPSY(For Confirmation)
  4. Elevated Serum AFP(more than 400ng/ml)
  • In patient with higher suspicion of HCC the best method of diagnosis involves:
  1. CT scan of the abdomen using IV Contrast agent and three phase scanning:
  2. Before contrast administration
  3. Immediately after contrast administration
  4. After Delay
  • Biopsy is not needed if following criteria are met on CT:
  1. Hypervascularity in the arterial phase scans
  2. Washout or deenhancement in the Portal and delayed phase studies
  3. Pseudocapsule and Mosaic Pattern
  • Liver Biopsy is not needed if these criteria are met on CT
  • Mallory hyaline
  • An alternative to a CT imaging study would be the MRI. MRI's are more expensive and not as available because fewer facilities have MRI machines
  • On CT, HCC can have three distinct patterns of growth:
  • A single large tumor
  • Multiple tumors
  • Poorly defined tumor with an infiltrative growth pattern
  • Tumor marker for primary hepatocellular carcinoma :
  • Alpha feto protein
  • PIVKA-2
  • Neurotensin
  • Vit B12 binding globulin
PATHOLOGY:
  • On CT, HCC can have three distinct patterns of growth:
  1. A single large tumor
  2. Multiple tumors
  3. Poorly defined tumor with an infiltrative growth pattern
  • Macroscopically,the tumour usually appears as single mass in the absence of Cirrhosis,or as a single/ multiple nodules in the presence of cirrhosis
  1. It takes its blood supply from the hepatic artery and tends to spread by invasion into the portal vein and its radicles.
  2. Lymph node metastases are common but Lung and bone metastases are rare.
  3. Microscopically,the tumour resembles hepatocytes when well differentiated and can be difficult to distinguish from normal Liver.
TREATMENT:
MANAGEMENT INDICATION PROGNOSIS Recurrence
HEPATIC RESECTION Non Cirrhotic HCC 5 year survival is about 50% 50% recurrence rate at 5 years
LIVER TRANSPLANTATION Cirrhotic HCC
Unresectable
case
5 year survival is about 75% Unfortunately Hepatitis B & C may also occur in transplanted Liver
PERCUTANEOUS ABLATION(ETHANOL) TUMOURS OF 3 cm or small 80% cure rate 50% at 3 years
Cirrhotic,Patients with unresectable HCC and good No survival benefit
CHEMOEMBOLIZATION Liver Functions at 2 years Beyond 4 years
DOXORUBICIN is used
CHEMOTHERAPY:
  • SORAFENIB(multitargeted oral tyrosine kinase inhibitor)
  • SUNITINIB,DOXORUBICIN,CISPLATIN,FLUOROURACIL are commonly used chemotherapeutic agents.
  • Unfortunately HCC is relatively chemotherapy resistant
RADIOTHERAPY:
  • The yttrium 90 microspheres are directly injected into the hepatic artery branches that supply the tumor.
  • The main indications are inoperable HCC118 and colorectal cancer hepatic metastases for which systemic chemotherapy has failed
COMPLICATIONS:
  • Gastrointestinal Bleeding
  • Liver Failure
  • Distant Metastases
  • Malignant portal vein thrombosis
Exam Question
  • Tumor marker for primary hepatocellular carcinoma are Alpha feto protein, PIVKA-2, Neurotensin,Vit B12 binding globulin
  • Yttrium 90 microspheres are used in treatment of hepatocellular carcinoma
  • Liver transplantation offers the only chance of cure in those with unresectable case of hepatocellular carcinoma
  • High incidence in East Africa and South east Asia with worldwide incidence parallels the prevalence of hepatitis B of hepatocellular carcinoma
  • Hepatomegaly ,Raised a- fetoprotein levels, Raised alkaline phosphatase are seen in hepatocellular carcinoma
  • Sorafenib a tyrosine kinase inhibitor is used to treat hepatocellular carcinoma
  • Transarterial chemoembolization (TACE) is used in the treatment of unresectable hepatocellular carcinoma without portal vein thrombosis. The drug commonly used for TACE is Doxorubicin Hepatocellular carcinoma has propensity to invade the portal or hepatic vein
  • Radiofrequency ablation ,Percutaneous Ethanol Injection and Resection are curative treatment modalities for hepatocellular carcinoma
  • Most common cause of malignant portal vein thrombosis is Hepatocellular carcinoma
  • Mallory hyaline is seen in Hepatocellular carcinoma
  • Liver biopsy is diagnostic for Hepatocellular carcinoma
  • Raised titre of HBV and HCV antibodies is seen in Hepatocellular carcinoma
  • Fibrolameller type is having good prognosis in hepatocellular carcinoma
  • The most unlikely clinical feature of Hepatocellular carcinoma is jaundice
  • In hepatocellular carcinoma, risk factor most important is Cirrhosis
Don't Forget to Solve all the previous Year Question asked on Hepatocellular Carcinoma