Hepatocellular Carcinoma Flashcards
Define hepatocellular carcinoma.
Primary malignancy of hepatocytes, usually occurring in a cirrhotic liver.
What are the risk factors for hepatocellular carcinoma?
- Cirrhosis
- HBV, HCV
- Alcohol use heavy
- Diabetes, Obesity → NAFLD
- FH of liver cancer
- Aflatoxins
- Haemochromatosis
- Cigarette smoking
- Alpha-1 antitrypsin deficiency
- Porphyria cutanea tarda
- PBC, PSC
- Androgenic steroids
- Oral contraceptive
- Male sex
What is the pathophysiology of hepatocellular carcinoma?
Chronic inflammation + cirrhosis play key parts. Acquiring HBV early in life → longer duration of disease and chronic inflammation/cirrhosis
HCC usually begins with nodules of high or low grade dysplasia and 33% of high-grade nodules develop into HCC within 2 years and 80% within 5 years.
How common is HCC?
- 6th most common malignancy worldwide
- Varies accord to HBV/HCV prevalence
- 44% due to HBV
How does HCC present?
Symptoms of malignancy - malaise, weight loss, loss of appetite
Symptoms of chronic liver disease -abdominal distension, jaundice
History of carcinogen exposure - high alcohol intake, HBV, HCV, aflatoxins.
What investigations would you do for hepatocellular carcinoma?
1st line:
- USS - not sensitive if tumour <1cm
- AFP - high sensitivity, high in 60%
Blood:
- Vitamin B12-binding protein is a marker of fibrolamelalr hepatocellular carcinoma
- LFT has poor specificity and sensitivity but may show biliary obstruction
- Coagulation screen - for extent of liver disease
Imaging:
- CT (thorax, abdo, pelvis) - defines structural lesion and spread
Invasive:
- Liver biopsy - core-needle biopsy; confirms histology of tumour but there is small risk of tumour seeding along biopsy tract
Other:
- Staging - CXR, CT (TAP), radionucleotide bone scan
- Screening - AFP and abdominal ultrasound in at-risk individuals
What is the management of HCC?
Depends on Barcelona Clinic Liver Cancer (BCLC) staging
- Resection
- Thermal ablation,
- Transplant
- Transarterial chemo-embolisation (TACE) - not curative
- Percutaneous ablation - ethanol injection or radiofrequency ablation
- Advanced disease: atezolizumab/bevacizumab, TK inhibitors
What are the complications of HCC?
- Biliary obstruction
- Cachexia
- Hypoglycaemia (non-diabetic) - due to IGF-1 production
- Hepatic failure
- Watery diarrhoea
- Hypercalcaemia
- Intraperitoneal bleeding due to tumour rupture
What is the prognosis with HCC?
5yr survival is 20%
HCC is very aggressive and clinical course depends on stage at diagnosis
Intermediate stage HCC treated with TACE only has 19-20months survival