Liver Cancer(Hepatocellular Carcinoma)

Hepatocellular Carcinoma(liver cancer) Is a primary malignant tumor of the liver composed of neoplastic liver cells; maybe well, moderately, or poorly differentiated; secretes α-fetoprotein, which serves as a useful serologic marker.

Risk Factors

• Chronic liver disease of any type is a risk factor and predisposes to the development of

liver cell carcinoma.

• These conditions include:

Alcoholic liver disease

Hepatitis (HBV, HCV)

Non-alcoholic steatohepatitis

Aflatoxin B1 or other mycotoxins

Alfa1-antitrypsin deficiency

Primary biliary cirrhosis

Hemochromatosis

Hereditary tyrosinemia

Wilson’s disease

Epidemiology

• Primary hepatocellular carcinoma is one of the most common tumors in the world.

• It is especially prevalent in regions of Asia and sub-Saharan Africa, where the annual

incidence is up to 500 cases per 100,000 populations.

• Hepatocellular carcinoma is up to four times more common in men than in women and

usually arises in a cirrhotic liver.

• The incidence peaks in the fifth to sixth decades of life in western countries but one to

two decades earlier in regions of Asia and Africa with a high prevalence of liver

carcinoma.

• Hepatocellular tumors may occur with long-term androgenic steroid administration

Clinical Features of Hepatocellular Carcinoma

• Cancers of the liver initially may escape clinical recognition because they occur in

patients with underlying cirrhosis.

• Symptoms and signs may suggest the progression of the underlying disease. The Most

Common Presenting Features are 

-Abdominal pain

-Abdominal mass in the right upper quadrant

It is hard, nodular surface, rounded edges, non-tender

-There may be a bruit over the liver in 6 – 25%

-Blood-tinged ascites occurs in about 30- 60% of cases

-Jaundice is rare unless there is significant deterioration of liver function or

mechanical obstruction of the bile ducts

-The paraneoplastic syndrome maybe found in a small percentage of patients

-Erythrocytosis may result from the erythropoietin-like activity produced by the tumor

-Hypercalcemia may result from secretion of a parathyroid-like hormone

-Mild Hypoglycaemia in rapidly growing HCC (also caused by end-stage liver

failure)

-Hypercholesterolaemia

-Dysfibronogenemia

-Carcinoid syndrome

-Increased thyroxine-binding globulin

-Changes in secondary sex characteristics (gynecomastia, testicular atrophy,

precocious puberty)

Differential Diagnoses, Investigations, Treatment, and Complications of

Hepatocellular Carcinoma

Differential Diagnosis

• Amoebic liver abscess

• Hepatoblastoma

• Capillary haemangioma

• Cavernous haemangioma

• Metastasis from a nonhepatic primary site

Investigations

Laboratory

• Serum elevations of alkaline phosphatase and alfa fetoprotein (AFP) are common.

• AFP levels >500 ug/L are found in about 70 to 80% of patients with hepatocellular

carcinoma.

 Imaging Procedures

• Ultrasound

• CT -Abdomen scanning

• MRI

Procedures

• Percutaneous liver biopsy

Treatment

• Treatment cannot be achieved at dispensary or health center levels and even in the

hospitals, the options are very limited. Counseling the patient and the relatives on poor

prognosis is very important.

• The course of the clinically apparent disease is rapid.

• If untreated, most patients die within 3 to 6 months of diagnosis.

• When hepatocellular carcinoma is detected very early by the serial screening of α-fetoprotein

(AFP) and ultrasound, survival is 1 to 2 years after resection.

• Surgical resection offers the only chance for the cure; however, few patients have a

resectable tumor at the time of presentation.

• Liver transplantation may be considered as a therapeutic option.

• Tumor recurrence or metastases are the major problems.

• Treatment options for unresectable diseases are limited.

• The liver cannot tolerate high doses of radiation.

• The disease is not responsive to chemotherapy (chemoresistant).

Prevention

• Prevention is the preferred strategy.

• Hepatitis B vaccine can prevent infection and its sequelae, and a reduction in

hepatocellular carcinoma has been seen in Taiwan with the introduction of universal

vaccination of children.

• Interferon treatment reduces the incidence of hepatic failure, death, and liver cancer in

patients infected with HBV.

• Treatment with interferon may lower the risk of development of liver cancer in patients

with hepatitis C-related cirrhosis.

• In patients at high risk for the development of hepatocellular carcinoma, screening

programs have been initiated to identify small tumors when they are still resectable.

Because 20 to 30% of patients with early hepatocellular carcinoma do not have elevated

levels of circulating AFP, ultrasonographic screening is recommended as well as AFP

determination.

                                                                                                 

REFERENCES;

•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill

•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1^st Ed. Hodder Arnold

•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford

•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.

•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF

•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1^st Ed. Mosby

•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.