Hepatocellular carcinoma is the most common primary liver tumor. Risk factors include hepatitis B and C infections, alcohol use, and exposure to aflatoxins. It typically presents with nonspecific symptoms in patients with underlying liver disease or cirrhosis. Diagnosis involves blood tests like alpha-fetoprotein along with imaging modalities. Treatment options depend on tumor stage and liver function, and may include surgical resection, liver transplantation, ablation, or chemoembolization. Prevention focuses on hepatitis B vaccination and screening high-risk groups to detect cancer early.
4. Introduction
The most common primary tumor
Sixth most common CA
⢠Incidence
â 28/100,000 in SEA
(d/t increased prevalence of HBV inf)
â 10/100,000 in South EU
â 5/100,000 in North EU
(d/t increase incidence of HCV related cirrhosis)
5. Pathogenesis
⢠The precise mechanisms of carcinogenesis
â unknown
⢠Repeated circle of cell death & regeneration
mutation of hepatocytes
⢠Preneoplastic changes â hepatocytes
dysplasia can be seen.
6. Aetiological factors
1. Viral infection
(repeated circle of cell death &
regeneration)
2. Aflatoxins
(mutation in proto-oncogene/tumor
suppressor gene, p53)
3. Cirrhosis
(inflammation of the hepatocytes)
7. ⢠Others
â Age
â Sex
â Chemicals
â Viruses
â Hormones
â Alcohol
â Nutrition
8. ⢠The most important HVB infection
(100 folds increase in risk to develop HCC)
⢠COL (-) â 0.4% per year
(+) â 2-6% per year HCC
⢠75-90% of HCC pt - COL (+)
9. Morphology
⢠Gross
â 3 types
⢠Unifocal
⢠Multifocal
⢠Diffusely infiltrative
â Unifocal lesion mostly seen in pt without COL
â Multifocal lesion mostly seen in pt with COL
10. ⢠Microscopic appearance
â Well to moderately differentiated tu â nearly
similar to the n/l hepatocytes
â Poorly differentiated tu â pleomorphoic
11. ⢠Spread
â Tend to spread by invasion into the vasculature,
mostly the portal vein
â Highly metastases to lymph nodes
â Lung & bone metastasis are not uncommon
and seen in terminal cases
12. Clinical Features
⢠Seldom characteristics
⢠Masked by the underlying liver disease
⢠May present with features of chr. VH or
COL
⢠May c/o about ill-defined abd
pain/discomfort, fullness of abd, malaise,
fatigue, LOA and LOW.
13. ⢠Examination may reveal hepatomegaly or
a right hypochondrial mass.
⢠Tumour vascularity can lead to an
abdominal bruit, and hepatic rupture with
intra-abdominal bleeding may occur.
14. Investigations
(i) Serum alpha feto-protein
⢠Produced by 60% of HCC
⢠Level depends on size of tu
⢠May be n/l in small tu
⢠Both sensitivity and specificity â low
⢠Can be high in presence of HBV & HCV
replication and a/c liver necrosis
15. ⢠Should be used in conjunction with other
imaging techniques
⢠In the (-)ce of obvious liver disease, if
there is increasingly rising AFP or AFP >
400 ng/ml, HCC must be search
aggresively.
16. (ii) USG
⢠Can show small tu about 2-3cm
⢠Also portal vein involvement and
coexisting COL
⢠USG contrast agent can also be used
17. (iii) CT and MRI
⢠Contrast enhanced helical CT can show
HCC â hypervascular appearance.
⢠MRI can also be used instead of CT.
⢠But tumors <2cm â difficult to differentiate
from hyperplastic nodule of cirrhosis.
18. (iv) Liver biopsy
⢠To confirm the diagnosis & exclude
metastasis tu from other
⢠Done in pt with large tu, no COL and HBV
inf
⢠Avoid in pt eligible for transplantation or
surgical resection (<2% risk of tumor
seedling along the needle tract)
19. Tumor Staging Systems
⢠Various systems used to determine the
stages of HCC
⢠Most of them describe the prognosis of
HCC depending upon
â The severity of underlying liver d/s
â The size of tumor
â Extension of tumor into adjacent structures
â Presence of metastasis
21. Stage Survival rate
⢠I â no positive 8.3 mth
⢠II â 1 or 2 (+)ve 2 mth
⢠III â 3 or 4 (+)ve 0.7 mth
22. ⢠Does not stratify pt by vascular invasion or
presence of nodal metastasis
⢠Not important for treatment (surgery)
⢠Only pure clinical scoring system
23. TNM staging (American Joint Committee
on Cancer )
⢠This system recognizes the most important
predictors of prognosis
ď The number and size of tumor
ď Extent of vascular invasion
ď Condition of regional lymph node
ď Presence or absence of metastasis
24. Primary tumor
⢠TX â primary tu cannot be assessed
⢠T0 â no evidence of primary tu
⢠T1 â solitary tu without vascular invasion
⢠T2 â solitary tu with vascular invasion
⢠T3a â multiple tu more than 5 cm
⢠T3b â single or multiple tu of any size
involving maj branch of portal vein
of hepatic vein
⢠T4 â tu with direct invasion of adjacent
organs other than gallbladder or with
perforation of visceral peritoneum
27. Five year survival rates
⢠Stage I â 55%
⢠Stage II â 37%
⢠Stage III â 16%
⢠Stage IV <16%
28. Barcelona Clinic Liver Cancer
System
⢠Considers in combination of tu burden,
hepatic function and performance status
together with evidence based treatment
argorithm
⢠Can provide not only the prognosis but
also the treatment plan
29. STAGE TU BURDEN CHILD- PST MEDIUM
PUGH SURVIVAL
Very early (0) Single tu <2cm A 0
Early (A) Single tu <5cm or A-B 0-2 53 mth
3 tu <3cm each
Intermediate (B) Single tu >5cm or A-B 0-2 16 mth
Multiple tu largest >3cm
Advanced (C) Any tu burden A-B 1-2 7 mth
Terminal (D) Any tu burden C >2 3mth
30. Hepatocellular carcinoma
Very early stage Early stage Intermediate Advanced Terminal
stage stage stage
Single 3 nodules
Portal increase Asso: d/s
pressure
Normal No Yes
Resection Transplantation Ablation Chemo- Newer
Symptomatic
embolisation agent
32. Hepatic resection
⢠Treatment of choice for non-cirrhotic pt
⢠5yr survival rate â 50%
⢠Recurrence rate at 5 yr â 50%
⢠Can be consider in cirrhotic pt with small tu
and good liver functions (risk of a/c liver
failure)
33. ⢠Tu clearence margin at least 1-2cm
⢠In COL pt, the volume of resection must be
minimized to avoid post-operative liver
failure
35. Transarterial chemo-embolisation
⢠Embolisation of hepatic artery with
gelfoam and doxirubicin
⢠Used in pt unresected HCC and good liver
function
⢠Contraindicated in pt with cirrhosis and
multifocal HCC
⢠Survival rate 60% at 2 yr and lost in 4 yr.
37. Prevention
⢠As viral infection with HBV is the most
important aetiology and HBV vaccination is
already avaliable, vaccination should be
done.
⢠Consider about the universal precaution in
handling infected blood and its products in
medical personal
⢠Reduce the risk of vertical transmission of
hepatitis viruses
38. ⢠Early diagnosis and prompt treatment
â To get early diagnosis, screening procedures
should be done in endemic area
â All pt must be given prompt treatment after
being diagnosed as HCC or chr. hepatitis
⢠So that tu burden will be reduced and QOL
of the pt will improve.