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neo_hepatic

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hepatocellular carcinoma

introduction

  • globally, liver cancer is the 5th most common cancer in men, and the 7th most common in women
  • 80-90% have cirrhosis as the main risk factor
  • it is rare < 40 years age, and reaches a peak at 70 years age
  • hepatocellular carcinoma due to HCV is the fastest rising cause of cancer-related death in the Western world, with incidence in USA tripling over past 20 years while 5yr survival rate remains below 12%.
  • surveillance using alpha fetoprotein levels (20ng/ml cutoff gives sensitivity only 25-65%) and US imaging every 6-12 months for those with cirrhosis but no cancer may reduce mortality of hepatocellular carcinoma by up to a third.1)

risk factors

    • 5 year cumulative risk of hepatocellular carcinoma in patients with cirrhosis 5-30% depending upon:
      • cause: highest risk with HCV
      • region/ethnicity: Japan 30%, USA 17%
      • stage of cirrhosis: highest risk is among those with decompensated disease
    • globally, chronic HBV infection accounts for 50% of all cases, and virtually all childhood cases
      • although HBV can cause cancer without cirrhosis, 70-80% of cancer patients due to HBV have cirrhosis
      • risk of cancer with chronic HBV increases if either:
        • stage of cirrhosis
        • long duration of HBV infection
        • male
        • elderly
        • FH hepatocellular carcinoma
        • exposure to mycotoxin aflatoxin
        • have used alcohol or tobacco
        • co-infected with HCV or hepatitis delta virus
        • high levels of HBV hepatocellular replication (ie. high levels of HBV DNA)
        • infected with HBV genotype C
    • HCV infection confers a 15-20x risk of hepatocellular carcinoma (but most of this risk is limited to those with advanced hepatic fibrosis or cirrhosis)
      • HCV epidemics: Japan 1920's; southern Europe 1940's; Nth America 1960's-70's;
      • in patients with hepatocellular carcinoma, HCV markers are found in 80-90% if Japanese, 44-66% if Italian, 30-50% if USA.
      • risk factors of hepatocellular carcinoma with HCV infection include:
        • older age at time of infection
        • males
        • coinfection with HIV or HBV
        • possibly diabetes or obesity
        • chronic heavy alcohol intake
    • prolonged heavy use of alcohol
      • daily ingestion > 40g alcohol increases risk independently by 1.5-2x, and in combination with HCV, and to a lesser extent HBV infection
    • appears to be a 1.5-2.0x risk factor for hepatocellular carcinoma but requires further study
    • 90% of obese patients have fatty liver disease, while up to 70% of type 2 diabetics have fatty liver disease

diagnosis

  • 4 phase (unenhanced, arterial, venous and delayed) CT scan
    • should be adequate to give a diagnosis of focal hepatic mass > 2cm diameter in patients with cirrhosis
    • patients with lesions 1-2cm diameter generally require confirmation with dynamic contrast-enhanced MRI or an alpha-fetoprotein level > 400ng/ml
  • atypical features or the absence of cirrhosis may require image guided biopsy for diagnosis
    • if biopsy negatiev, further studies should be done at 3-6 month intervals until it either disappears, grows larger, or displays diagnostic characteristics.
1)
NEJM 2011 365:12
neo_hepatic.txt · Last modified: 2013/08/15 14:00 (external edit)