Hepatocellular carcinoma

Hepatocellular carcinoma (hepatoma)

Risk factors

1. Hepatitis b virus
2. Hepatitis c virus
3. Aflatoxin, derived from the fungus “Aspragellus flavus“
4. Liver cirrhosis

Clinical features

Symptoms

1. Asymptomatic in the early stage (even if 15cm tumor)
2. Abdominal pain
3. Sudden deterioration in the liver function due to extension of the tumor into the portal vein in patient with chronic liver disease
4. Common presenting features involve progression of existing liver disease symptoms (abdominal pain, weight loss, abdominal distention, fever, spontaneous intraperitoneal hemorrhage)
5. Jaundice is not common unless there is advanced cirrhosis

screen cirrhotic patient every 6 month and alpha fetoprotein

Signs Examination may reveal features of established liver disease and hepatomegaly

Investigations

Lab tests: LFT is generally deranged. α-fetoprotein (AFP) is tumor marker which elevated in some patient with HCC and can be used as screening test in high risk patients (e.g. cirrhosis)

Imaging: Ultrasound, CT scan and MRI can assess the site, size, diagnosis of the tumor and can help in planning the surgical resection. CT scan will show hypervascular tumor.

HCC CT FINDINGS Arterial phase shows hypervascularity of the HCC tumor on right lobe - washing in in venous its opposite - washing out

diagnostic for HCC gold standard- doesnt need biopsy

irregular margin, liver shrink, ascites present

CT scan : Huge hepatocellular carcinoma in the right lobe of the liver

Biopsy

Gross HCC - Liver Cirrhosis (HBV – HCV) cirrhotic, tumour round homogenous on right lobe

Huge hepatocellular carcinoma in the right lobe of the liver

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HCC Staging is Multifaceted

Staging is used for prognosis and to guide treatment1Y Staging HCC1

• Most patients have underlying liver disease
• Key prognostic indicators are not clearly defined
• Prognostic indicators vary during the course of disease

Factors affecting staging systems 2,3Y

• Tumor stage
• Liver function
• Health status
• Impact of treatment

Z

Liver Transplantation for HCC “Patient Selection”

No Macro-Vascular Invasion & No Extra-hepatic Spread

Milan’s Criteria

• Single tumor ≤ 5 cm or
• ≤ 3 lesions, each lesion ≤ 3 cm

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Y Barcelona Clinic Liver Cancer staging and treatment strategy

HCC

Stage 0 Child-Pugh A; PST 0

• Very early stage (0)
• Single HCC <2cm
• Carcinoma in situ

Stage A-C Okuda 1-2; Child-Pugh A-B; PST 0-2

• Early Stage (A)
  • Single HCC or
  • 3 nodules <3cm
  • PST 0
• Intermediate stage (B)
  • Multinodular; PST 0
• Advanced stage (C)
  • Portal invasion N1, M1,
  • PST 1-2

Stage D Okuda 3; Child-Pugh C; PST >2

• Terminal stage (D)

Single HCC

Portal pressure/bilirubin

• Normal
  • Resection
  • Liver transplantation
    • Curative treatments (30%)
    • 5-years survival: 50-70%
• Increased
  • 3 nodules ≤3cm
    • Associated diseases
      • No
        • PEI/RF
      • Yes
        • Chemoembolisation
          • Randomised controlled trials (30%)
          • 3-years survival: 20-40%
  • Extrahepatic disease
    • No
    • Yes
      • Sorafenib
        • Symptomatic treatment (30%)
        • 1-year survival: 10%

PST=Performance status

Llovet JM, et al, Lancet 2003;362:1907-17