Hepatocellular Carcinoma (HCC)

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of liver that has a very high incidence in Asia especially Japan. Other places like Taiwan Penghu, Shanghai (china) have high incidence of liver cancer. There are generally 2 pathological types of hepatocellular carcinoma. The 2 pathological types are fiberlamellar vs non-fibrolamellar (most common type).

• Fibrolamellar: This is not associated with Hepatitis B, C or Cirrhosis.
• Nonfibrolamellar (most common) and associated with cirrhosis from alcoholics, hepatitis B and C.

Etiology and association of Hepatocelluar Carcinoma:

• Cirrhosis causing risk factors that eventually lead to hepatocellular carcinoma.
  • Wilson Disease, Hemochromatosis, alpha-1-anti-trypsin deficiency
  • Alcohol, Chronic Hepatitis B/C cause mutation with integration of viral DNA
  • Coinfection with HCV and HBV has also been associated with an increased risk of HCC than individual infection alone.
  • Non-alcoholic fatty liver disease (NAFLD), Primary or secondary biliary sclerosis
• Hepatic adenoma (10% chance of transformation to HCC)
• Aflatoxin B1 (carcinogen found in fungus) called aspergillus that induce p53 mutation which is a guardian tumor suppressor gene.
• Schistosomiasis parasite infection can also cause liver cancer.
• Protectibbe factors: consumption of white meat and statin use has been associated with decreased risk of hepatocellular carcinoma.

Pathogenesis of Liver Cancer from HBV and HCV infection

• The pathogenesis is believed to be from hepatocyte damage and rapid cellular turnover from healing in a cronic inflammatory setting caused by chronic hepatitis B or C infection.
• The imbalance in microenvironment of  liver and cytokines of livers infected with the hepatitis C virus, and ultimately causing cirrhosis.
• Poorly differentiated hepatocytes likely proliferate and develop into dysplastic nodules and HCC

Symptoms and Clinical Presentation

• Painful hepatosplenomegaly, fatigue, jaundice,cCachexia weight loss
• Cirrhosis complications symptoms are common: Portal hypertension symptoms (ascites, palmer erythema, esophageal varices, hemorrhoids, etc)
• Paraneoplastic syndrome : Increased RBC, Platelets, Calcium, Carcinoid syndrome, hypoglycemia, increased cholesterol, hypertrophic pulmonary osteodystrophy.

Diagnosis of hepatocellular cercinoma

• Liver biopsy – most accurate diagnosis of liver hepatocellular cercinoma
  • pathology can be unifocal or multifocal with diffuse infiltration
  • Paler than surrounding parenchyma cells
• Alpha fetoprotein (AFP) elevation – useful screening tool and monitor response to treatment.
  • Cirrhosis patient need screening for hepatocellular cercinoma via ultrasound (US) and AFP levels every 6 months.

Complications and Progression

• Hepatocellular cercinoma have the tendency for hematogenous spread to other areas.
• May lead to Budd Chiari Syndrome that occlude/thrombosis in the IVC, hepatic vein.

Treatment and Management

• The mainstay of treatment is surgical resection but most of the patients are not eligible due to metastasis or underlying liver dysfunction.
• Other treatment modalities include: Liver transplantation (if diagnosed early and able to get on the list). Others include: radiofrequency ablation (RFA) and microwave ablation, percutaneous ethanol or acetic acid ablation, Radioembolization, transarterial chemoembolization, Cryoablation, radiation therapy and stereotactic radiotherapy.
• Systemic chemotherapy and targeted therapies with molecular agents are currently being studied.
• The specific treatment option depend on both the disease extend and the severity of underlying liver disease, which limits the tolerance to any therapy.
• For patients with cirrhosis, the Child-Pugh classification is used to stratify patients according to their underlying liver disease. Sometimes other measures are increasingly used.

Related care at Gastro in Florida

Learn how this condition is diagnosed and treated at our practice: Liver Disease · FibroScan. More articles like this one are in the Liver, Gallbladder & Bile Ducts section of our Patient Education Library.