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.
Briefly describe the MELD score
Recent scores such as the MELD score have been shown to be a better predictor of mortality. The latest MELD score calculator includes parameters of creatinine, bilirubin, INR, sodium, and the use of dialysis (at least twice per week).
A MELD score can also be used to predict the likelihood of a patient tolerating a potential liver transplant.
Who is involved in the MDT of HCC management?
Treatment for hepatocellular carcinoma is best organised through a multidisciplinary team, including oncologists, radiologists, hepato-biliary surgeons, and specialist nurses.
Briefly describe the surgical management of HCC
Surgical resection and transplantation are the only curative options, but are limited by tumour size and liver function, alongside any co-morbidities present.
What is the role of surgical resection when treating HCC?
The treatment of choice in patients without cirrhosis and with a good baseline health status. Five-year recurrence of HCC post-resection occurs in 50-60% of cases.
What is the role of transplantation in HCC?
Can be considered in patients that fulfil the Milan Criteria:
- One lesion is smaller than 5cm or three lesions are smaller than 3cm
- There are no extrahepatic manifestations
- There is no vascular infiltration
What are the non-surgical management options for HCC?
Image guided ablation and Transarterial Chemoembolisation (TACE).
What is the role of image guided ablation in HCC?
Image-guided ablation is indicated for patients with early HCC (BCLC 0 or A).
Ultrasound probes (or microwave probes) are placed in the tumour mass to induce necrosis.
What is the role of Transarterial Chemoembolisation (TACE) in HCC?
Transarterial Chemoembolisation (TACE) is reserved for patients with BCLC stage B (a large multinodular tumour), whereby high concentrations of chemotherapy drugs are injected directly into the hepatic artery and an embolising agent is then added to induce ischaemia.
Radiological techniques are used to selectively inject and embolise the branches of the hepatic artery supplying the tumour, which preserves the majority of the liver.
What is the prognosis of HCC?
The prognosis of hepatocellular carcinoma depends on the extend of the underlying cirrhosis, as this plays a large role in determining how aggressively the cancer can be treated. Median survival time from diagnosis is around 6 months.
