Hepatic carcinoma is one of the most prevalent, malignant disease in the world which is called “the king of cancer” killing up to 1.25 million persons per year.
Hepatocellular carcinoma is the seventh most common cancer in the world and the most common cancer diagnosed in men, with a male female ratio of 7:1 in high-incidence regions, such as China and Korea ,south-east Asia , especially the hepatocellular carcinoma which is often secondary to liver cirrhosis.
A large number of associations between hepatic viral infections, environmental exposures, alcohol use, smoking, genetic metabolic diseases, cirrhosis, and the development of HCC have been recognized.
What is clear from research is that the development of HCC is a complex and multistep process that involves any number of these risk factors. The certain reason is unknown, but HBV, HCV infection may play an important role in the disease.
Once patients infected with hepatitis C develop cirrhosis, the risk of hepatocellular carcinoma is 1% to 2% per year.
The latency period between hepatitis B or C exposure and the development of hepatocellular cancer varies between 30 and 50 years.
In China, most HCC patients show HBV or HCV infection or carry the virus. Alcoholic cirrhosis is a predisposing factor for HCC. Aflatoxins are important carcinogens in experimental animals.
Under the microscope, hepatic carcinoma can be divided into hepatocelluar, biliary cell or mixed cell carcinoma. According to gross appearance, we divide the cancer into three types: nodular, massive, diffuse. Small HCC refers to the tumor less than 5cm
HCC largely metastasizes to the lung, bone, peritoneum and intrahepatic metastases, and preoperative history and examination should focus on symptoms referable to these areas. Extent of disease in the liver including macrovascular invasion and the presence of multiple liver masses must also be considered. A preoperative chest radiograph is mandatory and should be followed with CT if any abnormalities are present. Routine bone scans are not performed unless there are suggestive symptoms or signs.
Symptoms and signs
Most commonly, patients presenting with HCC are men 50 to 60 years of age . who complain of right upper quadrant abdominal pain, weight loss, and a palpable mass.
Unfortunately, in unscreened populations, HCC tends to present at a late stage because of the lack of symptoms in early stages. Presentation at this advanced stage is often with a vague right upper quadrant abdominal pain that sometimes radiates to the right shoulder.
Nonspecific symptoms of advanced malignancy such as anorexia, nausea, lethargy, and weight loss are common.
Another common presentation of HCC is hepatic decompensation in a patient with known mild cirrhosis or even in patients without previously recognized cirrhosis.
Some patients initially experience an acute abdominal event, such as rupture of the tumor, hemorrhage, hemobilia or fever with unknown origin. Less than 1% of cases of HCC present as a paraneoplastic syndrome, most commonly hypercalcemia, hypoglycemia, and erythrocytosis.
Physical findings depends on the stage of the disease .Hepatomegaly is the most common sign. Two thirds of the patients with an obvious cancer exhibit many signs of liver disease, eg. Abdominal pain and tenderness, dyspnea, hepatomeghly, splenomegaly jaundice, ascites, peripheral edema, weight loss. Spider angiomas and signs of portal hypertension.
Diagnosis qualitative and orientation
Elevated AFP level deserves special notice because of its specific value.
In China, 69-93% of HCC patients exhibit positive results. It is an important screening test to find out early stage HCC.AFP may return to normal after successful surgical resection and is a useful tumor marker for follow up. AFP levels are particularly useful in monitoring treated patients for recurrence.
Elevation of AFP may also be found in acute viral hepatitis, chronic active liver disease, teratocarcinoma, yolk sac tumors and pregnancy. Rarely, some hepatic metastasis carcinoma may secret AFP.
Proposed surveillance for the early detection of hepatocellular carcinoma among high-risk populations includes liver ultrasonography every 3 to 6 months and evaluation of alkaline phosphatase, albumin, and AFP
A recent study found that preoperative serum C-reactive protein (CRP) levels can predict early recurrence and poor prognosis in patients with hepatocellular cancer who undergo resection.
Location of the tumor
Ultrasound plays a significant role in screening and early detection of HCC , can detect 80% of tumors, tumors larger than 2cm can be found. It is a noninvasive examination and available for follow-up or screening, is a routine examination in chronic disease patient.
CT&enhanced CT may find tumor less than 1cm ,enhanced CT aimed at diagnosing HCC take advantage of the hypervascularity of these tumors and may differentiate from hepatic anginoma and other liver disease
MRI DSA ECT PET Laparoscopy, percutaneous fine needle biopsy are also available. But the needle aspiration may add some hazard for hypervascular masses which can cause hemorrhage.
Computed tomography (CT) or magnetic resonance imaging (MRI) should be performed to better define the extent and number of primary lesions, vascular anatomy, vessel involvement, and extrahepatic disease. Helical CT or MRI should include early arterial phase enhancement.
A number of staging systems for HCC exist, but none has ever been shown to be particularly superior. The TNM staging system is not routinely used for HCC, and it does not accurately predict survival because it does not take liver function into account. The Okuda system is a good example of a system that takes into account liver function and tumor-related factors. It is simple and reliably distinguishes patients with a prohibitively poor prognosis and those with potential for long-term survival.
American Joint Committee on Cancer (AJCC) TNM Staging for Liver Tumors (Including Intrahepatic Bile Ducts
Orthotopic liver transplant
Acetic acid injection
Thermal ablation (cryotherapy,
radiofrequency ablation, microwave)
External beam radiation
Surgical Assessment and Evaluation
Surgery, including transplantation, remains the only curative modality for hepatocellular cancer.
Presurgical assessment may require additional imaging to rule out metastatic disease and to better assess the extent of intrahepatic disease. Determination of liver reserve and comorbid conditions are essential in the assessment of potential surgical candidates.
First-choice treatment. In general, however, only 10% to 20% of patients are considered to have resectable disease. Mortality rates for partial hepatectomy range from 1% to 20%, but if performed in healthy patients without advanced cirrhosis, most modern series have a mortality rate less than 5%. If the tumor is resectable , the operation should be considered, especially small HCC less than 5cm.The indication of the operation are as follows, The mass is limited, not larger than half of the liver, no severe liver cirrhosis, no large vessle, diaphragm, peritoneal invasion, no obvious jaundice, ascites, and metastasis.
The treatment of choice for noncirrhotic patients is surgical resection whenever possible. Resection of liver tumors in the cirrhotic patient is more controversial. The best indication for resection is in cirrhotic patients with small peripheral lesions and preserved liver function (Child-Pugh class A). Treatment paradigms have been developed that include Child-Pugh classification, fibrosis score, and the determination of the future liver remnant (ie, the amount of the remaining viable liver after resection) to determine the safety of resectability. If deemed unsafe for resection, small hepatocellular carcinoma tumors are treated with ablation or liver transplantation
Theoretically, liver transplantation is the ideal treatment for HCC because it addresses both the liver dysfunction and the HCC. The limitations of transplantation are the need for chronic immunosuppression as well as the lack of organ donors.
Early series of transplantation for HCC had high recurrence rates and relatively poor long-term survival. This has largely been attributed to the fact that most of these patients were being transplanted for advanced disease.
Refinements in patient selection, patients with single tumors less than 5 cm or multiple tumors no more than three in number and 3 cm have resulted in improved outcome. Long-term survival rates in recent years have ranged from 25% to 75%.
The United Network for Organ Sharing (UNOS) criteria for liver transplant include patients who are not candidates for resection who have (1) a single tumor that is 5 cm or less in diameter, or who have 2 to 3 tumors, each 3 cm or less in diameter; (2) no macrovascular invasion; and (3) no extrahepatic spread to surrounding lymph nodes, lungs, abdominal organs, or bone.
Patients with advanced cirrhosis (Child’s B and C) and early-stage HCC should be considered for transplant, whereas those with Child’s A cirrhosis have similar results with transplant and resection and should probably undergo resection .
Ethanol injection (percutaneous or open operation), HACE, Mircowave coagulative therapy, cryotherapy, systemic chemotherapy.
Emergent tumor resection if possible or hepatic artery ligation
Follow-up consists of imaging studies every 3 to 6 months for 2 years, then annually; AFP levels, if initially elevated, can be measured every 3 months for 2 years, then every 6 months.
Other Liver tumor
Hepatoblastoma: is a malignant disease finding in child; resection rate is higher than HCC. Over 50% long term survival in patient, who undergoing resection of the tumor is expected.
Hepatic adenomas: related to oral contraceptive is important in differential diagnosis from HCC.
Hemangiomas, maybe no symptoms, rare rupture when it grows too huge , may cause pain ,upper abdominal malaise, compression symptoms.
Metastasis carcinoma : often secondary to colon, gastric, gall bladder, pancreatic ,breast, lung carcinoma, multiple node.