Hepatobiliary cancers: Hepatocellular carcinoma

Question 1

Definition

Answer 1

Hepatocellular carcinoma (HCC) is the most common primary liver cancer
- Arise from liver parenchyma
- Chronic inflammation predisposes the development of HCC with cirrhosis secondary to chronic infection, or heavy exposure to toxins established risk factors
- HCC initially begins with the development of dysplastic nodules within the liver with ‘high-grade’ nodules more likely to transform into HCC

Question 2

Risk factors

Answer 2

Chronic Hep B/C
Chronic alcohol abuse
PBC
Haematochromatosis
NAFLD
FHx
AIAT def
HIV

Question 3

Metastasis

Answer 3

Lymph nodes
Bones
Lungs
Via haematogenous spread

Question 4

Signs

Answer 4

Ascites: decompensated cirrhosis
Jaundice
Cachexia
Haematemesis: oesophageal bleed
Asterixis: hepatic encephalopathy
Spider naevi
Palmar erythema
Caput medusae

Question 5

Symptoms

Answer 5

Abdominal distention
Early satiety: due to pressure from ascites
Weight loss
RUQ pain
Confusion: hepatic encephalopathy
Bone pain: metastases

Question 6

Diagnosis

Answer 6

FIRST LINE = Abdo USS
LFTs: transaminitis, raised bilirubin and low albumin in chronic liver disease
Clotting screen: can be deranged in chronic liver disease
Alpha fetoprotein (AFP): raised in 60% of patients with HCC
Liver ultrasound: to identify suspicious lesions
GOLD STANDARD: CT

Question 7

Surveillance

Answer 7

six-monthly liver ultrasound and serum AFP measurements

Question 8

Treatment

Answer 8

Early stage 0-A:
- Surgical resection of tumour
- Patients no eligible = liver transplant
= single lesion no greater than 5cm or 3 lesions no greater than 3cm
Intermediate disease: BCLC Stage B
- Trans arterial chemo-embolization (TACE)
- Radiofrequency ablation (RFA)
Advanced disease: Stage C
- Multi tyrosine-kinase inhibitors: sorafenib, Lenvatinib
End stage: Stage D
- Palliative care
Prevention = HBV vaccination