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Liver cancer: Difference between revisions
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<section begin="radiology" />'''Hepatocellular carcinoma''' (<abbr>HCC</abbr>) is the most common histological type of '''liver cancer'''. It’s mostly a disease of older men. In almost all cases it develops in an already [[Cirrhosis|cirrhotic]] liver, so the risk factors for HCC are the same as those for cirrhosis.<section end="radiology" /> | <section begin="surgery" /><section begin="oncology" /><section begin="radiology" />'''Hepatocellular carcinoma''' (<abbr>HCC</abbr>) is the most common histological type of '''liver cancer'''. It’s mostly a disease of older men. In almost all cases it develops in an already [[Cirrhosis|cirrhotic]] liver, so the risk factors for HCC are the same as those for cirrhosis.<section end="radiology" /> | ||
The incidence of HCC is increasing. Due to the long asymptomatic period, most cases are irresectable at presentation. This gives it a poor prognosis, with a 5-year survival of 30 – 50%. | The incidence of HCC is increasing. Due to the long asymptomatic period, most cases are irresectable at presentation. This gives it a poor prognosis, with a 5-year survival of 30 – 50%. | ||
== Etiology == | == Etiology == | ||
80% of HCC are preceded by cirrhosis, so the risk factors for HCC are similar to those of cirrhosis. However, some risk factors which are independent of cirrhosis are known: | |||
Common causes: | Common causes: | ||
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Rare causes: | Rare causes: | ||
* | * Overuse of hepatotoxic drugs like [[paracetamol]] | ||
* [[Haemochromatosis]] | * [[Haemochromatosis]] | ||
* [[Autoimmune hepatitis]] | * [[Autoimmune hepatitis]] | ||
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A special form of HCC called ''fibrolamellar HCC'' is very rare. Only 200 new cases are diagnosed every year. This type of HCC develops in young adults without cirrhosis or other risk factors for HCC. | A special form of HCC called ''fibrolamellar HCC'' is very rare. Only 200 new cases are diagnosed every year. This type of HCC develops in young adults without cirrhosis or other risk factors for HCC. | ||
== | === Staging === | ||
The Barcelona Clinic Liver Cancer (BCLC) staging is the most frequently used staging system, and at least the one preferred in POTE. The Child-Pugh score and ECOG are important in determining the BCLC stage. | The Barcelona Clinic Liver Cancer (BCLC) staging is the most frequently used staging system, and at least the one preferred in POTE. The Child-Pugh score and ECOG are important in determining the BCLC stage. | ||
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The so-called ''Milan criteria'' are used to evaluate whether the patient is a candidate for liver transplant or not. The Milan criteria are fulfilled if there is either a single tumour not > 5 cm, or up to 3 tumours, none of which are > 3 cm. There must also be no vascular invasion or extrahepatic spread. | The so-called ''Milan criteria'' are used to evaluate whether the patient is a candidate for liver transplant or not. The Milan criteria are fulfilled if there is either a single tumour not > 5 cm, or up to 3 tumours, none of which are > 3 cm. There must also be no vascular invasion or extrahepatic spread. | ||
== Clinical features == | |||
The tumour itself is usually asymptomatic, but the patient usually has symptoms from the underlying disease ([[cirrhosis]] or [[hepatitis]]), like [[ascites]] and [[jaundice]]. [[Constitutional cancer symptom|Constitutional cancer symptoms]] like weight loss, weakness, abdominal pain may be present but may also be caused by the underlying disease.<section begin="radiology" /> | |||
== Diagnosis and evaluation == | |||
Patients at high risk for <abbr>HCC</abbr> (cirrhosis of any cause, chronic hep B) should be screened regularly for HCC. Screening involves measuring abdominal [[ultrasound]] and [[AFP]] levels. Focal lesions in a cirrhotic liver are primary liver cancer until proven otherwise. AFP is elevated only in 50% of cases, in which case the level correlates with the tumour size. | |||
Contrast [[CT]] or [[MR]] confirms the diagnosis and shows any extrahepatic spread. Typical features on imaging include early contrast uptake, “washout”, and vascular spread.<section end="radiology" /> | |||
[[Liver biopsy]] is often not needed as the definitive diagnosis can be made with imaging, and biopsy carries a risk of bleeding and tumour spread. | |||
== Treatment == | == Treatment == | ||
[[File:Treatment of HCC.gif|thumb|Treatment of HCC.<ref>https://abdominalkey.com/liver-transplantation-for-hcc-the-milan-criteria/</ref>]] | |||
Generally, only BCLC stages 0 and A are curable. Curative modalities include surgical resection, liver transplantation, as well as local ablative techniques. The choice of modality depends on the BCLC stage. For terminal stage (D), no tumor-directed therapy is indicated; only palliative care is used. | |||
=== Surgery === | |||
Surgical resection, preferably laparoscopically, is an option for very early or early stage liver cancer. Anatomical resection refers to resection which respects segmental and lobar anatomy. This may include segmentectomy (or bisegmentectomy or trisegmentectomy), hemihepatectomy, or sectionectomy. Atypical resection refers to resection which does not respect the liver anatomy. | |||
=== Liver transplantation === | |||
[[Liver transplantation]] is a treatment option for early stage tumour. Liver transplantation is only considered if the Milan criteria are fulfilled.<section end="surgery" /> | |||
=== Local ablation === | |||
Local ablation of the tumour, by radiofrequency or microwave ablation, or percutaneous ethanol injection, may be curative options in intermediate stage tumours. | |||
The | === TACE === | ||
Transarterial chemo-embolisation (TACE) is a minimally invasive technique which is the standard of care for patients with intermediate stage HCC. It involves intra-arterial injection of an emulsion of oil and a chemotherapeutic drug followed by embolisation of the blood vessel. The theory is that the combination of the chemotherapeutic drug and the ischaemia kills the cancer cells. TACE can not be used for cure and is therefore used with palliative intent. | |||
=== Sorafenib === | |||
<noinclude> | Sorafenib is a small molecule protein kinase inhibitor which is indicated for advanced stage HCC. It inhibits a variety of protein kinases. Sorafenib may be used as palliation in advanced stage HCC.<section end="oncology" /><noinclude> | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Gastrointestinal surgery]] | [[Category:Gastrointestinal surgery]] | ||