This presentation is about hepatocellular carcinoma. Discussing in detail about neoplasia and neoplasia progression,nomencleature, carcinogens, oncogenic microbes, serum tumor markers, pathogenesis, morphology and clinical features.

1. HEPATOCELLULAR CARCINOMA
Ovya pugalenthi aruna (313)

2. CONTENTS
➤ Introduction
➤ Neoplasia and neoplasia progression
➤ Nomenclature
➤ Grade vs stage
➤ Carcinogens and oncogenic microbes.
➤ Serum tumor markers
➤ Pathogenesis
➤ Morphology
➤ Clinical features
➤ Bibliography

3. NEOPLASIA AND NEOPLASIA PROGRESSION
➤

5. TUMOR NOMENCLATURE
➤ Benign tumors
➤ Malignant tumors (cancers)
➤ Carcinoma
➤ sarcoma

6. ➤ Terms for non-neoplastic malformations include Hamartoma
and Choristoma.

8. CARCINOGENS
➤ TOXIN :Aflatoxin from aspergillus.
➤ EXPOSURE: Stored grains and nuts.
➤ IMPACT: Hepatocellular carcinoma.
➤ ORGAN: Liver.
ONCOGENIC MICROBES
➤ MICROBE: HBV,HCV.
➤ ASSOCIATED CANCER: Hepatocellular carcinoma.

9. SERUM TUMOR MARKER
➤ MARKER: α-fetoprotein
➤ ASSOCIATIONS:
Hepatocellular carcinoma,
Endodermal sinus (yolk sac) tumor,
Mixed germ cell tumor,
Ataxia-telangiectasia,
Neural tube defects.
➤ (HE-MAN is the alpha male!)

10. PATHOGENESIS
➤ Three major etiologic associations have been established:
infection with HBV or HCV, alcoholic cirrhosis, and aflatoxin
exposure.
➤ Many variables, including age, gender, chemicals, viruses,
hormones, alcohol, and nutrition, interact in the development of
HCC( tyrosinemia).
➤ In most cases, tumor develops from small-cell, high-grade
dysplastic nodules in cirrhotic livers.
➤ The tumors may arise from both mature hepatocytes and
progenitor cells.
➤ An important criterion is nodule vascularization, visualized by
imaging, which is almost always a clear indication of malignancy.

12. ➤ Well-differentiated
hepatocellular carcinoma

14. ➤ An almost universal feature of hepatocellular carcinoma is the
presence of structural and numeric chromosomal
abnormalities indicative of genomic instability.
➤ The precise origin of genomic instability in this tumor is
not known, but several factors seem to be most important:
Inflammation and regeneration
Acquired mutations in specific oncogenes
Acquired defects in DNA repair
➤ Neither HBV nor HCV contains oncogenes.
➤ The HBV-X gene may have some oncogenic potential.
➤ The tumorigenic capacity of these viruses probably relates
primarily to their capacity to cause chronic inflammation and
increased cell turnover.

15. Most common 1° malignant
tumor of
liver in adults.
contrast CT/MRI

16. MORPHOLOGY
➤ HCC may appear grossly as
A unifocal
A multifocal tumor
A diffusely infiltrative
➤ Particularly in the later two patterns, it may be difficult to
radiologically distinguish regenerative cirrhotic nodules from
neoplasms of similar size.
➤ Discrete tumor masses usually are yellow- white, punctuated
sometimes by bile staining and areas of hemorrhage or necrosis.
➤ HCC has a strong propensity for vascular invasion.

17. Unifocal Multifocal
Diffusely infiltrative

18. Focul-nodular hyperplasia

19. ➤ On histologic examination, HCCs range from well-
differentiated lesions that reproduce hepatocytes arranged in
cords, trabeculae or glandular patterns, to poorly
differentiated lesions, often composed of large, multinucleate
anaplastic giant cells.
➤ In the better-differentiated variants, globules of bile may be
found within the cytoplasm of cells and in pseudocanaliculi
between cells.
➤ Acidophilic hyaline inclusions within the cytoplasm may be
present, resembling Mallory bodies. There is little stroma in
most hepatocellular carcinomas, explaining their soft
consistency.

20. ➤ Extensive intrahepatic
metastases are characteristic,
and occasionally snakelike
masses of tumor invade the
portal vein (with occlusion of
the portal circulation) or
inferior venacava, extending
even into the right side of the
heart.

21. ➤ A distinctive clinicopathologic variant of HCC is the
fibrolamellar carcinoma. It occurs in young male and female
adults (20 to 40 years of age) with equal incidence and has no
association with cirrhosis or other risk factors.
➤ It usually consists of a single tumor with fibrous bands
coursing through it, superficially resembling focal nodular
hyperplasia.
➤ The fibrolamellar variant has a better prognosis than that of
the other, more common variants.

22. CLINICAL FEATURES
➤ Although HCC may manifest with silent hepatomegaly, it is more
often encountered in persons with symptomatic cirrhosis of the liver.
➤ In these persons,
1. a rapid increase in liver size,
2. sudden worsening of ascites, or the appearance of bloody ascites,
3. fever, and
4. pain call attention to the development of a tumor.
➤ There are no good serologic screening tests for hepatocellular
carcinoma.
➤ The most commonly used marker is serum alpha-fetoprotein level,
but it rises only with advanced tumors and only in 50% of patients.

23. ➤ Furthermore, false-positive results are obtained in yolk-sac
tumors, and many non-neoplastic conditions such as
cirrhosis, chronic hepatitis, normal pregnancy, and massive
liver necrosis.
➤ Hence the test is neither specific nor sensitive. Radiologic
screening of patients with cirrhosis at 6-month intervals, looking for
dysplastic nodules or early, small hepatocellular carcinomas, is the
current clinical frontier.

24. ➤ The overall prognosis with advanced HCC is grim.
➤ Resection or ablation may be curative for a single small lesion (most
often those with the uncommon fibrolamellar variant), but does not
prevent de novo emergence of new HCCs in a chronically diseased liver.
➤ Transplantation can be curative,
➤ Median survival is 7 months.
➤ Treatment with sorafenib - a broad-spectrum tyrosine kinase
inhibitor,
➤ In some countries such as Taiwan, HBV immunization programs have
lowered the incidence of HCC substantially, proving that preventive
measures can alleviate the terrible toll taken by this disease in endemic
regions.

25. BONE
METASTASIS

26. PERITONEAL
METASTASIS

27. SURVIVAL RATE
➤ HCC is typically diagnosed late in its course, with a median
survival following diagnosis of approximately 6 to 20
months. In the United States, 2 years survival is less than
50% and 5-year survival is only 10%.

28. BIBLIOGRAPHY
➤ International Consensus Group for Hepatocellular Neoplasia:
Pathologic diagnosis of early hepatocellular carcinoma.
Hepatology 49:658, 2009. [A good example of how change comes to
medicine, individual efforts combining, over years, to achieve a new
consensus.]
➤ Robbins Basic Pathology, NINTH EDITION, Vinay Kumar,
MBBS, MD, FRCPath, Abul K. Abbas, MBBS, Jon C. Aster, MD,
PhD. (637-639)
➤ First Aid For The USMLE Step 1, 2020, 30th Anniversary edition,
MATTHEW SOCHAT,MD, SARAH SCHIMANSKY, MB BCh
BAO, KIMBERLY KALLIANOS, MD, VIKAS BHUSHAN, MD,
VAISHNAVI VAIDYANATHAN, MD, JORDAN ABRAMS
➤