Updated: 10/28/2019

Hepatocellular Carcinoma (HCC)

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
4
0
0
0%
0%
Evidence
3
0
0
0%
0%
Videos / Pods
1
Topic
Snapshot
  • A 65-year-old man presents to his primary care physician for right upper quadrant abdominal pain. He was diagnosed with hepatitis C infection, complicated by hepatic cirrhosis. Abdominal ultrasound demonstrates a focal hepatic lesion. He underwent a multi-phase contrasted abdominal CT scan, which demonstrated an enhancing focal hepatic mass during the arterial phase with rapid washout during the portal venous phase.
Introduction
  • Overview
    • primary malignancy affecting hepatocytes 
    • may result in a paraneoplastic syndrome
      • hypoglycemia
      • erythrocytosis
      • hypercalcemia
      • severe diarrhea
      • EPO, insulin-like growth factor, and PTHrP 
  • Epidemiology
    • risk factors
      • cirrhosis (80-90% of cases)
      • chronic hepatitis B infection
      • chronic hepatitis C infection
      • aflatoxin, produced by Aspergillus species
      • alcohol use
      • hereditary hemochromatosis
      • α1-antitrypsin deficiency
      • obesity
      • diabetes mellitus
      • non-alcoholic fatty liver disease
  • Pathophysiology
    • β-catenin activation and inhibition of p53 play a role in the development of hepatocellular carcinoma
Presentation
  • Symptoms/physical exam
    • right upper quadrant pain
    • weight loss
    • ascites
    • obstructive jaundice
    • however, patients can be asymptomatic and be incidentally found to have HCC due to routine screening in patients with cirrhosis
Imaging
  • Abdominal ultrasound
    • indication
      • monitoring lesions < 1 cm every 3-6 months for up to 2 years 
      • can be used as a screening imaging study in patients with cirrhosis
        • if there are findings concerning for HCC, then confirmatory imaging (or possibly biopsy) is needed 
    • findings
      • masses with poorly defined margins
      • irregular echoes
  • Multi-phase contrasted CT abdomen
    • indication
      • a confirmatory imaging study
    • findings
      • typically a focal nodule with early enhancement (in the arterial phase) and rapid contrast washout (in the portal venous phase)
  • Multi-phase contrasted MRI abdomen
    • indication
      • a confirmatory imaging study
    • findings
      • enhancement in the arterial phase with rapid contrast washout
Studies
  • Serum labs
    • α-fetoprotein (AFP) 
      • if elevated > 400-500 ng/mL
        • may be suggestive of HCC
        • may be seen in patients with active liver disease (e.g., HCV or HBV infection)
      • a normal value does not exclude HCC
Differential
  • Hepatic adenoma
    • differentiating factor
      • benign liver tumor seen in patients with prolonged contraception use, anabolic steroid use, glycogen storage disorders, and pregnancy
Treatment
  • Surgical
    • resection
      • indication
        • recommended if the lesion is resectable and the patient has good performance status
    • liver transplantation
      • indication
        • recommended based on the patient's performance status and that the tumor is unresectable
    • liver-directed therapies
      • indication
        • in patients with local disease who are not candidates for resection or liver transplantation
          • may potentially down-stage the tumor, enabling the possibility of transplantation or resection
      • modalities
        • radioablation
          • delivers local radiofrequency thermal energy
        • transarterial chemoembolization (TACE)
          • delivers high-dose chemotherapy (e.g., cisplatin and doxorubicin) to local areas in the liver 
            • therefore, this decreases the risk of developing systemic toxicities
Complications
  • Hepatic failure
  • Hemoperitoneum
  • Portal, hepatic, or renal vein thrombosis

Please rate topic.

Average 5.0 of 1 Ratings

Questions (4)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M1.ON.17.4707) A 67-year-old male presents to his primary care physician for evaluation of fever and an unintended weight loss of 25 pounds over the last 4 months. He also has decreased appetite and complains of abdominal pain located in the right upper quadrant. The patient has not noticed any changes in stool or urine. He emigrated from Malaysia to the United States one year prior. Social history reveals that he smokes half a pack per day and has 5-7 drinks of alcohol per day. The patient is up to date on all of his vaccinations. Physical exam findings include mild jaundice as well as an enlarged liver edge that is tender to palpation. Based on clinical suspicion, biomarker labs are sent and show polycythemia and an elevated alpha fetoprotein level but a normal CA 19-9 level. Surface antigen for hepatitis B is negative. Ultrasound reveals a normal sized gallbladder. Given this presentation, which of the following organisms was most likely associated with the development of disease in this patient?

QID: 108436
1

Acute angle branching fungus

24%

(12/49)

2

Curved gram-negative bacteria

14%

(7/49)

3

Enveloped DNA virus

27%

(13/49)

4

Naked DNA virus

6%

(3/49)

5

Trematode from undercooked fish

27%

(13/49)

M 1 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (3)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (5)
Private Note