Hepatocellular Carcinoma

Question 1

Define hepatocellular carcinoma.

Answer 1

Primary malignancy of hepatocytes, usually occurring in a cirrhotic liver.

Question 2

What are the risk factors for hepatocellular carcinoma?

Answer 2

• Cirrhosis
• HBV, HCV
• Alcohol use heavy
• Diabetes, Obesity → NAFLD
• FH of liver cancer
• Aflatoxins
• Haemochromatosis
• Cigarette smoking
• Alpha-1 antitrypsin deficiency
• Porphyria cutanea tarda
• PBC, PSC
• Androgenic steroids
• Oral contraceptive
• Male sex

Question 3

What is the pathophysiology of hepatocellular carcinoma?

Answer 3

Chronic inflammation + cirrhosis play key parts. Acquiring HBV early in life → longer duration of disease and chronic inflammation/cirrhosis

HCC usually begins with nodules of high or low grade dysplasia and 33% of high-grade nodules develop into HCC within 2 years and 80% within 5 years.

Question 4

How common is HCC?

Answer 4

• 6th most common malignancy worldwide
• Varies accord to HBV/HCV prevalence
• 44% due to HBV

Question 5

How does HCC present?

Answer 5

Symptoms of malignancy - malaise, weight loss, loss of appetite

Symptoms of chronic liver disease -abdominal distension, jaundice

History of carcinogen exposure - high alcohol intake, HBV, HCV, aflatoxins.

Question 6

What investigations would you do for hepatocellular carcinoma?

Answer 6

1st line:

• USS - not sensitive if tumour <1cm
• AFP - high sensitivity, high in 60%

Blood:

• Vitamin B12-binding protein is a marker of fibrolamelalr hepatocellular carcinoma
• LFT has poor specificity and sensitivity but may show biliary obstruction
• Coagulation screen - for extent of liver disease

Imaging:

• CT (thorax, abdo, pelvis) - defines structural lesion and spread

Invasive:

• Liver biopsy - core-needle biopsy; confirms histology of tumour but there is small risk of tumour seeding along biopsy tract

Other:

• Staging - CXR, CT (TAP), radionucleotide bone scan
• Screening - AFP and abdominal ultrasound in at-risk individuals

Question 7

What is the management of HCC?

Answer 7

Depends on Barcelona Clinic Liver Cancer (BCLC) staging

1. Resection
2. Thermal ablation,
3. Transplant
4. Transarterial chemo-embolisation (TACE) - not curative
5. Percutaneous ablation - ethanol injection or radiofrequency ablation
6. Advanced disease: atezolizumab/bevacizumab, TK inhibitors

Question 8

What are the complications of HCC?

Answer 8

• Biliary obstruction
• Cachexia
• Hypoglycaemia (non-diabetic) - due to IGF-1 production
• Hepatic failure
• Watery diarrhoea
• Hypercalcaemia
• Intraperitoneal bleeding due to tumour rupture

Question 9

What is the prognosis with HCC?

Answer 9

5yr survival is 20%

HCC is very aggressive and clinical course depends on stage at diagnosis

Intermediate stage HCC treated with TACE only has 19-20months survival