Hepatocellular carcinoma is the most common primary liver tumor. Risk factors include hepatitis B and C infections, alcohol use, and exposure to aflatoxins. It typically presents with nonspecific symptoms in patients with underlying liver disease or cirrhosis. Diagnosis involves blood tests like alpha-fetoprotein along with imaging modalities. Treatment options depend on tumor stage and liver function, and may include surgical resection, liver transplantation, ablation, or chemoembolization. Prevention focuses on hepatitis B vaccination and screening high-risk groups to detect cancer early.

1. HEPATOCELLULAR CARCINOMA
Presented by
HO. Myo Mg Mg
Liver Unit, MGH
23.11.2010

3. • Introduction • Investigations
• Pathogenesis • Management
• Clinical • Prevention
Features

4. Introduction
The most common primary tumor
Sixth most common CA
• Incidence
– 28/100,000 in SEA
(d/t increased prevalence of HBV inf)
– 10/100,000 in South EU
– 5/100,000 in North EU
(d/t increase incidence of HCV related cirrhosis)

5. Pathogenesis
• The precise mechanisms of carcinogenesis
– unknown
• Repeated circle of cell death & regeneration
mutation of hepatocytes
• Preneoplastic changes – hepatocytes
dysplasia can be seen.

6. Aetiological factors
1. Viral infection
(repeated circle of cell death &
regeneration)
2. Aflatoxins
(mutation in proto-oncogene/tumor
suppressor gene, p53)
3. Cirrhosis
(inflammation of the hepatocytes)

7. • Others
– Age
– Sex
– Chemicals
– Viruses
– Hormones
– Alcohol
– Nutrition

8. • The most important HVB infection
(100 folds increase in risk to develop HCC)
• COL (-) – 0.4% per year
(+) – 2-6% per year HCC
• 75-90% of HCC pt - COL (+)

9. Morphology
• Gross
– 3 types
• Unifocal
• Multifocal
• Diffusely infiltrative
– Unifocal lesion mostly seen in pt without COL
– Multifocal lesion mostly seen in pt with COL

10. • Microscopic appearance
– Well to moderately differentiated tu – nearly
similar to the n/l hepatocytes
– Poorly differentiated tu – pleomorphoic

11. • Spread
– Tend to spread by invasion into the vasculature,
mostly the portal vein
– Highly metastases to lymph nodes
– Lung & bone metastasis are not uncommon
and seen in terminal cases

12. Clinical Features
• Seldom characteristics
• Masked by the underlying liver disease
• May present with features of chr. VH or
COL
• May c/o about ill-defined abd
pain/discomfort, fullness of abd, malaise,
fatigue, LOA and LOW.

13. • Examination may reveal hepatomegaly or
a right hypochondrial mass.
• Tumour vascularity can lead to an
abdominal bruit, and hepatic rupture with
intra-abdominal bleeding may occur.

14. Investigations
(i) Serum alpha feto-protein
• Produced by 60% of HCC
• Level depends on size of tu
• May be n/l in small tu
• Both sensitivity and specificity – low
• Can be high in presence of HBV & HCV
replication and a/c liver necrosis

15. • Should be used in conjunction with other
imaging techniques
• In the (-)ce of obvious liver disease, if
there is increasingly rising AFP or AFP >
400 ng/ml, HCC must be search
aggresively.

16. (ii) USG
• Can show small tu about 2-3cm
• Also portal vein involvement and
coexisting COL
• USG contrast agent can also be used

17. (iii) CT and MRI
• Contrast enhanced helical CT can show
HCC – hypervascular appearance.
• MRI can also be used instead of CT.
• But tumors <2cm – difficult to differentiate
from hyperplastic nodule of cirrhosis.

18. (iv) Liver biopsy
• To confirm the diagnosis & exclude
metastasis tu from other
• Done in pt with large tu, no COL and HBV
inf
• Avoid in pt eligible for transplantation or
surgical resection (<2% risk of tumor
seedling along the needle tract)

19. Tumor Staging Systems
• Various systems used to determine the
stages of HCC
• Most of them describe the prognosis of
HCC depending upon
– The severity of underlying liver d/s
– The size of tumor
– Extension of tumor into adjacent structures
– Presence of metastasis

20. OKUDA SYSTEM
CRITERIA POSITIVE NEGATIVE
Tu. size >50% <50%
Ascities Clinically detectable Clinically absent
Albumin <3 mg/dl >3 mg/dl
Bilirubin >3 mg/dl <3 mg/dl

21. Stage Survival rate
• I – no positive 8.3 mth
• II – 1 or 2 (+)ve 2 mth
• III – 3 or 4 (+)ve 0.7 mth

22. • Does not stratify pt by vascular invasion or
presence of nodal metastasis
• Not important for treatment (surgery)
• Only pure clinical scoring system

23. TNM staging (American Joint Committee
on Cancer )
• This system recognizes the most important
predictors of prognosis
 The number and size of tumor
 Extent of vascular invasion
 Condition of regional lymph node
 Presence or absence of metastasis

24. Primary tumor
• TX – primary tu cannot be assessed
• T0 – no evidence of primary tu
• T1 – solitary tu without vascular invasion
• T2 – solitary tu with vascular invasion
• T3a – multiple tu more than 5 cm
• T3b – single or multiple tu of any size
involving maj branch of portal vein
of hepatic vein
• T4 – tu with direct invasion of adjacent
organs other than gallbladder or with
perforation of visceral peritoneum

25. Regional lymph node
• NX – regional lymph cannot be assessed
• N0 – no regional lymph metastasis
• N1 – regional lymph metastasis
Distant metastasis
• M0 – no distant metastasis
• M1 – distant metastasis

27. Five year survival rates
• Stage I – 55%
• Stage II – 37%
• Stage III – 16%
• Stage IV <16%

28. Barcelona Clinic Liver Cancer
System
• Considers in combination of tu burden,
hepatic function and performance status
together with evidence based treatment
argorithm
• Can provide not only the prognosis but
also the treatment plan

29. STAGE TU BURDEN CHILD- PST MEDIUM
PUGH SURVIVAL
Very early (0) Single tu <2cm A 0
Early (A) Single tu <5cm or A-B 0-2 53 mth
3 tu <3cm each
Intermediate (B) Single tu >5cm or A-B 0-2 16 mth
Multiple tu largest >3cm
Advanced (C) Any tu burden A-B 1-2 7 mth
Terminal (D) Any tu burden C >2 3mth

30. Hepatocellular carcinoma
Very early stage Early stage Intermediate Advanced Terminal
stage stage stage
Single 3 nodules
Portal increase Asso: d/s
pressure
Normal No Yes
Resection Transplantation Ablation Chemo- Newer
Symptomatic
embolisation agent

31. Management options
• Hepatic resection
• Liver transplantation
• Transarterial chemo-embolization

32. Hepatic resection
• Treatment of choice for non-cirrhotic pt
• 5yr survival rate – 50%
• Recurrence rate at 5 yr – 50%
• Can be consider in cirrhotic pt with small tu
and good liver functions (risk of a/c liver
failure)

33. • Tu clearence margin at least 1-2cm
• In COL pt, the volume of resection must be
minimized to avoid post-operative liver
failure

34. Liver transplantation
• Curative treatment for cirrhotic pt
• 5 yr survival rate – 75%

35. Transarterial chemo-embolisation
• Embolisation of hepatic artery with
gelfoam and doxirubicin
• Used in pt unresected HCC and good liver
function
• Contraindicated in pt with cirrhosis and
multifocal HCC
• Survival rate 60% at 2 yr and lost in 4 yr.

36. Radio-frequency ablation
• used to produce coagulative necrosis of ca
cells

37. Prevention
• As viral infection with HBV is the most
important aetiology and HBV vaccination is
already avaliable, vaccination should be
done.
• Consider about the universal precaution in
handling infected blood and its products in
medical personal
• Reduce the risk of vertical transmission of
hepatitis viruses

38. • Early diagnosis and prompt treatment
– To get early diagnosis, screening procedures
should be done in endemic area
– All pt must be given prompt treatment after
being diagnosed as HCC or chr. hepatitis
• So that tu burden will be reduced and QOL
of the pt will improve.

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