Hepatocellular Carcinoma

(Hepatology. 2005;42:1208-29)

DEFINITION:

Hepatocellular carcinoma (HCC) or Hepatoma is a primary (as opposed to metastases) tumor of the liver

EPIDEMIOLOGY:

Mortality: 4th most common cause of world cancer deaths (400,000-1 million) annually; Incidence remains on the rise worldwide: 3 per 100,000
♂ > ♀ (2-6 times more men affected); Mean age at presentation is 50-60 years with most being older than 55
Approximately 80% of patients with HCC have cirrhosis

ETIOLOGIES:

Can be seen in any chronic liver disease, but most often seen with:
- Chronic hepatitis C (probably the most common); Chronic Hepatitis B; Hemochromatosis; α1-AT; Alcoholic cirrhosis
- Environmental toxin exposure (i.e. alflatoxin)
- Cirrhosis of any cause!

PATHOPHYSIOLOGY:

▪	Presenting forms:	Nodular: most common, multiple nodules of varying size scattered throughout liver
		Solitary: occurs in younger patients; large, solitary mass, often right lobe
		Diffuse: rare; difficult to detect on imaging; widespread infiltration of minute tumor foci

Fibrolamellar carcinoma (represents 7% of HCC): occurs in young people (mean age 26), ♂ = ♀, seldom have history of prior liver disease
- Usually presents with abdominal pain due to large mass, most often left lobe (75%); AFP is normal
- Histology includes deeply eosinophilic malignant cells interspersed between laminated strands of collagen
- Imaging studies show fibrous central scar from bleed/necrosis; MRI T2 demonstrates hypointense (don’t confuse with FNH)
- Recognition is key as 50-80% are resectable at diagnosis; Liver transplant may be indication if not resectable

CLINICAL MANIFESTATIONS/PHYSICAL EXAM:

Usually have no symptoms or may be manifestations of chronic liver disease
- Rare: abdominal pain, early satiety, weight loss, jaundice, paraneoplastic syndromes, fever
- In previously compensated cirrhotics, the development of decompensation should raise suspicion of HCC!
Physical exam usually reflects the underlying liver disease:
- Hepatomegaly/splenomegaly, ascites, jaundice; Less common: fever, palpable liver mass, hepatic bruit

LABORATORY STUDIES: