Updated: 1/30/2021

Hepatocellular Carcinoma

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Snapshot
  • A 58-year-old man presents to his primary care physician for a routine follow-up. He was diagnosed with hepatitis C infection, complicated by hepatic cirrhosis. He reports that he currently feels well with no acute complaints. Abdominal ultrasound demonstrates a focal hepatic lesion. He underwent a multi-phase contrasted abdominal CT scan, which demonstrated an enhancing focal hepatic mass during the arterial phase with rapid washout during the portal venous phase.
Introduction
  • Overview
    • primary malignancy affecting hepatocytes
    • may result in a paraneoplastic syndrome
      • hypoglycemia
      • erythrocytosis
      • hypercalcemia
      • severe diarrhea
  • Epidemiology
    • risk factors
      • cirrhosis (80-90% of cases)
      • chronic hepatitis B infection
      • chronic hepatitis C infection 
      • aflatoxin, produced by Aspergillus species
      • alcohol use
      • hereditary hemochromatosis
      • α1 antitrypsin deficiency
      • obesity
      • diabetes mellitus
      • non-alcoholic fatty liver disease
  • Pathophysiology
    • β-catenin activation and inhibition of p53 play a role in the development of hepatocellular carcinoma
Presentation
  • Symptoms/physical exam 
    • right upper quadrant pain
    • weight loss
    • ascites
    • obstructive jaundice
    • however, patients can be asymptomatic and be incidentally found to have HCC due to routine screening in patients with cirrhosis
Imaging
  • Abdominal ultrasound
    • indication
      • monitoring lesions < 1 cm every 3-6 months for up to 2 years 
      • can be used as a screening imaging study in patients with cirrhosis
        • if there are findings concerning for HCC, then confirmatory imaging (or possibly biopsy) is needed
    • findings
      • masses with poorly defined margins
      • irregular echoes
  • Multi-phase contrasted CT abdomen
    • indication
      • a confirmatory imaging study
    • findings
      • typically a focal nodule with early enhancement (in the arterial phase) and rapid contrast washout (in the portal venous phase)
  • Multi-phase contrasted MRI abdomen
    • indication
      • a confirmatory imaging study
    • findings
      • enhancement in the arterial phase with rapid contrast washout
Studies
  • Serum labs
    • α-fetoprotein (AFP)
      • if elevated > 400-500 ng/mL
        • may be suggestive of HCC
        • may be seen in patients with active liver disease (e.g., HCV or HBV infection)
      • a normal value does not exclude HCC
Differential
  • Hepatic adenoma
    • differentiating factor
      • benign liver tumor seen in patients with prolonged contraception use, anabolic steroid use, glycogen storage disorders, and pregnancy
Treatment
  • Surgical
    • resection
      • indication
        • recommended if the lesion is resectable and the patient has good performance status
    • liver transplantation
      • indication
        • recommended based on the patient's performance status and that the tumor is unresectable
    • liver-directed therapies
      • indication
        • in patients with local disease who are not candidates for resection or liver transplantation
          • may potentially down-stage the tumor, enabling the possibility of transplantation or resection
      • modalities
        • radioablation
          • delivers local radiofrequency thermal energy
        • transarterial chemoembolization (TACE)
          • delivers high-dose chemotherapy (e.g., cisplatin and doxorubicin) to local areas in the liver 
            • therefore, this decreases the risk of developing systemic toxicities
Complications
  • Hepatic failure
  • Hemoperitoneum
  • Portal, hepatic, or rein vein thrombosis

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