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Hepatocellular carcinoma

  • Hepatocellular carcinoma (HCC) is a primary malignant disease of the liver
  • Uncommon in Europe where hepatic secondaries are a 30 times more common cause of liver tumours
  • Highest incidence is seen in East Africa and South-east Asia
  • In these countries it is one of the commonest malignant tumours
  • Male : female ratio = 4:1
  • In Europe peak age at presentation is 80 years
  • In Africa and Asia peak presentation is 40 years

Aetiology

  • Incidence of HCC parallels the world-wide prevalence of hepatitis B
  • Aetiological factors are:
    • Cirrhosis
    • Viral hepatitis - particularly Hepatitis B and C
    • Mycotoxins - e.g. aflatoxin produced by Aspergillus flavus
    • Alcohol
    • Anabolic steroids
    • Primary liver diseases - e.g. primary biliary cirrhosis, haemochromatosis

Clinical presentation

  • Suspect in any patient with cirrhosis who shows evidence of clinical deterioration
  • Often present with right hypochondrial pain +/- mass
  • Malaise, weight loss and low grade pyrexia are often present
  • Jaundice is a late feature
  • Haemobilia or haemoperitoneum are often the immediate cause of death
  • Median survival in those with irresectable disease is 6 months
  • As most tumours cause symptoms late screening of high risk patients has been advocated
  • Can be imaged by:
    • Ultrasound - transabdominal or laparoscopic
    • CT scanning - Conventional or lipiodal enhanced
    • CT portography
  • Assessment of serum alpha-fetoprotein (Alpha-FP) may also be useful

CT scan showing a hepatocellular carcinoma in the right lobe of the liver

Picture provided by Ahmed Gowish, Alexandria University, Alexandria, Egypt

Alpha-fetoprotein

  • Alpha-fetoprotein is a normal fetal serum protein produced by the yolk sac and liver
  • Progress increases in serum levels are seen in 70-90% of patients with HCC
  • Slightly increased and often fluctuating serum levels also seen in hepatitis and cirrhosis
  • In HCC serum levels correlate with tumour size
  • Rate of increase in serum levels correlate with growth of tumour
  • Tumour resection results in a fall in serum concentrations
  • Serial assessment useful in measuring response to treatment

Surgery for hepatocellular carcinoma

  • Only about 25% patients are suitable for surgery
  • The two surgical options are:
    • Surgical resection
    • Liver transplantation

Surgical resection

  • Surgical resection involves either hemi-hepatectomy or segmental resection
  • Most tumours are irresectable to :
    • Large size
    • Involvement of major vessels
    • Associated advanced cirrhosis
    • Metastatic disease or extra-hepatic spread
  • The presence of cirrhosis increases the operative mortality (from ~5 to >20%)
  • After resection, 5 year survival is typically 30-60%
  • Only a small proportion of patients are cured
  • The 5-year recurrence rate is over 80%

Liver transplantation

  • Useful for irresectable disease confined to the liver
  • Operative mortality is often 10-20%
  • Metastases after transplantation occur in 30-40% of patients
  • After transplantation, 5-year survival is less than 20%

Liver transplant for hepatoma in the left lobe of the liver

Picture provided by Seo-Kiat Goh, Singapore General Hospital, Singapore

Palliative therapy

  • Possible palliative interventions include:
    • Devascularisation procedures
    • Chemotherapy
    • Cryotherapy
    • Chemo-embolisation
    • Thermotherapy
  • Chemoembolisation improves survival compared to palliative therapy

Bibliography

Al-Mufti R A M,  Taylor I.  Hepatocellular carcinoma.  In:  Johnson C D,  Taylor I (eds.).  Recent Advance in Surgery 21.  Edinburgh:  Churchill Livingstone. 1998. 33-54.

Badvie S.  Hepatocellular carcinoma.  Postgrad Med J 2000;  76:  4-11.

Lau W Y.  Management of hepatocellular carcinoma.  J R Coll Surg Ed 2002;  47:  389-399.

Llovet J M,  Real M I, Montana X et al.  Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma:  a randomised controlled trial.  Lancet 2002;  359:  1734-1739.

Schafer D F,  Sorrell M F.  Hepatocellular carcinoma.  Lancet 1999;  353:  1253-1257.

Yang H-I,  Lu S-N,  Liaw Y-F et al.  Hepatitis B e antigen and the risk of hepatocellular carcinoma.  N Eng J Med 2002;  347:  168-174.

 

 
 

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