Hepatocellular Carcinoma

Question 1

Define hepatocellular carcinoma

Answer 1

A primary malignant neoplasm of the liver parenchyma, usually occurring in a cirrhotic liver

Question 2

What are the causes/risk factors of HCC?

Answer 2

• genetic mutations leading to malignant transformation of hepatocytes
• Chronic Viral Hepatitis: HBV and HCV –often via the integration of viral DNA in hepatocyte genomes
• Chronic Liver Disease, especially cirrhosis:
- Autoimmune Hepatitis
- Alcoholic Hepatitis
- NAFLD
• Metabolic Disease:
- Haemochromatosis
- Wilson’s Disease
• Toxins: Aflatoxin –Aspergillus flavus. activation into a carcinogen by the enzyme P450 in the liver

Question 3

What are the symptoms of HCC?

Answer 3

• History of alcoholism, chronic liver disease, cirrhosis or aflatoxin exposure

Symptoms of Malignancy
• Systemic features: Fever, lethargy, anaemia, weight loss and night sweats.
• RUQ Pain

Symptoms of Chronic Liver Disease 
• Jaundice 
• Swelling 
• Abdominal distention and ascites 
• Bruising

Question 4

What are the signs of HCC?

Answer 4

• Cachexia
• Hepatomegaly –nodular or smooth
• Tenderness of the liver may be elicited on deep palpation
• Bruit over the liver may be heard
• Lymphadenopathy
• Signs of chronic liver disease (A-J)

Question 5

What investigations are carried out for HCC?

Answer 5

• FBC - microcytic Anaemia ± Thrombocytopaenia in splenomegaly secondary to portal hypertension, secondary to cirrhosis
• LFTs - usually indicative of the cause. It often shows an obstructive picture, High BR and low Albumin
• U&Es - may have hyponatraemia due to volume overload. Urea can be elevated secondary to hepatorenal syndrome
• Clotting Screen - normal or elevated PT/ INR. Determines the synthetic functional liver capacity
• AFP - alpha Fetoprotein: Elevated. AFP > 400 μg/L has 95% specificity
• Liver USS - poorly defined margins and coarse, irregular internal echoes. Not good for nodules < 1 cm, Duplex USS: May demonstrate vessel invasion.
• CT Scan (Thorax, abdomen and pelvis) - to define structural lesion and spread.
• Liver Biopsy - confirms histology of tumour but there is small risk of tumour seeding along biopsy tract.
• Staging - CXR, CT (thorax, abdomen and pelvis) and radionuclide bone scan.