Etiology
Cirrhosis:
HCC often develops against the background of cirrhosis. It is most common in hepatitis C cirrhosis.
The cause of cirrhosis with the highest risk of HCC is hemochromatosis, while the lowest is primary biliary cholangitis and Wilson's disease.
Non-cirrhotic causes:
Chronic alcohol consumption
NASH
Hepatitis B virus (can make HCC without cirrhosis, responsible antigen is HbxAg)
Aflatoxin
Genetic diseases: Glycogen storage diseases, citrullineemia, orotic aciduria, tyrosinemia
Thorotrast and arsenic can often cause angiosarcoma and HCC.
Estrogens and anabolic steroids can cause hepatic adenoma and HCC.
Clinic
• Symptoms: Abdominal pain, weight loss, abdominal swelling, etc.
• Findings: Hepatomegaly, ascites, splenomegaly, jaundice, etc.
If the clinical picture of a patient with cirrhosis worsens, HCC should be considered.
• Paraneoplastic findings:
Hypoglycemia (IGF2 production)
Polycythemia (Erythropoietin production)
hypercalcemia
Gynecomastia, feminization
clubbing finger
Dermatomyositis, Lasser-Trelat sign
Diagnosis
• Elevated alpha-fetoprotein in the laboratory is helpful in diagnosis. AFP > 200ng/ml indicates high specificity for HCC.
• Radiological examination
ultrasonography
The population at risk is screened for HCC every 6 months.
Nodules < 1 cm detected in liver USG are observed every 3 months. If there is growth, dynamic imaging is performed.
In liver USG, dynamic imaging (4-phase multidetector CT or contrast-enhanced MRI) is performed in nodules > 1 cm.
dynamic display
In dynamic CT/MR, contrast enhancement in the early arterial phase and wash-out phenomenon in the late phase are diagnostic for HCC.
• In cases where AFP and imaging methods are not diagnostic, biopsy is performed.
Treatment
• Early stage
Surgical resection, liver transplantation and ablative treatments are curative approaches in HCC.
surgical resection
It is primarily preferred in patients with Child A cirrhosis who do not have cirrhosis or who have sufficient liver reserve, in lesions limited to one lobe and < 5 cm.
Liver transplant
In patients who are not suitable for resection (Child B and Child C), transplantation is performed in the presence of a single lesion not exceeding 5 cm or a maximum of 3 lesions not exceeding 3 cm (Milan criteria).
ablative treatments
Chemical ablation (Ethanol etc.), Thermal ablation (Radiofrequency, laser, cryoablation etc.)
• middle stage
Transarterial chemoembolization (TAKE)
• Advanced stage
HCC is a tumor resistant to classical chemotherapy.
Sorafenib, a multireceptor tyrosine kinase inhibitor, is given.