Hepatocellular Carcinoma

Question 1

Name the lobes of the liver.

Answer 1

The liver has four lobes: a large right lobe, a smaller left lobe, and posteromedial caudate and quadrate lobes, which are functionally part of the right lobe

Question 2

The liver is surrounded by a tough fibrous capsule known as what?

Answer 2

Glisson’s capsule

Question 3

Name the peritoneal folds or “ligaments” attaching the liver to the diaphragm and the abdominal walls.

Answer 3

These include the falciform ligament dividing the right and left lobes anteriorly, right and left coronary ligaments superiorly and right and left triangular ligaments posteriorly.

Question 4

What anatomically connects the the liver to the stomach and the first part of the duodenum?

Answer 4

The lesser omentum is another double-layered sheet of peritoneum which extends downwards

Question 5

Where is the portal triad contained?

Answer 5

Its lower free edge is called the hepatoduodenal ligament and contains the portal triad, hepatic nerve plexus and lymphatics.

Question 6

Describe the oxygenated blood supply to the liver.

Answer 6

25% of its blood supply is derived from the hepatic artery, a branch of the coeliac trunk, which supplies oxygenated blood to the liver.
the other 75% comes from the portal vein, which is formed by the union of the superior mesenteric and splenic veins behind the neck of the pancreas. This drains nutrient-rich blood from the stomach, small intestines and most of the large intestine into the liver.

Question 7

Describe the venous blood drainage of the liver.

Answer 7

venous blood from the liver drains directly into the inferior vena cava via three hepatic veins

Question 8

What does the oral triad consist of?

Answer 8

hepatic artery, portal vein and common bile duct

Question 9

Describe the anatomical location of the hepatic artery, portal vein and common bile duct relatively to one another.

Answer 9

The portal vein is the most posterior structure, and the bile duct is the most anterior, making it easy to access surgically. The artery lies between the two.

Question 10

Name the 5 functions of the liver.

Answer 10

filtration, metabolic, storage, synthetic and detoxification functions

Question 11

Describe the filtration role of the liver.

Answer 11

it receives and filters massive amounts of venous blood from the intestines, and any contaminants are removed by special phagocytes called Kupffer cells which line hepatic sinusoids.

Question 12

Describe the metabolic role of the liver.

Answer 12

it processes and metabolises substances absorbed by the digestive system, and has vital roles in the metabolism of carbohydrates, fats and amino acids. It also conjugates bilirubin, a red blood cell breakdown product.

Question 13

Describe the storage role of the liver.

Answer 13

it stores substances such as glycogen, iron, copper, and vitamins A, B12, D and K.

Question 14

Describe the detoxification role of the liver.

Answer 14

it breaks down hormones such as insulin and sex hormones, and converts toxic ammonia into urea, which is excreted by the kidneys. It also has a vital role in drug metabolism.

Question 15

Describe the synthetic role of the liver.

Answer 15

it produces bile and secretes it into the gallbladder and duodenum. Bile neutralises stomach acid, emulsifies dietary fats to facilitate the absorption of cholesterol, triglycerides and fat-soluble vitamins, and allows excretion of excess bilirubin and cholesterol. The liver also produces other essential substances such as clotting factors, albumin, thrombopoietin and IGF-1.

Question 16

Name some risk factors of developing hepatocellular carcinoma.

Answer 16

alcoholic liver disease (ALD) – 5x risk
non-alcoholic fatty liver disease (NAFLD) – 4x risk
viral hepatitis: hepatitis B or hepatitis C infection – can increase risk up to 60x, responsible for 85% of cases worldwide
autoimmune liver diseases such as primary biliary cirrhosis (PBC – 6x risk), primary sclerosing cholangitis (PSC – mainly increases the risk of cholangiocarcinoma), and autoimmune hepatitis (AIH – much lower risk than PBC)
haemochromatosis – some sources say it leads to >100x risk
Wilson’s disease
alpha-1 antitrypsin deficiency
cystic fibrosis (CF) liver disease
porphyria cutanea tarda, hereditary tyrosinaemia and other rare metabolic disorders
drug-induced hepatotoxicity (e.g. paracetamol overdose, chemotherapy, antibiotics)

Question 17

Describe how a patient with hepatocellular carcinoma would present.

Answer 17

patients with underlying liver disease often present with features of decompensated cirrhosis such as ascites, spontaneous bacterial peritonitis (SBP), jaundice, variceal bleeding, encephalopathy or hepatorenal syndrome
as the tumour grows, patients may develop upper abdominal pain, indigestion or early satiety

Question 18

Describe the positive findings on examination of a patient with hepatocellular carcinoma.

Answer 18

general examination may reveal pallor and weight loss/cachexia, or signs of chronic liver disease such as clubbing, palmar erythema, leuconychia, bruising, spider naevi, gynaecomastia, caput-medusae and peripheral oedema
there may be signs of decompensation such as ascites, peritonitis, sepsis, jaundice, haematemesis/malaena and hepatic encephalopathy with confusion and “liver flap”
abdominal examination may reveal hepatomegaly, which can be smooth or hard and irregular, abdominal distension and splenomegaly due to portal hypertension
a systolic liver bruit may be audible over the tumour

Question 19

Name a tumour marker of hepatocellular carcinoma

Answer 19

AFP

Question 20

Describe the 3 diagnostic criteria for hepatocellular carcinoma.

Answer 20

1. cytohistological diagnosis from a biopsy of the lesion
2. radiological diagnosis using 2 imaging techniques (USS/CT/MRI) showing a focal lesion >2cm in diameter with arterial hypervascularisation
3. combined diagnosis usingAFP level >200ng/ml and imaging criteria as described above.

Question 21

What staging system is used in hepatocellular carcinoma?

Answer 21

TNM (tumour nodes metastasis) system.

Question 22

Describe the management of HCC.

Answer 22

1. Conservative management may be considered best in some cases, for example in elderly frail patients or those with decompensated end-stage cirrhosis who are unfit for active treatment. This involves “watchful waiting” with monitoring of AFP levels and the patient’s clinical condition.
2. Medical therapies for hepatocellular carcinoma are fairly limited. External beam radiotherapy is rarely used, as liver cells are extremely sensitive to its toxic effects, meaning the whole liver could die. Systemic chemotherapy is usually futile as HCCs are chemoresistant tumours.
3. Liver resection

Question 23

When is liver transplantation an option?

Answer 23

When a patient meets the Milan criteria.

Question 24

What is the Milan criteria?

Answer 24

1 lesion <5cm in size or up to 3 lesions <3cm in size
no metastatic disease
no macroscopic vessel invasion on CT/MRI

Question 25

Name some prevention strategies for HCC.

Answer 25

education and awareness schemes to encourage a healthy alcohol intake, smoking cessation and the reduction of lifestyle factors such as obesity and poor diet which can lead to NAFLD
hepatitis B vaccination for healthcare workers and other at-risk individuals
needle exchange facilities and methadone programmes for IV drug users
use of sterilised blood products for transfusion
screening and decontamination of grains, nuts and other foods to neutralise aflatoxins