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Hepatocellular Carcinoma

by | 5 Dec, 2020

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Introduction

Hepatocellular carcinoma (HCC) is the most common liver cancer and the 6th most common cancer worldwide.

Epidemiology

75-90% of HCC patients have cirrhosis. Males are affected more than females.

Risk factors

Cirrhosis, usually alcoholic, is the main cause of HCC in developed countries. In developing countries, the commonest cause is hepatitis B and C viruses.

Pathophysiology

The tumour takes its blood supply from the hepatic artery and tends to spread by invasion into the portal vein and its radicals.

Macroscopically, there are single or multiple nodules throughout the liver, with or without cirrhosis.

Clinical features

The rapid development of the following features in cirrhotic patients suggests HCC:

  • Weight loss
  • Anorexia
  • Jaundice
  • Fever
  • Upper abdominal pain
  • Ascites
  • Variceal haemorrhage

Examination may reveal hepatomegaly with a tender, irregular liver.

Investigations

There are multiple methods of investigating HCC, including:

  • Serum: α-fetoprotein is a marker that is raised in 60% of HCC cases and its levels increase with the size of the tumour. However, it is also raised in active viral hepatitis infection, so ultrasound imaging should be used to confirm the diagnosis.
  • Imaging: ultrasound imaging is the first-line investigation for diagnosing HCC as it can detect lesions as small as 2-3 cm. CT and MRI can be used to further delineate the lesion and stage the condition.
  • Biopsy: Used in patients without cirrhosis or hepatitis B viral infection to confirm the diagnosis of large tumours and exclude metastatic disease. It should be avoided in those eligible for transplantation or resection due to the risk of seeding.

Management

The management of HCC depends on the tumour stage and if cirrhosis is present. Surgical treatment and chemotherapy are the main options for HCC.

Hepatic resection is the treatment of choice for non-cirrhotic patients. 5-year survival is 50%.

Liver transplantation cures the underlying disease and reduces the risk of tumour recurrence. However, it requires long-term immunosuppression. 5-year survival is 75%.

Percutaneous therapies include radiofrequency ablation and percutaneous ethanol injection to produce necrosis in small tumours.

Trans-arterial chemo-embolisation involves embolization of the hepatic artery. It is effective in cirrhotic, non-resectable HCC. 2-year survival is 60%.

Cirrhotic patients can receive sorafenib as a form of chemotherapy. It improves survival from 8 months to 12 months.

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