Hepatocellular Carcinoma (HCC)

Notes
  • It is also known as hepatoma.
  • HCC is the 6th most common cancer globally and the 3rd cause of cancer-related deaths
  • The cause and risk factors for HCC include: cirrhosis (mainly as a result of chronic alcoholism), aflatoxins and hepatitis B and C viral infections and to a lesser extent environmental exposure, autoimmune conditions or hereditary conditions
  • Statistics: The 5-year overall survival rate for the liver cancer patients of any stage -15%.
  1. Staging of HCC

STAGE

STAGE GROUPING

COMMENTS

1

T1

N0

M0

♦T1-A single tumor that hasn't grown into blood vessels

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

1I

T2

N0

M0

 

 

 

 

♦T2- Either a single tumor that has grown into blood vessels, OR more than one tumor but no tumor is larger than 5 cm

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

IIIA

T3a

N0

M0

 

 

 

 

 

♦ T3a - More than one tumor, with at least one tumor larger than 5 cm across

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

IIIB

T3b

N0

M0

 

♦At least one tumor that has grown into a major branch of a large vein of the liver

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

IIIC

T4

N0

M0

 

♦T4-The tumor has grown into a nearby organ (apart from gall bladder), OR the tumor is growing into the thin layer of tissue covering the liver

♦N0 -The tumor has not spread to the lymph node

♦M0 - The tumor has not metastasized

IVA

Any T

N1

M0

♦Any T

♦N1-The cancer has spread to the regional lymph nodes

♦M0 - The tumor has not metastasized

IVB

Any T

Any N

M1

♦Any T

♦Any N

♦M1 -Distant metastasis

 

Risk assessment by Child-plugh

Measure

1 point

2 points

3 point

Total bilirubin (µMol/L)

< 34

35-50

>50

Serum albulin (gm/L)

>35

28-35

< 28

PT INR

< 1.7

1.7 – 2.3

>2.3

Ascite

None

Moderate

Moderate  to severe

Hepatic encephalopathy

None

Grade

I-II

(Respond to treatment

Grade

III-IV

(Refractory to Treatment)

Symptoms
  • Abdominal pain
  • Bloody ascites
  • Fever
  • Loss of appetite
  • Jaundice
  • Hepatic friction rub
  • Peritonitis
  • Right upper quadrant mass
  • Shock
  • Weight loss
  • Encephalopathy
  • Splenomegaly
  • Hepatomegaly
  • Erythrocytosis
  • Hypercalcemia
  • Hyperlipidemia
  • Hypoglycemia
Diagnosis
  • Alpha-fetoprotein (AFP) measurement
  • CT
  • Ultrasonography
  • MRI
  • Biopsy and staging
Differential
  • Cholangiocarcinoma
  • Fibrolamellar hepatocellular carcinoma
  • Focal nodular hyperplasia
  • Haemangioma of liver
  • Hepatic adenoma
  • Hepatic cystEpithelioid haemangioendothelioma
  • Liver abscess
  • Metastatic liver disease
Prevention
  • Immunization against Hepatitis B virus
  • Treatment of hepatitis B and C
  • Measures to reduce exposure to aflatoxins
  • Safe injection practice
Management
  • Surgical resection;

♦Exclude extensive cirrhosis

♦Ensure that the remaining sections are adequate to carry out liver functions.

  • Liver transplantation;

♦This is normally the best option for treatment of 5% of HCC cases.

  • Radiofrequency ablation (RFA);

♦Particularly useful for small nodules that are less than 2cm

♦The total number of nodules should not be more than 5 and the total size should not be more than 5cm

  • Percutaneous ethanol injection (PEI);

See terms under RFA

  • External-beam radiation therapy (EBRT).
  • Intra-arterial treatment delivers a therapy that kills the tumor directly via the hepatic artery hence reducing adverse side effects of the administered drug.
  • Chemotherapy that include: doxorubicin and 5-fluorouracil (5-FU) that are particularly useful in the Low-resource setting where most of the HCCs are discovered late. Other drugs that can be used are: cisplatin, capacitabine, interferon alpha, oxaliplatin and gemcitabine. Where resurces are available Sorafenib is a drug of choice.
  • Embolizing material such as coils, gelatin sponge particles. Transarterial chemoembolization (TACE) can be administered in multi-nodular BCLC stage B with effective liver function.
  • Radioactive particles.
  • Treatment of the complications of cirrhosis;

♦Ascites - diuretics and paracentesis

♦Encephalopathy - lactulose

♦Variceal bleeding - sclerosis or banding ♦Bacterial peritonitis- antibiotics

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