Liver Cancer Flashcards
What is the main liver cancer?
Hepatocellular carcinoma.
Briefly describe the pathophysiology of hepatocellular carcinoma (HCC)
HCC arises as a result of a chronic inflammatory process affecting the liver. The aetiology of the inflammation varies, yet worldwide it is most commonly due to viral hepatitis. Other common causes for HCC are chronic alcoholism, hereditary haemochromatosis, primary biliary cirrhosis (PBC), and aflatoxin (a toxic fungal metabolite that can be found on cereals and nuts).
How common is HCC?
Hepatocellular carcinoma is the sixth most common cancer worldwide and the third leading cause of cancer death.
What are the risk factors for HCC?
- Viral hepatitis
- Hepatitis B virus and Hepatitis C virus are the most common causative organisms
- High alcohol intake
- Smoking
- Advanced age (>70yrs)
- Aflatoxin exposure
- Family history of liver disease
Briefly describe the prevalence of HCC and hepatitis worldwide
In developing countries, viral hepatitis accounts for around 90% of HCC cases. HCC is found more commonly among Asian individuals, secondary to childhood infections with hepatitis B, however this is declining due to current vaccination programmes. In the UK, only 16% of cases are thought to arise secondary to hepatitis.
What are the clinical features of HCC?
The main presenting symptoms of hepatocellular carcinoma are that of liver cirrhosis. This may include vague, non-specific symptoms, such as fatigue, fever, weight loss and lethargy.
A dull ache in the right upper abdomen is uncommon, yet when present is characteristic of hepatocellular carcinoma, and should raise suspicion in patients with known cirrhosis. Advanced disease may present with features of liver failure (such as worsening ascites or jaundice)
On examination, an irregular, enlarged, craggy and tender liver is highly suggestive of liver malignancy.
Briefly describe what is shown in the picture
Ascites, an indicator of late stage liver disease.
What investigations should be ordered for HCC?
Note: laboratory investigations
A patient with suspected liver cancer should have initial liver function tests (ALP, ALT, AST*, bilirubin), which may be deranged. Other routine bloods should be taken, which may show low platelets or prolonged clotting associated with liver failure.
An alpha fetoprotein (AFP) level should be measured in all suspected cases, as it is raised in 70% of cases. It is also used to monitor treatment response and recurrence.
What protein is used to monitor treatment response and recurrence in HCC?
Alpha fetoprotein (AFP) level.
How does AST:ALT ratio differ between alcoholic liver disease and viral hepatitis?
AST:ALT ratio >2, likely alcoholic liver disease.
AST:ALT around 1, likely viral hepatitis.
What investigations should be ordered for HCC?
Note: imaging
Ultrasound is the initial imaging modality of choice. If a mass of >2cm is found with a raised AFP, this is virtually diagnostic. This may then be followed by a staging CT scan for further evaluation.
Patients with rising AFP and suggestive US nodules can also undergo MRI liver scanning for further assessment.
If the diagnosis is still in doubt, a biopsy or percutaneous fine-needle aspiration may be performed to confirm, yet is last-resort due to difficulties commonly in this setting of active ascites and/or deranged clotting, and the risks associated with biopsy and tumour-seeding.
What are the characteristic findings of HCC on MRI scanning and contrast CT angiography?
MRI scanning and contrast CT angiography may demonstrate a mass with arterial hypervascularisation- a characteristic feature of HCC.
What staging system is used for HCC?
The Barcelona Clinic Liver Cancer staging system (BCLC) is the most accepted staging system for HCC. It takes into account the tumour stage, liver function, physical status and cancer related symptoms to provide guidance on what treatment is most suitable.
What are the risk assessment tools for HCC? And what is their function?
Risk assessment tools, such as the Child-Pugh and MELD scores, can be used to assess the risk of mortality from cirrhosis and to predict potential effectiveness from potential treatment options.
Briefly describe the Child-Pugh score
The well-known and widely used Child-Pugh score uses parameters of serum bilirubin, albumin, INR, degree of ascites, and evidence of encephalopathy to calculate prognosis of patients with liver cirrhosis.
