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HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma is a malignant tumor derived from hepatocytes. It is frequently found in association with chronic liver disease, especially cirrhosis liver cancer, hepatocellular carcinoma, cancer of the liver.

Epidemiology

Hepatocellular carcinoma is the predominant primary malignancy of the liver. It accounts for more than 80% of these tumors and has an annual incidence of approximately 1 million new cases of liver cancer, hepatocellular carcinoma, cancer of the liver. Eighty to ninety percent of patients with hepatocellular carcinoma have underlying cirrhosis; alcoholic cirrhosis is the predominant type in Western countries, whereas in the Far East, posthepatic cirrhosis is more common.

Etiology

Hepatitis B Virus Infection

A strong correlation exists between hepatocellular carcinoma and hepatitis B surface antigen (HBsAg) carriers, with some authors asserting that chronic infection with hepatitis B virus may be responsible for as much as 80% of human

Hepatitis C Virus Infection

Persistent hepatitis C virus infection is closely linked to the occurrence of hepatocellular carcinoma; antibodies to hepatitis C virus are found in as many as 80% of patients with hepatocellular carcinoma in countries such as

Aflatoxins

The toxins produced by Aspergillus flavus and Aspergillus parasiticus, which are usually associated with grains and food products, such as peanuts, are known hepatotoxins; however, chronic exposure seems to be needed for liver cancer. 

Synthetic Hepatocarcinogens

Azo dyes and aromatic amines, N-nitroso compounds, chlorinated hydrocarbons, and pesticides have been implicated.

Alcohol

Alcohol may act as a cocarcinogen, promoting the development of cirrhosis.

Other Factors Associated with Hepatocellular Carcinoma

Radiation, thorotrast, smoking, alpha1 -antitrypsin deficiency, hemochromatosis, Budd-Chiari syndrome, porphyria, oral contraceptives, and anabolic androgenic steroids, among others, have been implicated.

Clinical Features

Initial Complaints

General malaise, upper abdominal pain, anorexia, abdominal fullness, weight loss, ascites, palpable mass, nausea, vomiting, jaundice, and wasting are the most common presenting symptoms. In individuals without cirrhosis, abdominal pain and a palpable abdominal mass are the most common initial complaints. Acute abdominal pain is almost always associated with hemoperitoneum caused by tumor rupture or 

Clinical Manifestations

When a mass is palpated, an arterial bruit may rarely be heard on auscultation. The right diaphragm may be elevated. In addition, other less common clinical observations include hepatomegaly, ascites, splenomegaly, jaundice, dilated abdominal veins, varices, gastrointestinal bleeding, fever, and encephalopathy.

Diagnosis

Histologic diagnosis is ideal but may rarely result in severe complications if a coagulopathy is present and cannot be corrected. A percutaneous biopsy with ultrasound or computed tomography (CT) guidance is almost always possible; open biopsy is rarely necessary. A presumed diagnosis without histologic confirmation may be made based on a

Laboratory Findings

Alpha-fetoprotein, fucosylated AFP, DCP, variant alkaline phosphatase (ALP), carcinoembryonic antigen (CEA), novel gamma-glutamyltranspeptidase isoenzyme, alpha- L-fucosidase, thrombin-antithrombin III complex, isoferritins, and transcobalamin 1, among others, have been used with various degrees of success as 

Radiologic Diagnosis  
Sonography.

Real-time sonography can detect liver masses, changes associated with cirrhosis, and the status of hepatic vessels and bile ducts. Most hepatocellular carcinomas tend to be faintly hypoechoic, although they may be difficult to 

Treatment

Surgical--The University of Pittsburgh Experience  
Surgical Resection.

Between 1981 and 1996, 101 patients underwent hepatic resection (Hx) for hepatocellular carcinoma. Of these, 31.7% had concomitant cirrhosis, 32.7% had bilobar tumors, 35.6% had multiple tumors, 26.7% had macrovascular invasion, 15.8% had positive margins on pathologic examination, and none had positive lymph nodes. The

Liver Transplantation--General Observations.

Between 1981 and 1996, 307 patients underwent orthotopic liver transplantation (OLTx) in the presence of hepatocellular carcinoma at the University of Pittsburgh Medical Center. Of these, 92.2% had concomitant cirrhosis, 50.8% had multiple tumors, 33.6% had bilobar tumors, 20.2% had macrovascular invasion, 5.9% had positive

Prediction of Recurrence.

In an effort to reduce placing donor livers in patients with certain, early hepatocellular carcinoma recurrence but at the same time not denying transplantation to those who would enjoy long-term survival after OLTx for hepatocellular carcinoma, the authors recently developed a multivariate clinical model that could predict, on an individual patient

Nonsurgical Treatment  

Systemic Chemotherapy.

The response rate in most studies is poor, although successes have been reported. Currently, chemotherapy should be reserved for cases in which other modalities are not possible or as an adjunct to

Intra-Arterial Chemotherapy.

Chemotherapy is directed in high concentrations at the tumoral site by catheterization of the hepatic artery. Results have not met the initial expectations, and complications are 

Arterial Embolization.

Gelfoam embolization of the arterial supply to the tumor with 1-mm to 2-mm particles has shown encouraging results in select cases. Rearterialization may occur, and frequent treatments may be required. Complications from this modality of treatment include aseptic cholecystitis, splenic infarcts, and 

Chemoembolization and Targeting Chemotherapy.

Chemotherapeutic agents are added to the arterial embolization technique, sometimes mixed with lipiodol. Results have varied in success.

Radiation Therapy.

External radiation has associated complications, such as late hepatic failure in cirrhotics. Results for both external and internal radiation are

Intratumor Ethanol Injection.

Injection of absolute ethanol into tumors of inoperable patients has been used by various groups with relative