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  • • 80% of primary hepatic malignancy

    • 50% with fibrous capsule

    • 70% with extrahepatic disease

    • Metastases most common to hilar and celiac nodes

    • Distant metastases most common to lung and peritoneum

    • Highly vascular tumors

    • Often multicentric with nodular satellite lesions

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Epidemiology

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  • • Equal incidence among genders

    • 9000 cases/yr in United States

    • Incidence increases among persons older than 50 years

    • Fibrolamellar variant (not associated with cirrhosis) peak incidence at age 25

    • Associated with all etiologies of cirrhosis

    • Associated with hepatitis B and C prevalence

    • Greatest incidence in Asia and Africa

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Symptoms and Signs

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  • • Right upper quadrant pain

    • Weight loss

    • Jaundice

    • Hepatomegaly

    • Hepatic bruit

    • Fever

    • Ascites

    • Gastroesophageal varices

    • Distant metastases

    • Asymptomatic

    • Intraperitoneal hemorrhage

    • Decompensated cirrhosis

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Laboratory Findings

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  • • Hyperbilirubinemia (33% of patients)

    • Hyperalkaline phosphatase (25% of patients)

    • Hepatitis B or C positive (75% of patients)

    • Alpha-fetoprotein > 200 ng/mL

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Imaging Findings

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  • • CT with IV portography often shows hypervascular tumor, frequently with multicentric disease

    • US hyperechoic tumor

    • MRI with or without magnetic resonance cholangiopancreatography (MRCP) shows gadolinium-enhancing lesion

    • Combination of CT, US, and MRI is 80% sensitive

    • Angiography shows hypervascular tumor

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  • • Biopsy of limited usefulness given high degree of sampling error and risk of tumor seeding

    • Overall and planned reserve liver function

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Rule Out

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  • • Metastatic hepatic carcinoma

    • Cholangiocarcinoma

    • Benign neoplasms if possible

    • Other abdominal malignancy

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  • • Serum alpha-fetoprotein

    • CT

    • US

    • Angiography

    • Biopsy in limited circumstances

    • Resection for diagnosis and treatment

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When to Admit

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  • • Liver failure

    • Hemorrhage

    • Cholangitis

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When to Refer

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  • • Always to centers of excellence for planned resection, ablative or transplant therapy

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Surgery

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  • • Liver transplantation (treatment of choice in the presence of cirrhosis)

    • Partial hepatectomy with at least 0.5 cm margins (25% are candidates)

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Contraindications

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  • • Medical comorbidity

    • Total tumor volume > 6.5 cm (for liver transplantation)

    • Extrahepatic disease or distant metastases

    • Bilobar disease and total volume > 6.5 cm

    • Poor liver function (class C) and not transplant candidate

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Procedures

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  • • Ethyl alcohol ablation (75% complete necrosis)

    • Radiofrequency ablation (RFA)

    • Chemoembolization (50% response in 25% of patients)

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Treatment Monitoring

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  • • Alpha-fetoprotein

    • CT

    • Liver function tests

    • Physical exams

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Complications

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  • • Hemorrhage

    • Biliary leak

    • Abdominal infection

    • Liver failure

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Prognosis

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  • Negative prognosis:

    • -Age older than 50

      -Cirrhosis

      -Vascular invasion

      -Portal thrombosis

      -Multilobar or multicentric ...

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