Hepatocellular carcinoma

Question 1

A 58 year old man presents with a two month history of right upper quadrant discomfort and weight loss. His liver function tests are normal but a CT scan of his abdomen shows a solitary mass in the liver. How would you assess him?

Answer 1

Impression
Given solitary lung mass on CT and systemic features of malignancy with weight loss, I am concerned about HCC as my provisional diagnosis.

Would want to consider other differential causes of a liver mass;

• Malignant: mets from other primary, cholangiocarcinoma,
• Benign: hepatic cyst, hepatic adenoma

Question 2

HCC - History

Answer 2

History

sx: pain, discomfort, jaundice, changes in urine/bowels (colour), pruritus, abdominal distension, haemorrhoids,
- sx of liver failure: easy bruising,
- systemic features of malignancy; weight loss, night sweats, fevers
- sx of mets: bone pain, neurology, respiratory changes
- RISKS: age, smoking, fam history, liver cirrhosis, other liver pathology (Wilsons, haemachromatosis, etc)
- PMHx, Medications/allergies,
- SNAP

Question 3

HCC - Examination

Answer 3

Examination

• General appearance: jaundice, cachexia, bruising, scleral icterus
• Vital signs: temperature
• abdominal examination: shifting dullness, peripheral stigmata, jaundice, tenderness, organomegaly, DRE for CRC
• systems review: bone pain, neurology

Question 4

HCC - Investigations

Answer 4

Investigations

• bedside: vital signs
• bloods: FBC, LFT, Coags, CMP (paraneoplastic syndrome), tumour markers (AFP for HCC)
• imaging: US with elastography, triphasic CT, staging imaging (CT CAP for mets)
• Childs-Pugh score to characterise degree of liver failure

If there is diagnostic uncertainty, can utilise FNA/surgical excision and histopathological analysis for ultimate diagnosis.

Question 5

HCC - Management

Answer 5

Management
- requires MDT approach, would involve gastro/hepatology + oncology + gen surg for management planning.

Definitive:

• surgical resection +/- chemotherapy +/- other systemic therapy (sorafenib - multikinase inhibitor)
• liver transplantation

Lost of liver tumours are unresectable, and so there area number of de-bulking management options available:

• ablation
• embolisation
• percutaneous injection therapy
• external beam radiation therapy