Diagnosis

Hepatocellular carcinoma

Etiology

Cause [hvv][a6i]

• Persistent viral hepatitis --> 75-80% of cases of primary liver cancer

  • HBV (50%–55%)

  • HCV (25%–30%)

• Alcoholic liver disease

• Non-alcoholic steatohepatitis (NASH)

• Non-alcoholic fatty liver disease (NAFLD)

• Aflatoxins produced by Aspergillus flavus and Aspergillus parasiticus

Pathophysiology [a6i]

1. Integration of the hepatitis B virus genome into the host genome --> mutation accounting for 60% of HCC cases

2. Chronic liver inflammation (hepatitis C virus, NASH) --> Fibrosis --> Cirrhosis with recurrent necrosis/regeneration --> mutation --> HCC

Risk factors [zsa]

Metabolic syndrome, Obesity, Diabetes, Non-alcoholic fatty liver disease (NAFLD), Alcohol abuse, Hepatitis B, Hepatitis C, Cirrhosis, Aflatoxins (found in peanuts), Liver flukes, Hemochromatosis, alfa1-antitrypsin deficiency, Anabolic steroid use, PSC, PBC, Alpha1-antitrypsin deficiency, Thorotrast radioactive contrast, Oral contraceptives, Porphyria cutanea tarda

Epidemiology

Incidence per 100.000 [a6i][zsa][6fv][sqb][avh][hvv][tso][mhs]

Approach

• Blood test: cell blood count, AFP, electrolytes, liver function tests [4r6]

  • Virology: Hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), anti-HCV

  • Hemochromatosis: Increased iron saturation (> 50%)

  • α1-Antitrypsin deficiency: Low α1-antitrypsin levels

  • HCC: Increased AFP > 400 ng/mL are considered diagnostic

  • Hypercalcemia - Ectopic parathyroid hormone production is possible in 5-10% of patients with HCC

• CT abdomen

• Ultrasound abdomen

• MR abdomen

• Liver biopsy

Treatment

1. Prophylaxis: [4r6]

   • Vaccination of HBV

   • Eradication of HCV

   • Treatment of obesity, type 2 diabetes, dyslipidemia, and hypertension

2. Treatment of cirrhosis: [4r6]

   • Ascites: Sodium restriction, diuretics, and paracentesis

   • Encephalopathy: Lactulose

   • Pruritus: Ursodiol

   • Variceal bleeding: Sclerosis or banding

   • Spontaneous bacterial peritonitis: Antibiotics

3. Early cancer stages: [zsa]

   • Antiviral treatment of hepatitis

   • Radiation

   • Transarterial chemoembolization (TACE)

   • Local radiofrequency ablation (RFA)

   • Surgery: the only chances of cure, the main prognostic factors for resectability are tumor size and liver function

     • Resection

     • Liver transplantation remains the best option for patients with HCC but the supply of deceased-donor organs is limited. Selection for transplantation: Milan criteria, Upto7, Metroticket

4. Advanced stage:

   • Chemotherapy: sorafenib (multi-kinase inhibitor), Regorafenib, Pembrolizumab, Cabozantinib, Ramucirumab, Nivolumab plus ipilimumab, Dostarlimab, Selpercatinib

Differential diagnoses

Benign bile duct tumor, Benign liver tumor, Breast cancer, Cholangiocarcinoma, Cirrhosis, Colorectal cancer, Lung cancer, Lymphoma