neo_hepatic
Table of Contents
hepatocellular carcinoma
see also:
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 04:00 by 127.0.0.1