- Hepatocellular carcinoma (HCC) is a primary malignant disease of the
liver
- Uncommon in Europe where hepatic secondaries are a 30 times more
common cause of liver tumours
- Highest incidence is seen in East Africa and South-east Asia
- In these countries it is one of the commonest malignant tumours
- Male : female ratio = 4:1
- In Europe peak age at presentation is 80 years
- In Africa and Asia peak presentation is 40 years
Aetiology
- Incidence of HCC parallels the world-wide prevalence of hepatitis B
- Aetiological factors are:
- Cirrhosis
- Viral hepatitis - particularly Hepatitis B and C
- Mycotoxins - e.g. aflatoxin produced by Aspergillus flavus
- Alcohol
- Anabolic steroids
- Primary liver diseases - e.g. primary biliary cirrhosis,
haemochromatosis
Clinical presentation
- Suspect in any patient with cirrhosis who shows evidence of clinical
deterioration
- Often present with right hypochondrial pain +/- mass
- Malaise, weight loss and low grade pyrexia are often present
- Jaundice is a late feature
- Haemobilia or haemoperitoneum are often the immediate cause of death
- Median survival in those with irresectable disease is 6 months
- As most tumours cause symptoms late screening of high risk patients
has been advocated
- Can be imaged by:
- Ultrasound - transabdominal or laparoscopic
- CT scanning - Conventional or lipiodal enhanced
- CT portography
- Assessment of serum alpha-fetoprotein (Alpha-FP) may also be useful
Picture provided by Ahmed Gowish, Alexandria
University, Alexandria, Egypt
Alpha-fetoprotein
- Alpha-fetoprotein is a normal foetal serum protein produced by the
yolk sac and liver
- Progress increases in serum levels are seen in 70-90% of patients
with HCC
- Slightly increased and often fluctuating serum levels also seen in
hepatitis and cirrhosis
- In HCC serum levels correlate with tumour size
- Rate of increase in serum levels correlate with growth of tumour
- Tumour resection results in a fall in serum concentrations
- Serial assessment useful in measuring response to treatment
Surgery for hepatocellular carcinoma
- Only about 25% patients are suitable for surgery
- The two surgical options are:
- Surgical resection
- Liver transplantation
Surgical resection
- Surgical resection involves either hemi-hepatectomy or segmental
resection
- Most tumours are irresectable to :
- Large size
- Involvement of major vessels
- Associated advanced cirrhosis
- Metastatic disease or extra-hepatic spread
- The presence of cirrhosis increases the operative mortality (from ~5
to >20%)
- After resection, 5 year survival is typically 30-60%
- Only a small proportion of patients are cured
- The 5-year recurrence rate is over 80%
Picture provided by Magdy Sorour, University of
Alexandria, Egypt
Liver transplantation
- Useful for irresectable disease confined to the liver
- Operative mortality is often 10-20%
- Metastases after transplantation occur in 30-40% of patients
- After transplantation, 5-year survival is less than 20%
Picture provided by Seo-Kiat Goh, Singapore General
Hospital, Singapore
Palliative therapy
- Possible palliative interventions include:
- Devascularisation procedures
- Chemotherapy
- Cryotherapy
- Chemo-embolisation
- Thermotherapy
- Chemoembolisation improves survival compared to palliative therapy
Bibliography
Al-Mufti R A M, Taylor I.
Hepatocellular carcinoma.
In: Johnson C D,
Taylor I (eds.). Recent Advance in
Surgery 21. Edinburgh:
Churchill Livingstone. 1998. 33-54.
Badvie S. Hepatocellular
carcinoma.
Postgrad Med J 2000;
76: 4-11.
Cormier J N, Thomas K T, Chari R S et al.
Management of Hepatocellular carcinoma. J Gastrointest Surg
2006; 10: 761-780
Lau W Y. Management of hepatocellular carcinoma. J R
Coll Surg Ed 2002; 47: 389-399.
Llovet J M, Real M I, Montana X et al. Arterial
embolisation or chemoembolisation versus symptomatic treatment in patients
with unresectable hepatocellular carcinoma: a randomised controlled
trial. Lancet 2002; 359: 1734-1739.
Schafer D F, Sorrell M F.
Hepatocellular carcinoma.
Lancet 1999; 353:
1253-1257.
Yang H-I, Lu S-N, Liaw Y-F et al. Hepatitis B
e antigen and the risk of hepatocellular carcinoma. N Eng J Med
2002; 347: 168-174. |