Hepatocellular Carcinoma Flashcards
what is hepatocellular carcinoma (HCC)?
a primary cancer arising from hepatocytes in predominantly cirrhotic liver
what are the causes of HCC?
- ArLD
- NAFLD
- viral hepatitis
- autoimmune (e.g. PBC, PSC, AIH)
- haemochromatosis
- wilson’s disease
- alpha-1 antitrypsin deficiency
- drug-induced hepatotoxicity
aside from liver cirrhosis, what are the risk factors for HCC?
- aflatoxins
- parasitic (e.g. schistosomiasis)
- alcohol
- smoking
- obesity
- immunosuppression
- genetic
- chemical (e.g. vinyl chloride)
what are the symptoms of HCC?
- pallor
- cachexia
- signs of CLD (e.g. spider naevi, caput-medusae)
- hepatomegaly
- splenomegaly
- signs of decompensated cirrhosis (e.g. ascites, encephalopathy)
what may be heard on auscultation of a patient with HCC?
a systolic liver bruit may be audible over the tumour
what symptoms may occur in HCC as the tumour grows?
- upper abdominal pain
- indigestion
- early satiety
what is a complication of HCC that may cause shock?
a tumour can spontaneously rupture, causing intraperitoneal haemorrhage and presentation with an acute abdomen or shock
what complications can occur if HCC invades vascular structures?
- portal hypertension with variceal bleeding + ascites
- IVC thrombosis with risk of pulmonary embolism + sudden death
what tests are included in a ‘liver screen’ for patients with new onset jaundice or liver failure?
- GGT +/- ethanol
- lipid profile
- hepatitis A-E, CMV + EBV
- HIV
- autoantibodies
- ferritin + iron studies
- caeruloplasmin
- alpha-1 antitrypsin
what is the significance of alpha-fetoprotein (AFP) in HCC?
- AFP is a fetal glycoprotein antigen raised in 80% of HCCs
- > 200 ng/ml is highly suggestive of HCC + >400 ng/ml is considered diagnostic
what imaging may be used to diagnose HCC?
- US +/- US-guided biopsy
- CT abdomen +/- CT-guided biopsy
- MRI
why should caution be taken when deciding to biopsy liver tumours?
cancer cells can seed along the biopsy tract, causing local recurrence
what are the three accepted diagnostic criteria for HCC?
- cytohistological diagnosis from a biopsy
- radiological diagnosis with two imaging techniques (e.g. US/CT/MRI) showing a focal lesion >2cm with arterial hypervascularisation
- combined diagnosis using AFP >200 ng/ml + imaging as above
what system is used to indicate the stage of HCC?
the barcelona clinic liver cancer (BCLC) system, which is a composite of:
- TNM
- child-pugh score
- WHO performance status
what are minimally invasive localised therapies used for in HCC treatment?
treat inoperable tumours or downstage borderline unresectable tumours to make surgery possible
which minimally invasive localised therapies are used in HCC treatment?
- ethanol injection
- radiofrequency or microwave ablation
- cryotherapy
- acetic acid
- laser
what is transhepatic arterial chemoembolisation (TACE)?
- uses gelatin or cellulose fragments to block off the blood supply to the tumour, then delivers high-concentration localised chemotherapy to the area
- for large, multifocal tumours with good underlying liver function and no metastases
what is selective internal radiotherapy treatment (SIRT)?
uses radioactive yttrium beads to block off the blood supply to the tumour and deliver a dose of targeted radiotherapy to the area within a 4mm radius around them
what is irreversible electroporation (IRE)?
a non-thermal cell destruction technique which uses the direct application of short bursts of high-voltage electric current to destroy cancer cells
what size of tumour can be removed by resection of the liver?
solitary tumours <3 cm in diameter
what procedures may be performed to resect the liver?
- segmental/wedge resection
- right/left hepatectomy
- caudate resection
what are the milan criteria for liver transplantation eligibility?
- 1 lesion <5 cm or up to 3 lesions <3 cm
- no metastates
- no macroscopic vessel invasion on CT/MRI
how are patients who undergo surgery for HCC monitored for recurrence?
monitoring of AFP levels + imaging every 6-12 months
