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Hepatocellular Liver Carcinoma (HCC)

Etiology

  • Cirrhosis is present >75% of pts with HCC
    • Can be due to HBV (MCC), HCV, haemochromatosis, alcohol, NASH, α1-AT deficiency, anabolic steroids
  • Chronic HBV infection is a major RF
    • Higher risk in  HBeAg-positive patients
    • Activated immune cells release reactive oxygen species– cause DNA damage. Creates a cycle of damage and repair
      • Can lead to mistakes during repair – leads to carcinogenesis
  • Aflatoxin (product of fungus aspergillus)

Pathology

  • Macroscopically
    • In absence of cirrhosis – tumour appears as a single mass
    • Presence of cirrhosis – appears as a single nodule or multiple nodules
  • Supplied by the hepatic artery
  • Spreads by invasion into the portal vein
  • Lymph node mets are common
  • Well-diff tumours can resemble hepatocytes – difficult to distinguish from normal liver cytology

Clinical features

  • Patients with underlying cirrhosis
    • Deterioration in liver function
    • Worsening ascites/jaundice/variceal haemorrhage
  • Other common sx
    • Weight loss, anorexia, abdominal pain
    • Hepatomegaly
    • R.hypochondrial mass
    • Abdominal bruit – due to tumour vascularity
    • Hepatic rupture with intra-abdominal bleeding
  • Screening pts at risk of HCC
    • Detected earlier, with increased treatment options

Investigations

  • Serum markers
    • ↑AFP – >400ng/ml (N=<10ng/ml)
  • Imaging
    • USS  – can detect focal liver lesions. Image enhanced by use of US contrast
    • Contrast CT  – shows hypervascular appearance of HCC
  • Liver biopsy – histology confirmation advised in pts with large tumours who don’t have cirrhosis or HBV
  • Screening high risk pts – cirrhosis due to HBV, HCV; haemochromatosis, alcohol, NASH, AAT def

Management

  • Cirrhotic patients – see flowchart. Use CLIP score to assess prognosis.
    • Prognosis depends on tumour size, vascular invasion and LFTs
  • Hepatic resection – treatment of choice for non-cirrhotic patients
  • Liver transplantation
  • Percutaneous therapy – ethanol injection into tumour under USS guidance
  • Radiofrequency ablation (electrode inserted into tumour)
  • Trans-arterial chemo-embolisation – hepatic artery embolisation with Gelfoam and doxorubicin
    • In cirrhotic pts with unresectable HCC and good liver function
  • Chemotherapy
    • Sorafenib – multikinase inhibitor with activity against Raf, VEGF + PDGF

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