Hepatocellular Carcinoma

Question 1

Define hepatocellular carcinoma

Answer 1

Primary cancer arising from hepatocytes in predominantly cirrhotic liver

Question 2

Aetiology of hepatocellular carcinoma

Answer 2

Multifactorial, often from a cirrhotic liver

Dysplastic nodules → high grade dysplasia → conversion to HCC

Question 3

Risk factors for hepatocelllular carcinoma

Answer 3

Older age
Chronic Hepatitis B and C
Heavy alcohol consumption → cirrhosis
NAFLD
- Diabetes Mellitus
- Obesity
- Metabolic syndrome
Family history

Paraneoplastic syndromes have been associated with HCC, including hypercalcaemia, erythrocytosis, watery diarrhoea (due to vasoactive intestinal peptide or gastrin), dermatomyositis, pemphigus foliaceus, and acanthosis nigricans.

Question 4

Epidemiology of hepatocellular carcinoma

Answer 4

6th most common cause of cancer
Second leading cause of cancer-related death

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
Liver disease:
- Asterixis
- Spider naevi
- Palmar erythema
- Periumbilical collateral veins
- Fetor hepaticus

Question 7

Investigations for hepatocellular carcinoma

Answer 7

FBC: Microcytic anaemia (esp. in variceal bleeding) ± thrombocytopenia (portal HTN)
U&Es: hyponatraemia (volume overload), high urea (renal failure)
LFTs: raised AST/ALT, raised ALP, raised bilirubin, low albumin
Clotting: ?liver function
Viral hep serology: ?hep B/C
Alpha-fetoprotein: tumour marker for HCC

US liver: Poorly defined margins and coarse, irregular internal echoe
Contrast CT/MRI abdomen: Typical hypervascular pattern
CT chest: Enhancing nodule or mass in the lungs is suggestive of metastatic lesion from HCC
Bone scan: “hot spots”
Liver biopsy: Well-differentiated to poorly differentiated hepatocytes with large multinucleated giant cells having central necrosis

Question 8

Management for hepatocellular carcinoma

Answer 8

Depends on stage (BCLC)

Options:
Surgical resection
Liver transplantation
transarterial chemo-embolisation (TACE) and/or radiofrequency ablation (RFA) bridging therapy
Percutaneous ethanol injection
Sorafenic

BCLC Stage D: end-stage disease → Hospice care +/- Liver transplantation

Question 9

Complications of hepatocellular carcinoma

Answer 9

Obstructive jaundice (biliary obstruction)
Cachexia
Hypoglycaemia (from IGF-2 production)
Hepatic failure → varices, encephalopathy, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome
Watery diarrhoea (immunoreactivity of vasoactive intestinal polypeptide or gastrin)
Hypercalcaemia (bone mets or PTHr)
Tumour rupture → intraperitoneal bleed

Question 10

Prognosis for hepatocellular carcinoma

Answer 10

5 year survival for symptomatic hepatocellular carcinoma 0-10%
Transplant is the main course of therapy
After transplant, 5 year survival is 70% and <15% recurrence