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Hepatocellular carcinoma

Last updated: August 23, 2021

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Hepatocellular carcinoma (HCC) is a malignant, most often solitary tumor of the liver, which occurs primarily in patients with preexisting liver cirrhosis or chronic hepatitis. Typically, it is an incidental diagnosis in these high-risk patients that is made either via ultrasound or an increase in the hepatic tumor marker alpha-fetoprotein. Most patients typically present with symptoms caused by underlying disease (e.g., ascites, jaundice) rather than the tumor itself. Potentially curative treatment options include tumor resection, liver transplantation, and ablative therapies. Unfortunately, it is usually not possible to remove all tumor tissue, which explains the poor prognosis of HCC. In western countries, the five-year survival is less than 50%.

Epidemiological data refers to the US, unless otherwise specified.

Aflatoxins are considered one of the most potent carcinogens!

Laboratory tests

Imaging

Liver biopsy

  • Can provide a definitive diagnosis but carries the risk of bleeding and tumor spread
  • Recommended when both lab and imaging studies are inconclusive

Malignant liver tumors

Benign liver tumors

The differential diagnoses listed here are not exhaustive.

Curative approach [7]

Surgery

  • Surgical resection
    • Provides the best outcome
    • Can only be performed in patients with sufficient liver function and without nodular invasion of the liver vasculature or distant metastases
  • Liver transplantation

Ablative therapies

Ablative options are mostly palliative, but can also be curative. They usually result in shrinking and scarring of the tumor and involve the following methods:

  • Radiofrequency ablation (RFA)
    • An image-guided technique that involves the placement of a needle electrode within the tumor to destroy cancer cells using heat generated by high-frequency electrical currents
    • Indicated as primary treatment with curative intention under the following conditions :
      • Multiple (≤ 3), small liver lesions (largest lesion ≤ 3 cm) in patients that require bridging/downsizing while on a waiting list for liver transplant
      • Solitary, small lesion (≤ 3 cm)
  • Transcatheter arterial chemoembolization (TACE): local application of chemotherapy and embolic agent
  • Percutaneous ethanol injection (PEI)
  • Selective internal radiation therapy (SIRT)

Follow-up

Palliative care [8][9]

Palliative care is indicated mainly for individuals with decompensated, unresectable, multinodular, or metastatic disease and has the following options:

We list the most important complications. The selection is not exhaustive.

  • 5-year survival rate
    • Western countries: 27–49%
    • Asia and Africa: < 10%
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  7. Ya‐wen Zheng, Xin‐wei Zhang, Jia‐li Zhang, Zhen‐zhen Hui, Wei‐jiao Du, Run‐mei Li, Xiu‐bao Ren. Primary hepatic angiosarcoma and potential treatment options. Wiley Online Library. 2013 .
  8. Abdalla EK, Stuart KE. Overview of treatment approaches for hepatocellular carcinoma. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-treatment-approaches-for-hepatocellular-carcinoma.Last updated: December 13, 2016. Accessed: April 10, 2017.
  9. Ikeda M, Morizane C, Ueno M, Okusaka T, Ishii H, Furuse J. Chemotherapy for hepatocellular carcinoma: current status and future perspectives. Jpn J Clin Oncol. 2017; 48 (2): p.103-114. doi: 10.1093/jjco/hyx180 . | Open in Read by QxMD
  10. Ganeshan A, Upponi S, Hon L, Warakaulle D, Uberoi R. Hepatic arterial infusion of chemotherapy: the role of diagnostic and interventional radiology. Annals of Oncology. 2008; 19 (5): p.847-851. doi: 10.1093/annonc/mdm528 . | Open in Read by QxMD