- 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 fetal 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%
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
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