2. Epidemiology
• Hepatocellular carcinoma is the most common primary
malignancy of liver worldwide & one of the most common
malignancies worldwide (5th
).
• Its common in cirrhotics and hepatitis B and hepatitis C virus
infection
• Male to female ratio: 4:1
• Right lobe is commonly involved
• Usually unicentric
3. AETIOLOGY
• Hepatitis -increase risk 100 -200 fold, 75-80% of HCC are positive for HBs Ag.
• Hepatitis C
• Cirrhosis - 70% of HCC arise on top of cirrhosis
• Toxins -Alcohol ,Tobacco ,Aflatoxins ,DDT, Herbicides
• Clonarchis sineisis infection
• Inherited metabolic diseases
Hemochromatosis
Alpha-1 antitrypsin deficiency
Glycogen storage disease
Porphyria cutanea tarda
Autoimmune hepatitis
• Anabolic steriods , OCP’s
4. CLINICAL FEATURES
• Painless mass (irregular,hard) in right
hypochondriac region with loss of weight and
apetitie.
• Jaundice if present is due to heptic dysfunction,
but occasionaly due to compression of bile duct
• Ascites , splenomegaly and features of portal
hypertension
• Hepatic thrill /bruit
• Fever may be present due to tumour necrosis
5. • Gastrointestinal bleeding may be the
presentation in 10 % due to portal
hypertension
• Occasionally may present with paraneoplastic
syndromes 1%-
• Features of chronic liver diseases-
jaundice,dilated veins, palamar erythema,
gynecomastia, testicular atrophy.
6. HISTOLOGY
• Well differentiated
• Moderately differentiated
• Poorly differentiated
GROSSLY CLASSIFIED INTO
Hanging type
Pushing type
Infiltrative type
7. Spread of tumours
• Lymphatic spread
Lymphatic within liver, to lymph node in
porta hepatis, and other abdominal lymph
nodes.
Blood spread
To lung, bone, adrenals
Direct infiltration
To diaphragm and neighboring structures
10. • No elevation of AFP
• Tumor marker is vitamin b12 binding protein
• Increase in neurotensin levels
• Left lobe commonly involved
• Involve lymph node commonly
• Fibrous stroma with hyaline band are typical
11.
12. Investigations
1) AFP produced by 70% of HCC
> 400ng/ml
PIVKA II increased in 80 percent of patient
2) Imaging
USG: focal lesion in the liver of a patient with cirrhosis is highly likely
to be HCC,Hyperechoic mass,mosiac pattern with thin halo
- Spiral CT of the liver: more reliable and ideal
- MRI with contrast enhancement: useful for small hcc.MR
angiography is done to see tumor thrombus in portal vein and IVC
13. Biopsy is rarely required for diagnosis in 1-3 %
Biopsy of potentially operable lesions should be avoided
where possible
• Celiac angiography
• Liver function test
• Ascetic tap for cytology
• Metastatic workup- HRCT chest
17. Treatment(SURGERY)
• The only proven potentially curative therapy for HCC
• Hepatic resection or liver transplantation
• Patients with single small HCC (≤5 cm) or up to three
lesions ≤3 cm
• Involvement of large vessels (portal vein, Inferior vena
cava) doesnt automatically mitigate against a
resection; especially in fibrolamellar histology
18. • Hepatic resection should be considered in HCC
and a non-cirrhotic liver (including
fibrolamellar variant)
• Resection can be carried out in highly selected
patients with cirrhosis and well preserved
hepatic function (Child-Pugh A) who are
unsuitable for liver transplantation. It carries a
high risk of postoperative decompensation
19. • Recurrence rates of 50–60% after 5 years after
resection are usual (intrahepatic)
• Liver transplantation should be considered in any
patient with cirrhosis
• Patients with replicating HBV/ HCV had a worse
outlook due to recurrence and were previously
not considered candidates for transplantation
20.
21. Treatment (non-Surgical)
should only be used where surgical therapy is
not possible.
1) Percutaneous ethanol injection (PEI)
• has been shown to produce necrosis of small HCC.
• It is best suited to peripheral lesions, less than 3 cm in diameter
2) Radiofrequency ablation (RFA)
• High frequency ultrasound to generate heat
• good alternative ablative therapy
• No survival advantage
• Useful for tumor control in patients awaiting liver transplant
22. 3) Cryotherapy
• intraoperatively to ablate small solitary tumors outside a planned
resection in patients with bilobar disease
4) Chemoembolisation
• Concurrent administration of hepatic arterial chemotherapy
(doxirubicin) with embolization of hepatic artery
• Produce tumour necrosis in 50% of patients
• Effective therapy for pain or bleeding from HCC
• Affect survival in highly selected patients with good liver reserve
• Complications: (pain, fever and hepatic decompensation
23. 5) Systemic chemotherapy
– very limited role in the treatment of HCC with poor esponse
rate
– Best single agent is doxorubicin (RR: 10- 20%)
– Combination chemotherapy didn’t response but
survival
– should only be offered in the context of clinical trials
6) Hormonal therapy
- Nolvadex, stilbestrol and flutamide
7) Interferon-alfa
8) retinoids and adaptive immunotherapy (adjuvant)
