Hepatocellular Carcinoma

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Right upper quadrant pain

  • Weight loss

  • Jaundice

  • Hepatomegaly

  • Hepatic bruit

  • Fever

  • Ascites

  • Gastroesophageal varices

  • Distant metastases

  • Asymptomatic

  • Intraperitoneal hemorrhage

  • Decompensated cirrhosis

Laboratory Findings

• • Hyperbilirubinemia (33% of patients)

  • Hyperalkaline phosphatase (25% of patients)

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

  • Alpha-fetoprotein > 200 ng/mL

Imaging Findings

• • 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

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

  • Overall and planned reserve liver function

Rule Out

• • Metastatic hepatic carcinoma

  • Cholangiocarcinoma

  • Benign neoplasms if possible

  • Other abdominal malignancy

• • Serum alpha-fetoprotein

  • CT

  • US

  • Angiography

  • Biopsy in limited circumstances

  • Resection for diagnosis and treatment

When to Admit

• • Liver failure

  • Hemorrhage

  • Cholangitis

When to Refer

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

Surgery

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

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

Contraindications

• • 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

Procedures

• • Ethyl alcohol ablation (75% complete necrosis)

  • Radiofrequency ablation (RFA)

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

Treatment Monitoring

• • Alpha-fetoprotein

  • CT

  • Liver function tests

  • Physical exams

Complications

• • Hemorrhage

  • Biliary leak

  • Abdominal infection

  • Liver failure

Prognosis

• • Negative ...