Hepatocellular carcinoma: Difference between revisions

 
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==Background==
==Background==
*most common form of liver cancer
*Most common form of liver cancer<ref>Current status of surgery and transplantation in the management of hepatocellular carcinoma: an overview. Pal S, Pande GK. J Hepatobiliary Pancreat Surg. 2001; 8(4):323-36.</ref>
**5 new cases per 100,000 in western countries
**> 100 per 100,000 in Southeast Asia and sub-Saharan Africa
*Mean survival of 6-20 months, steady over the years despite progress in diagnosis and therapies directed at HCC
*Surgical resection with transplantation, remains the best chance for cure
**However, < 20% of patients meet criteria for resection at time of diagnosis<ref>Liver transplantation for hepatocellular carcinoma. Bismuth H, Majno PE, Adam R. Semin Liver Dis. 1999; 19(3):311-22.</ref>
**Thus, early diagnosis is the most important step in managing HCC
 
==Clinical Features==
==Clinical Features==
*Risk factors include:  
*Risk factors include:  
**[[Hepatitis]] B or C
**[[viral hepatitis|Hepatitis]] B or C
**toxins (alcohol or aflatoxin)
**Toxins ([[alcohol]] or aflatoxin)
**Metabolic conditions ([[hemochromatosis]], [[alpha 1-antitrypsin deficiency]], [[non-alcoholic fatty liver disease]])
**Metabolic conditions ([[hemochromatosis]], [[alpha 1-antitrypsin deficiency]], [[non-alcoholic fatty liver disease]])


==Differential Diagnosis==
==Differential Diagnosis==
*Cirrhosis
===Liver mass<ref>Helical CT screening for hepatocellular carcinoma in patients with cirrhosis: frequency and causes of false-positive interpretation. Brancatelli G, Baron RL, Peterson MS, Marsh W. AJR Am J Roentgenol. 2003 Apr; 180(4):1007-14.</ref>===
*[[Hepatitis]]
*Regenerating nodule
*[[Budd-Chiari syndrome]]
*Hemangioma
*Focal fat
*Dysplastic nodules
*Peliosis
 
{{Jaundice DDX}}
 
==Evaluation==
==Evaluation==
*LFT, CBC, BMP, GGT
[[File:Triphasic CT scan of hepatocellular carcinoma.jpg|thumb|Triphasic contrast CT of hepatocellular carcinoma.]]
*Ultrasound
*[[LFTs]], CBC, BMP, GGT
*[[RUQ Ultrasound|Ultrasound]]
*Initial contrasted CT
*Initial contrasted CT
*Multiphasic contrasted CT and MRI nonemergently
*Multiphasic contrasted CT and MRI non-emergently
*Biopsy
*Biopsy
*Surveillance with alfa-fetoprotein (AFP) in combination with US<ref>Bialecki ES and Di Bisceglie AM. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 26–34.</ref>
*Surveillance with alfa-fetoprotein (AFP > 400 ng/mL) in combination with US<ref>Bialecki ES and Di Bisceglie AM. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 26–34.</ref>


==Management==
==Management==
*Supportive, symptomatic treatment for complications and comorbidities
*Supportive, symptomatic treatment for complications and comorbidities
 
**Cirrhotic [[jaundice]]
**Cirrhotic jaundice
**[[Hepatic encephalopathy]]
**[[Hepatic encephalopathy]]
**[[Anasarca]]
**[[Anasarca]]
 
**[[Variceal bleeding]]
**Variceal bleeding
**[[Renal failure]]
 
**Renal failure
**Extrahepatic metastases, most commonly bone, lung, abdominal viscera
**Extrahepatic metastases, most commonly bone, lung, abdominal viscera
 
**[[Paraneoplastic]] processes, such as [[hypoglycemia]], [[hypocalcemia]], polycythemia, feminization syndrome
**Paraneoplastic processes, such as hypoglycemia, hypocalcemia, polycythemia, feminization syndrome
**Watery [[diarrhea]], [[dehydration]] are common in HCC with cirrhosis versus cirrhosis alone
**Watery diarrhea, dehydration


==Disposition==
==Disposition==
*Discussion with oncologist for first time diagnosis
*Dependent on complications and comorbidities


==See Also==
==See Also==
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[[Category:GI]]
[[Category:GI]]
[[Category:Heme/Onc]]

Latest revision as of 20:30, 8 July 2021

Background

  • Most common form of liver cancer[1]
    • 5 new cases per 100,000 in western countries
    • > 100 per 100,000 in Southeast Asia and sub-Saharan Africa
  • Mean survival of 6-20 months, steady over the years despite progress in diagnosis and therapies directed at HCC
  • Surgical resection with transplantation, remains the best chance for cure
    • However, < 20% of patients meet criteria for resection at time of diagnosis[2]
    • Thus, early diagnosis is the most important step in managing HCC

Clinical Features

Differential Diagnosis

Liver mass[3]

  • Regenerating nodule
  • Hemangioma
  • Focal fat
  • Dysplastic nodules
  • Peliosis

Jaundice

Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis

Masqueraders

Only bilirubin stains the sclera

  • Carotenemia
  • Quinacrine ingestion
  • Dinitrophenol, teryl (explosive chemicals)

Evaluation

Triphasic contrast CT of hepatocellular carcinoma.
  • LFTs, CBC, BMP, GGT
  • Ultrasound
  • Initial contrasted CT
  • Multiphasic contrasted CT and MRI non-emergently
  • Biopsy
  • Surveillance with alfa-fetoprotein (AFP > 400 ng/mL) in combination with US[4]

Management

Disposition

  • Discussion with oncologist for first time diagnosis
  • Dependent on complications and comorbidities

See Also

External Links

References

  1. Current status of surgery and transplantation in the management of hepatocellular carcinoma: an overview. Pal S, Pande GK. J Hepatobiliary Pancreat Surg. 2001; 8(4):323-36.
  2. Liver transplantation for hepatocellular carcinoma. Bismuth H, Majno PE, Adam R. Semin Liver Dis. 1999; 19(3):311-22.
  3. Helical CT screening for hepatocellular carcinoma in patients with cirrhosis: frequency and causes of false-positive interpretation. Brancatelli G, Baron RL, Peterson MS, Marsh W. AJR Am J Roentgenol. 2003 Apr; 180(4):1007-14.
  4. Bialecki ES and Di Bisceglie AM. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 26–34.