HEPATOCELLULAR
CARCINOMA
• INTRODUCTION
• CLASSIFICATION
• EPIDEMIOLOGY
• RISK FACTORS
• PATHOLOGY
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT
INTRODUCTION
• HCC is the most common 'PRIMARY' malignant
tumour of the ADULT liver
• Hepatoblastoma is the most common primary
malignant tumor of the childhood
EPIDEMIOLOGY
• HCCis the fifth most common cancer world wide
• Highest incidence is seen in Africa and Southeast
Asia
• Lowest incidence is seen in Australia, Europe and
North America.
• M:F = 8:1
RISK FACTORS
VIRAL HEPATITIS
Chronic Hepatitis B and C
TOXIC SUBSTANCE
Alcohol and Aflatoxin
METABOLIC DISEASE
Alpha 1 antitrypsin deficiency
Wilson's disease
Hemochromatosis
Metabolic syndrome
IMMUNE RELATED
Primary biliary cirrhosis
Autoimmune Hepatitis
ENVIRONMENTAL TOXINS
Nitrate related food products
Trichloroethylene
Herbicides
Carbontetrachloride
PATHOLOGY
• GROSS
3 types of growth pattern
1) Nodular Expanding pattern
2) Infiltrative pattern
3) Hanging type/Pedunculated
NODULAR EXPANDING
PATTERN
• Most common type
• Characterized by sharp demarcation between the
tumour mass and the compressed and hardly
atropic liver parenchyma.
• Surrounded by a fibrous capsule
INFILTRATIVE PATTERN
• The lesion is poorly circumscribed with illdefined
and invasive borders.
• The tumor extends into adjacent non tumor tissue
interdigitating with surrounding parenchyma.
PEDUNCULATED
• It is rare type
• Originates from a accessory hepatic lobe.
• It has good prognosis even in case of large tumors
because limited resection may give excellent
results.
HISTOPATHOLOGY
• WELL DIFFERENTIATED
• Tumour cells resemble more or less to normal
hepatocytes with a polygonal shape, distinct cell
membrane and clear cytoplasm
• POORLY DIFFERENTIATED
• Tumour is highly cellular with bizarre nuclei, high
mitosis and apoptotic bodies
CLINICAL FEATURES
Predominantly features of cirrhosis
Jaundice
Ascites
Cachexia
Spleenomegaly
Hepatomegaly
Spider angina
Palmar erythema
Testicular atrophy
Specific to Hepatocellular
carcinoma
MOST COMMON : Incidental finding during routine
ultrasound evaluation
MASS IN THE RIGHT UPPER QUADRANT
VAGUE PAIN IN THE RIGHT UPPER QUADRANT
WEIGHT LOSS
ANOREXIA
IMAGING
ROLE OF IMAGING
1. Screening
2. Diagnosis
3. Stageing
4. Excluding other complications of
cirrhosis
ULTRASOUND
Primary role is for screening in cirrhosis patients
Versatile and inexpensive
No radiation exposure and does not require contrast
agents
HYPOECHOIC LESION
WITH MIXED ECOGENECITY
IN A CIRRHOTIC LIVER
COMPUTED TOMOGRAPHY
TRIPLE PHASE CT
PATIENT POSITION : supine with arms raised above head
SCOUT : Diaphragm to iliac crest
VOLUME OF CONTRAST: 100 to 120 ml of non ionic
contrast
INSPIRATION WITH BREATH HOLD
THREE PHASES
• LATE ARTERIAL PHASE- 15 to 20 sec
• PORTO VENOUS PHASE - 60 to 75 sec
• DELAYED PHASE- 2 to 5 mins
"HYPERVASCULAR ON ARTERIAL PHASE WITH EARLY
WASHOUT ON DELAYED PHASE "
SCREENING
• All high risk patients should be screened every 6
months
• Ultrasound is the modality for screening
FOR LESIONS LESS THAN 2 CM - Frequency of
surveillance should be increased every 3 months
FOR LESIONS MORE THAN 2 CM - Triple phase CT and
AFP should be estimated
STAGING
• Barcelona clinic liver cancer (BCLC).
• TNM Staging
• Okuda Classification
• Cancer of the liver Italian program (CLIP)
MANAGEMENT
TREATMENT MODALITIES AVAILABLE FOR HCC
• SURGERY - 1) RESECTION
2) LIVER TRANSPLANTATION
• PERCUTANEOUS ETHANOL INJECTION
• RADIOFREQUENCY ABLATION
• CHEMOEMBOLISATION
• CHEMOTHERAPY – sorafenib
SURGERY
• HEPATECTOMY
• Left Hepatectomy- Removal of 2,3,4a, 4b segments.
• Right Hepatectomy – Removal of 5,6,7,8 segments.
• Extended Right Hepatectomy- Removal of
5,6,7,8,4a,4b segments.
• Extended Left Hepatectomy- Removal of
2,3,4a,4b,5,8 segments.
• Left lateral Hepatectomy- Removal of 2 and 3
segments.
• Left medial Hepatectomy- Removal of 4a and 4b
segments.
• Right anterior Hepatectomy - Removal of 5 and 8
segments.
• Right posterior Hepatectomy- Removal of 6 and 7
segments.
RADIOFREQUENCY
ABLATION
• High frequency alternating current.
• Heats up to 120 degree Celsius.
• MOA: Denaturation of protein and lipid bilayer of
tumor cells, results in tissue destruction and
coagulative necrosis.
• ADVANTAGE
• Reduces tumor bulk in unresectable disease.
• For patients who cannot tolerate surgeries because
of other comorbidities.
• Local recurrence rate are similar to liver resection,
if tumor size is < 3 cm.
• DISADVANTAGES
• Not suitable for lesions that are close to diaphragm,
heart, gall bladder, duodenum, colon, stomach.
• Central lesions may cause bile duct injury.
• Difficult for large tumors and tumors near large
vessels.
PERCUTANEOUS ETHANOL
INJECTION
• 95% alcohol is used.
• Done under ultrasound guidance.
• MOA- Cell dehydration and denaturation of
proteins.
• Nowadays RFA has largely replaced PEI.
TRANSCATHETER ARTERIAL
CHEMOEMBOLIZATION
• This technique involves occlusion of hepatic artery
supplying the tumor.
• A local delivery of chemotherapeutic agent.
• Done under digital subtraction angiography.
• Chemotherapeutic agent : Doxorubicin or Cisplatin
suspended in lipiodol. ( Oily contrast agent)
• Occlusion of artery by polyvinyl alcohol or gelatin
sponge.
CHEMOTHERAPY
• DOC : SORAFENIB
• MOA: Tyrosine kinase inhibitor that limits cell
proliferation and angiogenesis.
• Sirolimus, Rapamycin has been under trail.
THANK YOU
