Hepatocellular carcinoma 

Epidemiology

• ~15% of the primary hepatobiliary malignancies in Western communities
• 50% occur in patients with cirrhosis
• Commoner than in Africa & Far East
• M:F~4:1.3

Causes

• Chronic hep B – Chronic Hepatitis B accounts for 50% of Hepatocellular Carcinoma cases
• Cirrhosis eg hep C, haemochromatosis, Wilson’s dz
• Long standing UC  primary sclerosing cholangitis
• OCP
• Aflatoxin – produced by fungal action during food production, harvest, storage, and processing

• Autoimmune chronic active hepatitis
• Androgenic steroids

• Risk factors for developing hepatocellular cancer in Chronic Hepatitis B patients
  • Men over age 45 years
  • Cirrhosis as diagnosed by liver biopsy
  • Family History of Hepatocellular Carcinoma
  • Coinfection with Hepatitis CVirus or Hepatitis DVirus
  • HBV DNA Viral Load >10,000 IU/ml
  • HBV Genotype C
  • Tobacco Abuse
  • HBeAg positive

Clinical Features 

1. Effects of primary disease

• Abdominal mass and pain from hepatomegaly
• Jaundice from intrahepatic biliary tree obstruction or obstruction of CBD at porta hepatis. 
• Hepatic bruit. 

2. Systemic Effects of HCC

• Splenomegaly
• Abdominal swelling from ascites
• Haematemesis from oesophageal varices due to portal HT secondary to cirrhosis. 

• Weight loss
• Anorexia
• Fever

3. Effects due to secondaries

• Bone pain from metastases
• Malignant pleural effusions
• Dyspnoea due to elevation of diaphragm due to hepatomegaly or rib metastases

4. Paraneoplastic disorders

• Hypoglycaemia , Erythrocytosis, Hypercalcaemia, Hypercholesterolaemia , Dysfibrinogenaemia. 

5. Clinical history aspects: 

• Personal history of hepatitis, cirrhosis, IVDU, or blood transfusions
• FHx: hepatitis, cirrhosis, HCC or genetic metabolic disorders.
• Exposure to sex hormones

Screening for Hepatocellular Carcinoma

• Indications for highest risk patients as described above
• Protocol: Every 6-12 months (AASLD recommendation)
  • Hepatic Ultrasound
  • Serum Alpha-fetoprotein
• Vaccination against HBV (eliminate vertical transmission & underlying cause of HCC in endemic areas)