HCC or hepatoma is an epithelial tumor arising from malignant transformation of the hepatocyte
HCC was cause of death from cancer in the world, where its incidence up to 500/100,000 per year.HCC correlates with chronic HBV infection
Incidency hepatoma in US is 1-2 cases/100,000; male:female ratio 2 to 4:1 and commonly associated with liver disease caused by alcohol, HCV infection, hemochromatosis, or HBV infection
MANIFESTATION OF HCC
Classically, hepatoma presents as abdominal pain, a palpable abdominal mass, and/or constitutional symptoms in patients with cirrhosis
Other symptoms and signs include fever, anorexia, hepatomegaly, ascites, lower extremity edema, jaundice, early satiety, and an hepatic arterial bruit or friction rub
Hepatoma can also cause obstructive jaundice due to invasion or compression of the biliary tract or may bleed into the bile ducts. Hepatoma may also invade vascular structures and cause thrombosis of the portal or hepatic veins.
MANIFESTATION OF HCC
The tumor preferentially metastasizes to regional lymph nodes and lung
A small percentage of patients with HCC have a paraneoplastic syndrome: erythrocytosis, thrombocytosis, hypoglycemia, hypercholesterolemia, hypercalcemia, dysfibrinogenemia, cryofibrinogenemia, porphyria cutanea tarda, and hypertrophic osteoarthropathy
DIAGNOSIS HCC
Laboratory studies usually reflect abnormalities associated with the underlying chronic liver disease
AFP, an alpha1 -globulin produced in fetal, regenerating, and malignant hepatocytes, is a marker used in screening for hepatoma
AFP >500 ug/L 70 to 80% of patients with HCC
DIAGNOSIS HCC
High levels AFP (>500 to 1000 ug/L) in an adult with liver disease and without an obvious gastrointestinal tumor strongly suggest HCC
AFP over 20 ng/mL in CH have a sensitivity of 39 to 64% and a specificity of 64 to 91% for the presence of hepatoma
A rising level progression of the tumor or recurrence after hepatic resection or therapeutic approaches such as chemotherapy or chemoembolization
DIAGNOSIS HCC
AFP levels may also rise during hepatic regeneration associated with inflammation, so the specificity of the test is lower in active hepatitis
Lower levels large metastases from gastric or colonic tumors, acute or chronic hepatitis
DIAGNOSIS HCC
Other tumor markers : des-gamma-carboxy prothrombin, plasma urokinase-like plasminogen activator, alpha- L-fucosidase, and transcobalamin I (patients with fibrolamellar variant)
Imaging : US, CT and MRI. US generally shows a hypoechoic lesion
20 to 30% of patients with early HCC do not have elevated AFP, ultrasonographic screening is recommended as well as AFP determination
DIAGNOSIS HCC
Percutaneous liver biopsy can be diagnostic if the sample is taken from an area localized by ultrasound or CT
Biopsy may not be needed in CH with an elevated AFP and a typical liver mass,
But biopsy is reasonable in those without elevated tumor markers or when diagnostic uncertainty is present
Laparoscopy or minilaparotomy has the additional advantage of sometimes identifying patients who have a localized resectable tumor suitable for partial hepatectomy
STAGING
Staging HCC is based on tumor size (< or > 50% of the liver), ascites (absent or present), bilirubin (
The Okuda system predicts clinical course better than the American Joint Cancer Commission TNM system
TREATMENT
Include resection, transplantation, hepatic arterial chemo-embolization, intratumor injection of ethanol, and cryoablation
Chemotherapy and radiation therapy are of limited value. Randomized trials have not shown a survival advantage after chemoembolization
The choice of a particular therapy must be individualized because no single therapy has emerged as a treatment of choice
Liver transplantation is reserved for patients with small tumors, no extrahepatic disease, and poor liver reserve.
METASTATIC TUMORS
In United States, incidence of metastatic carcinoma is at least 20 times greater than that of primary carcinoma
At autopsy, hepatic metastases occur in 30 to 50% of patients dying from malignant disease
METASTATIC TUMORS
DIAGNOSIS
Lliver biochemical tests are often abnormal, but the elevations in marker levels are often only mild and nonspecific
An increase in serum alkaline phosphatase is the most common and frequently the only abnormality
Substantially elevated CEA are usually found when the metastases are from primary malignancies in the gastrointestinal tract, breast, or lung
A mass apparent on USG, CT, or MRI examination of the liver may provide a presumptive diagnosis
Blind percutaneous needle biopsy of the liver will result in a positive diagnosis of metastatic disease in only 60 to 80% of cases with hepatomegaly and elevated alkaline phosphatase levels
METASTATIC TUMORS
Carcinoembryonic antigen/ CEA
Increase level of CEA was indicative of colorectal cancer
But CEA is observed too in a variety of adenocarcinomas (lung, breast, pancreas, and stomach) as well as medullary cancer of the thyroid and some squamous cell cancers of the head and neck
Carcinoembryonic antigen/ CEA
CEA is not an effective screening test. In view of the lack of sensitivity or specificity for colorectal cancer
CEA is often not increased in early-stage colon cancer and may be increased in smokers and in association with a variety of benign conditions, including bronchitis, diverticulitis, peptic ulcer disease, fibrocystic breast disease, and a number of liver disorders
The risk of recurrence increased to 3.25-fold if the CEA was greater than 10 ng/m
PROGNOSIS
Prognosis of hepatoma is poor and is related to tumor size, residual liver function, and presence of extrahepatic disease
Patients who have a single lesion £5 cm or < 3 lesions £3 cm have survival after transplantation that is the same as survival after transplantation for nonmalignant liver disease
Survival HCC is 1 to 2 years after resection
For symptomatic unresectable disease, survival is less than 5% at 2 years
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