Medicine Reviews 1

Hepatocellular carcinoma  , Hepatoma   or  Liver cancer

The incidence of hepatocellular carcinoma(HCC) is rising  in many countries, but in a few areas such as  Japan and Singapore, the incidence of HCC seems to have  stabilized or even fallen slightly . Care of the patient  with HCC involves physicians from different disciplines,including hepatologists, surgeons, liver transplant teams,
oncologists, interventional radiologists, and to some extent radiation
oncologists. In most settings, the role of the hepatologist or gastroenterologist. in these multi-specialty groups (usually organized as Tumor Boards) is not based on specific expertise in the application of a given intervention, but rather in assessing the
degree of liver function impairment prior to, during and after therapy.

This specific expertise is important since HCC usually appears in the setting of underlying liverdisease. This results in a degree of complexity that is not present in othercancer typesthat seldom compromise vital organ function. All this suggests that patients with HCC should be managed in multidisciplinary settings, with all legitimate treatment options available.

Hepatocellular carcinoma  is one of the most common
tumor worldwide . Incidence is varies widely  on geographic location . The high incidence
region include Sub-saharan Africa , China ,Honkong and Taiwan .  With mean age of 40-50 years old (33 yearsn old in sub-Saharan Africa ) and predominantly found on male  ( Male:Female  about 4:1)

Clinical Features

Generally Patients with HCC  usually asymptomatic  ( but  may present with sign or symptom related to their chronic liver disease )  They may presented with Right upper
quardrant abdominal pain , palpable mass  or  with constitutional symptoms (
eg weight loss , anorexia   )  . patients with decompensated cirrhosis  are highly suspicious
to have HCC .

They may have some uncommon manifestrations such as

-Obstructive Jaundic

-Bone pain or Dyspnea  ( In late state due to Lung or bony
metastasis )

– Syncope , hypotension or  anemia  due to intraperitoneal bleeding from tumor bleeding

-Paraneoplastic syndrome     eg . Hypoglycemia  ( believe that from high tumor metabolic rate )  ,  Erythrocytosis  ( increased red blood cell from increased erythropoietin
)  , Hypercalcemia ( from bone metastasis)  , Watery diarrhea (  not understood yet but may be due to increased secretion of  VIP os gastrin)   and some cutaneous features.

Cutaneous features  that represents paraneoplastic ( not specific to only HCC but may be found in other malignancy )

Dermatomyositis with skin sign of  Heliotrope rash  , Gottron’s papule

Heliotrope rash  at both eyelid found in dermatomyositis

Gottron sign at Knuckle and PIP Joints

Pemphigus foliaceus Superficial blistering  rarely involve mucous membrane .Blister often appear as shallow erosion associated with erythrema , scale and crusted formation

Pemphigus foliaceus

Leser Trelat sign :  Sudden appearance of multiple seborrheic keratoses .   Often with inflammatory base in association with skin tags and acanthosis nigricans .

Pityriasis Rotunda Multiple Round or Oval  , Sharply demarcated  scaling patches

Pityriasis Rotunda

Porphyria cutanea tarda Exposure to Sun and/or Minor
Trauma leads to skin erythrema and develop vesicles and bullae that may become hemorrhagic  Relate Hepatitis C virus infection

Porphyria cutanea tarda

 

Who will be at risk for HCC  ???

– Hepatitis B virus  infection    take risk  100 folds than uninfected

– Hepatitis C virus  infection    plus  Liver cirrhosis

– Cirrhosis   ( compensated or decompensate )

– Environmental factor  eg.  smoking  , alcohol  or aflatoxin

Patients with increase risk for HCC should be screening and surveillance

As recommendations by  American Association  for the study of Liver disease  (AASLD
2010 )   patients at risk should be screening by abdominal ultrasound  and
Surveillance should be done at 6 months interval .   Patients at risk and should be screening and  surveillance include


Hepatitis B carrier

1.      Asian male    > 40 years

2.      Asian female > 50 years

3.      African over age  20 years

4.      Cirrhosis whether  successfully treated or not

5.      Family History of HCC , mainly in Asian and African

Non Hepatitis B patients  with cirrhosis

1.      Hepatitis C

2.      Alcoholic cirrhosis

3.      Primary biliary cirrhosis

4.      Genetic Hemochromatosis

5.      Alpha-1 antitrypsin deficiency

No recommendation for screening  can be made on the following groups  :  1.
Noncirrhotic chronic hepatitis B who respond to therapy with inactivation the
disease   2. Cirrhotic due to NASH or  auto immune hepatitis

Diagnosis of  HCC

By 1. Radiology  2. Tissue biopsy

Radiologic diagnosis of  HCC
– Ultrasonography   :
Patients at risk for HCC should be screening by abdominal Ultrasounds  ( sensitivity about 85% with tumor size > 3 cms)   with small tumor will shows hypoechoic lesions ,Large tumor will shows Hyperechoic lesion with hypoecchoic rim

– Dynamic imaging technique   ( contrasted ultrasound , 4
phase  CT scan , MRI )  will show  specific vascular pattern , contrast uptake during arterial phase and wash out during delayed/venous phase

tumor enhance in arterial phase

The enhance lesion washed out in delayed phase

 

AASLD recommendations for patients to investigate the small nodule that found during screening for  HCC


– Nodules found on U/S  < 1 cm Should be F/U with U/S  at interval 3 months  , If there has been no growth over a period of up to 2 years , one can revert to routine surveillance . Nodules > 1 cm  found on U/S screening of a cirrhotic liver Shoud Investigate further
with  4-phase MDCT  or Dynamic enhance contrast MRI   If Lesion Typical  the lesion shoud Rx as HCC

– If Lesion not typical  , A second Study should be Perform , or The lesion should be Biopsies . If The Biopsy is negative for Patient with HCC  the lesion should be
Follow by imaging at 3-6 Months

Treatment and staging system followed the BCLC  staging and treatment schedule

Reference from  AASLD guideline 2010  , UTD  18.2

 

 

 

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