Hepatocellular carcinoma
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
- Cirrhosis
- Hepatitis
- Budd-Chiari syndrome
- Liver masses - regenerating nodules, hemangiomas, focal fat, dysplastic nodules, peliosis[3]
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.