HEPATOCELLULAR

CARCINOMA

Hepatocellular Carcinoma is a primary cancer

meaning it originated in the Liver(as opposed

to Liver metastases,or secondary Liver Cancers

which have spread to Liver from other organs)

It is commonly associated with Cirrhosis and

Hepatitis.

Male to Female ratio is 4:1 for HCC.

Common Cause:

1.Cirrhosis from any cause

2.Hepatitis B or C chronic infection

3.Ethanol chronic consumption.

4.Aflatoxin B1 or other mycotoxins

Unusual Cause:

1.Primary Biliary Cirrhosis

2.Hemochromatosis

3.Alpha 1 Antitrypsin deficiency

4.Hemochromatosis

5.Wilson’s Disease

Abdominal Pain

Weight Loss

Weakness

Abdominal Fullness and swelling

Jaundice

Nausea

Hepatomegaly (50 to 90% of patients)

Ascites(30 to 60%)

Abdominal Bruits

Splenomegaly

Spider Angioma

Obstructive Jaundice

Paraneoplastic Syndromes

Erythrocytosis

Persistent fever

Hypoglycemia

Hypercalcemia

Hypercholesterolemia

Diagnosis of HCC should be bases on followings:

History & P/E

IMAGING(CT,MRI)

LIVER BIOPSY(For Confirmation)

Elevated Serum AFP(more than 400ng/ml)

In patient with higher suspicion of HCC the

best method of diagnosis involves:

CT scan of the abdomen using IV Contrast

agent and three phase scanning:

Before contrast administration

Immediately after contrast administration

After Delay

Biopsy is not needed if following criteria are met

on CT:

o Hypervascularity in the arterial phase scans

o Washout or deenhancement in the Portal and

delayed phase studies

o Pseudocapsule and Mosaic Pattern

Liver Biopsy is not needed if these criteria are met

on CT

An alternative to a CT imaging study would be the

MRI. MRI's are more expensive and not as available

because fewer facilities have MRI machines

On CT, HCC can have three distinct patterns

of growth:

A single large tumor

Multiple tumors

Poorly defined tumor with an infiltrative

growth pattern

Hepatocellular Carcinoma may appear grossly

as:

1.Unifocal(usually large mass)

2.Multifocal(widely distributed nodules of

variable size)

3.Diffusely Infiltrative(Cancer,permeating

widely and sometimes involving whole Liver)

Macroscopically,the tumour usually appears as

single mass in the absence of Cirrhosis,or as a

single/ multiple nodules in the presence of cirrho-

-sis

It takes its blood supply from the hepatic artery and

tends to spread by invasion into the portal vein and

its radicles.

Lymph node metastases are common but Lung and

bone metastases are rare.

Microscopically,the tumour resembles hepatocytes

when well differentiated and can be difficult to

distinguish from normal Liver.

The status of the non-tumorous liver:

Underlying cirrhosis.

Non-cirrhotic liver (HBV).

Size and extension of the tumour:

Is it ≤5 cm in size/≤3 lesions ≤ 3 cm ?

Vascular involvement.

General condition of patient, the age and

expected life expectancy.

24

MANAGEMENT INDICATION PROGNOSIS Recurrence

HEPATIC RESECTION Non Cirrhotic HCC 5 year survival is

about 50%

50%

recurrence

rate at 5

years

LIVER

TRANSPLANTATION

Cirrhotic HCC 5 year survival is

about 75%

Unfortunate

ly Hepatitis

B & C may

also occur

in

transplante

d Liver

PERCUTANEOUSABLATION

(ETHANOL)

TUMOURS OF 3 cm

or small

80% cure rate 50% at 3

years

CHEMOEMBOLIZATION Cirrhotic Patients

with unresectable

HCC and good Liver

Functions at 2 years

No survival benefit

Beyond 4 years

This Scoring system is used to assess the

prognosis of Chronic Liver Disease,mainly

Cirrhosis.

It is now used to determine the prognosis

as well as required strength of treatment

and the neccesity of Liver transplantation.

Scoring is done by following methods:

MEASURE 1 POINT 2 POINT 3 POINT

TOTAL BILIRUBIN

(mg/dL)

<2 2 to 3 >3

SERUM ALBUMIN

(gm/L)

>35 28 to 35 <28

PT/INR <1.7 1.71 to 2.30 >2.3

ASCITES NONE Mild Moderate

to Severe

HEPATIC

ENCEPHALOPATHY

NONE Grade I to II Grade III

to IV(or

refractory)

POINTS CLASS 1 Year survival 2 year survival

5 to 6 A 100% 85%

7 to 9 B 81% 57%

10 to 15 C 45% 35%

SORAFENIB(multitargeted oral tyrosine

kinase inhibitor)

SUNITINIB,DOXORUBICIN,CISPLATIN,FLURO-

-URACIL are commonly used

chemotherapeutic

agents.

Unfortunately HCC is relatively

chemotherapy resistant

BCLC Classification

TNM Classification

OKUDA Classification

CLIP Score for HCC

ECOG performance scale

Gastrointestinal Bleeding

Liver Failure

Distant Metastases

www.cancer.net

www.cancer.org

www.aapf.org

www.esmo.org

www.mayoclinic.com

DAVIDSON:Internal Medicine

ROBBINS:Pathology

THANK YOU