Updated: 10/28/2019

Hepatocellular Carcinoma (HCC)

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  • 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
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.ON.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? Review Topic

QID: 108436
1

Acute angle branching fungus

64%

(7/11)

2

Curved gram-negative bacteria

18%

(2/11)

3

Enveloped DNA virus

0%

(0/11)

4

Naked DNA virus

0%

(0/11)

5

Trematode from undercooked fish

18%

(2/11)

M1

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