Hepatocellular Carcinoma

Question 1

Define Hepatocellular Carcinoma

Answer 1

Primary cancer arising from hepatocytes in predominantly cirrhotic liver (not always)

Question 2

Aetiology of Hepatocellular Carcinoma

Answer 2

Often from a cirrhotic liver

Development of dysplastic nodules -> high grade dysplasia -> conversion to HCC

Question 3

Risk factors for Hepatocellular Carcinoma

Answer 3

Older age
Chronic Hep B or C
Heavy alcohol consumption
NASH (Diabetes, obesity, metabolic syndrome)
Family history

Question 4

Epidemiology of Hepatocellular Carcinoma

Answer 4

6th most common cancer but 2nd leading cause of cancer-related death
44% of cases attributable to chronic Hep C infection, most cases in Asia

Question 5

Symptoms of Hepatocellular Carcinoma

Answer 5

RUQ pain 
Early satiety (compression of stomach by ascites)
Weight loss
Leg swelling
Jaundice 
Melaena or haematemesis 

(Diarrhoea | Bone pain (mets) | Severe abdominal pain (rupture of tumour into peritoneal cavity))

Question 6

Signs of Hepatocellular Carcinoma on examination

Answer 6

Hepatomegaly 
Abdominal distension 
Leg oedema 
Hepatic encephalopathy 
Cachexia
Jaundice
Splenomegaly 

Chronic liver disease: Palmar erythema, Dupuytren’s contracture, asterixis, bruising, spider naevi, gynaecomastia, fetor hepaticus (parotid swelling, testicular atrophy)

Question 7

What paraneoplastic syndrome have been associated with Hepatocellular Carcinoma

Answer 7

Hypercalcaemia
Erythrocytosis
Watery diarrhoea (due to vasoactive intestinal peptide or gastrin)
Dermatomyositis
Pemphigus foliaceus
Acanthosis nigricans

Question 8

Investigations for Hepatocellular Carcinoma

Answer 8

Radiological diagnosis (liver biopsy for lesions >1cm or imaging studies are not typical in high risk patients)

FBC: Microcytic anaemia ± thrombocytopenia
Metabolic panel: hyponatraemia, elevated Urea
LFTs: elevated aminotransferases, alk phos, bilirubin, low albumin
PT/INR: normal or prolonged
Viral hepatitis panel: ?Hep B/C
Tumour markers: Alpha fetoprotein

USS liver: Poorly defined margins and coarse, irregular internal echoes
Contrast CT abdomen: Typical hypervascular pattern
Contrast MRI: High intensity (T2) or Low-intensity (T1)
CT chest: ?mets
Bone scan: ?mets

Liver biopsy: Well-differentiated to poorly differentiated hepatocytes with large multinucleated giant cells having central necrosis (not required in most)