Day #237 - Hepatoma and HCC

Hepatocellular carcinoma is a highly vascular primary cancer of the liver which often arises in the context of underlying cirrhosis and ongoing/chronic liver inflammation caused by viral hepatitis (B and C). In general the risk in cirrhosis is approximately 3% per year.



The diagnosis is often made based on the radiographic appearance and clinical context. From uptodate: "If the lesion is hypervascular, has increased T2 signal intensity, demonstrates venous invasion, or is associated with an elevated AFP, the diagnosis is almost certainly HCC."

There are several staging systems. One useful system is the CLIP score:

• Underlying liver disease:
  
  • Child-Pugh A = 0, B=1, C=2
• Size and extent of tumour
  
  • Uninodular and not extending more than 50% =0
  • Multinodular and not extending more than 50% =1
  • Massive or extending more than 50% = 2
• AFP greater than 400 = 1
• Portal vein thrombus =1

CLIP: 0, 1, 2, 3, 4, 5/6 has associated median survival of 31, 27, 13, 8, and 2 months respectively.

There can be several paraneoplastic syndromes associated with HCC:

• polycythemia (related to EPO)
• hypercalcemia
• hypoglycemia
• chronic watery diarrhea
  

Treatment:

• In general surgical resection is limited to patients with good hepatic reserve (CPA), absence of metastases, absence of invasion of major vascular studies.
  
• Surgery is generally more successful in lesions less than 5cm
• Transplantation of the liver can be an option in patients with inadequate reserve or otherwise unresectable lesions. This really is only an option for lesions less than 3-5cm and solitary or less than three lesions.

• Radiofrequency ablation (RFA) is an option for lesions less than 4-5 centimeters who are otherwise deemed unresectable.
• TACE (transarterial chemoembolization) is an option for unresectable lesions in the absence of portal vein thrombosis. It is relatively contraindicated in tumours making up more than 50% of the liver, heart failure, renal failure, ascites, GI bleeding or thrombocytopenia.
  

There was a recent publication on the use of tyrosine kinase inhibitors in the treatment of advanced HCC showing improved survival.

I have previously blogged about hepatitis B, the most common worldwide cause of hepatoma, here.