Hepatocellular carcinoma: Difference between revisions
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==Background== | ==Background== | ||
* | *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) | ||
**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== | ||
* | ===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>=== | ||
* | *Regenerating nodule | ||
* | *Hemangioma | ||
*Focal fat | |||
*Dysplastic nodules | |||
*Peliosis | |||
{{Jaundice DDX}} | |||
==Evaluation== | ==Evaluation== | ||
* | [[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 | *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
- Risk factors include:
- Hepatitis B or C
- Toxins (alcohol or aflatoxin)
- Metabolic conditions (hemochromatosis, alpha 1-antitrypsin deficiency, non-alcoholic fatty liver disease)
Differential Diagnosis
Liver mass[3]
- Regenerating nodule
- Hemangioma
- Focal fat
- Dysplastic nodules
- Peliosis
Jaundice
Indirect Hyperbilirubinemia
- Hemolytic
- G6PD
- Drug related
- Autoimmune hemolytic anemia
- Hematoma resorption
- Ineffective erythropoiesis
- Gilbert's
Direct (Conjugated) Hyperbilirubinemia
- Choledocholithiasis
- Cholecystitis
- Ascending cholangitis
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Pancreatic head
- Gallbladder
- Primary liver (e.g. hepatocellular carcinoma)
- Metastatic
- Obstructing AAA
Hepatocellular damage
Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase
- Viral hepatitis
- Fulminant hepatic failure
- alcoholic hepatitis
- Ischemic hepatitis
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulfonamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
Transplant Related
Pediatric Related
- Inborn error of metabolism
- Neonatal jaundice (physiologic)
Additional Differential Diagnosis
- Reye syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's disease
- Sarcoidosis
- Amyloidosis
Masqueraders
Only bilirubin stains the sclera
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
Evaluation
- 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
- Supportive, symptomatic treatment for complications and comorbidities
- Cirrhotic jaundice
- Hepatic encephalopathy
- Anasarca
- Variceal bleeding
- Renal failure
- Extrahepatic metastases, most commonly bone, lung, abdominal viscera
- Paraneoplastic processes, such as hypoglycemia, hypocalcemia, polycythemia, feminization syndrome
- Watery diarrhea, dehydration are common in HCC with cirrhosis versus cirrhosis alone
Disposition
- Discussion with oncologist for first time diagnosis
- Dependent on complications and comorbidities
See Also
External Links
References
- ↑ 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.
- ↑ Liver transplantation for hepatocellular carcinoma. Bismuth H, Majno PE, Adam R. Semin Liver Dis. 1999; 19(3):311-22.
- ↑ 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.
- ↑ Bialecki ES and Di Bisceglie AM. Diagnosis of hepatocellular carcinoma. HPB (Oxford). 2005; 7(1): 26–34.