Hepatocellular Carcinoma

 

• Background

  Pathophysiology

  • HCC accounts for 90% of primary hepatobiliary cancers. Most of the others are cholangiocarcinoma.
  • Characterised by aggressive angiogenesis.
  • Most liver tumours are in fact secondary.

  Causes and risk factors

  • NAFLD is overtaking ALD as the commonest cause.
  • Viral hepatitis is a major worldwide cause. HBV vaccination reduces this.
  • Diabetes is an independent risk factor.

• Presentation

  Symptoms of chronic liver disease or acute decompensation, the latter being a bad prognostic sign.

• DDx: Benign liver masses

  Tumours:

  • Haemangioma: commonest. Hyperechoic on US.
  • Focal nodular hyperplasia: 2nd commonest. Affects young to middle age, women > men.
  • Hepatic adenoma: linked to contraceptive pill. Hypodense on CT.
  • Mesenchymal hamartoma: congenital.

  Cysts and abscesses:

  • Simply cyst: congenital.
  • Abscess: can be pyogenic (linked to abdominal infection) or amoebic.
  • Hydatid cyst: Echinococcus infection. Large, thick walled cyst with septa.

• Investigations

  If liver US shows nodules:

  • Nodules <1 cm → repeat US in 6 months.
  • Nodules >1 cm → CT or MRI → biopsy if radiological findings not definitive (but beware seeding).

  Alpha fetoprotein (AFP):

  • Only 50% sensitive, and usually just in later disease.
  • Used in combination with US for HCC monitoring in cirrhosis.

• Management

  • Surgical resection is 1st line for solitary tumours <5 cm in patients with good liver function.
  • Transplantation if unresectable (usually due to poor liver function) and Milan criteria are met: 1 lesion ≤5 cm or 2-3 lesions ≤3 cm, and no extrahepatic or vascular disease.
  • Radiofrequency ablation is an alternative to surgery for localized but unresectable disease. May be curative, especially for small tumours.
  • Trans-arterial chemo-embolization (TACE) is a non-curative treatment for larger tumours >5 cm. Also used as bridge to transplant.
  • Chemotherapy with sorafenib for advanced disease.

• Prognosis

  • 50% detected too late for any treatment.
  • 5 year survival: 10%.