Hepatocellular carcinoma

Question 1

What is hepatocellular carcinoma?

Answer 1

AKA Hepatoma is a cancer arising from hepatocytes in predominantly cirrhotic liver. However, not all patients have cirrhosis beforehand, especially patients with chronic Hepatitis B.

Question 2

What are the risk factors of hepatocellular carcinoma? (x8)

Answer 2

• Risk factors for cirrhosis: Chronic hepatitis B and C infections, heavy alcohol consumption
• Metabolic syndrome: combination of diabetes, hypertension and obesity. Diabetes mellitus is synergistic as insulin resistance can lead to non-alcoholic steatohepatitis
• Family history
• Conditions such as primary biliary cholangitis, primary sclerosing cholangitis, haemochromatosis, alpha-1 antitrypsin deficiency
• !!! Some carcinogens such as AFLATOXIN (in certain moulds)
• Smoking
• Oral contraceptive pill
• Older age

Question 3

What is the epidemiology of hepatocellular carcinoma: Prevalence? Where? Gender?

Answer 3

6th most common worldwide cancer. Majority of cases in Asia and Sub-Saharan Africa because of increased incidence of HBV. Higher incidence in men.

Question 4

What are the symptoms of hepatocellular carcinoma? (x3)

Answer 4

• Symptoms of malignancy: malaise, weight loss, loss of appetite
• Symptoms of chronic liver disease: RUQ pain, abdominal distension, jaundice
• History of carcinogen exposure: alcohol, Hepatitis B or C, aflatoxins

Question 5

What are the signs of hepatocellular carcinoma? (x4)

Answer 5

• Signs of malignancy: cachexia, lymphadenopathy
• Signs of chronic liver disease: jaundice, ascites, spider naevi, palmar erythema
• Hepatomegaly
• May be bruit heard over the liver

Question 6

What are the blood investigations for hepatocellular carcinoma? (x4 points)

Answer 6

• Alpha Fetoprotein (AFP) increased – tumour marker with high sensitivity
• Vitamin B12-binding protein is a marker of fibrolamellar hepatocellular carcinoma
• LFTs have poor specificity and sensitivity but may show biliary obstruction.
• FBC: low MCV and Hb from variceal bleeding. Low platelets if portal hypertension.

Question 7

What are the other investigations for hepatocellular carcinoma? (x5) Definitive?

Answer 7

• USS: only sensitive for tumours over 1 cm
• CT: to define structural lesions and extent of spread (thorax, abdomen, pelvis)
• Liver biopsy: confirms histology of tumour
• Duplex scan of liver: monitor for large vessel invasion such as hepatic or portal veins
• Hepatic angiography

Question 8

Why is liver biopsy risky in hepatocellular carcinoma?

Answer 8

Tumour may seed along biopsy tract.

Question 9

What investigations are employed for hepatocellular carcinoma staging? (x3)

Answer 9

CR, CT, radionuclide bone scan.