Hepatocellular carcinoma

Introduction

Hepatocellular Carcinoma (HCC) is a primary malignancy of the liver cell and must be differentiated from malignancies elsewhere that metastasize to the liver.
Hepatocellular carcinoma occurs more commonly in men than in women and is often diagnosed several years after establishment of the initial causative condition.
The disease has a poor prognosis resulting from metastatic or locally advanced disease.

Complications of hepatocellular carcinoma

Complications of HCC include the following:

  • Liver failure
  • Variceal bleeding or tumour rupture with bleeding into the peritoneum. The tumour is often resistant to chemotherapy.

Current strategies to prevent or treat hepatitis B and C infections and liver cirrhosis can potentially reduce the prevalence of HCC in the long term.

Causes of hepatocellular carcinoma

The causes of HCC are:

  1. Cirrhosis of the liver
  2. Alcoholic liver disease
  3. Chronic hepatitis B virus infection
  4. Chronic hepatitis C virus infection
  5. Chronic exposure to hepatic carcinogens e.g. aflatoxin

Symptoms of hepatocellular carcinoma

The symptoms of hepatocellular carcinoma include the following:

  1. Jaundice
  2. Itching
  3. Anorexia
  4. Early satiety
  5. Feeling of a mass in the upper abdomen
  6. Right upper abdominal pain
  7. Weight loss
  8. Haematemesis
  9. Abdominal distension
  10. Bone pain
  11. Dyspnoea

Signs of hepatocellular carcinoma

  1. Jaundice
  2. Cachexia
  3. Hepatomegaly (irregular surface, multiple nodules, may be tender)
  4. Ascites
  5. Hepatic bruit

Investigations

  • FBC
  • LFTS
  • INR
  • Serum Alpha-Fetoprotein
  • Hepatitis B-Surface Antigen (HBsAg)
  • Hepatitis C Antibody (HCVab)
  • Chest X-Ray
  • Abdominal ultrasound scan
  • CT/MRI scan (if ultrasound inconclusive)

Treatment for hepatocellular carcinoma

Objectives

1. Curative treatment objective

  • To assess for potential resectability

2. Palliative treatment objectives

  • To relieve pain
  • To relieve discomfort from gross ascites
  • To prevent or treat hepatic encephalopathy (See ‘Hepatic Encephalopathy‘)

Non-pharmacological treatment

  • Surgical resection of non-metastatic localised lesions
  • Paracentesis for tense ascites (See ‘Ascites’)
  • Supportive care (multi-vitamin supplements)

Pharmacological treatment

A. Pain control

1st Line Treatment
Evidence Rating: [B]
Tramadol, oral, 50 mg 12 hourly (titrate further as tolerated to de sired effect: maximum 300 mg daily)

Or

Morphine sulphate, oral, 5-10 mg 8-12 hourly

Referral Criteria

Refer all patients with suspected HCC, especially those with small solitary lesion (<5 cm) who may be considered for percutaneous alcohol injection or surgical resection, to a specialist.