Hepatocellular Cancer

Predominant occurrence with diseases:

Chronic liver disease and cirrhosis

Difference between First & Second type

• single tumor spreads late in stage to other parts of live vs small nodules throughout the liver

• Second type appears w/ cirrhosis, mainly US

Incidence

41260; has tripled since 1980

Trends lending to increased Incidence

Obesity, T2DM, Nonalcoholic fatty liver disease

Modifiable risk factors

• obesity

• High fat diet

• NAFLD

• Diabetes

• Alcohol

• Smoking

• Exposure to chemical carcinogens

• Anabolic steroids

Nonmodifiable risk factors

• primary biliary cirrhosis

• Nonalcoholic steatohepatitis

• Hep B or C

• Hemochromatosis

• Wilson’s Disease

• Parasitic infection

• Male gender

• Asian Americans and Pacific Highlanders

Prevention

• Avoiding/treating hepatitis infections

• Limit alcohol use

• Limit smoking

• Healthy weight

• Limit exposure to carcinogenic chemicals

• Treat diseases increasing HCC risk

Diagnosis

• Angiography

• US

• Bone scan

• Abdominal multiphasic CT

• MRI

• Alpha fetoprotein

• Biopsy

Biopsy Considerations

• if solid tumor, determined by size

• Not required is lesion fulfills imaging criteria

Gross morphology

• nodular = associated with cirrhosis

• massive = noncirrhosis type

• Diffuse = small distinct areas throughout liver

Staging Systems

• Child-Pugh (cirrhosis)

• Model for ESLD

• Okuda

Localized tumor survival

30%

Advanced tumor survival

3%

Surgery Options

• partial hepatectomy: potentially curative in early stage, Child-Pugh A (need some liver function)

• Transplantation

Transplant considerations

• potentially curative in early stage

• May include bridge therapy - transarterial chemoembolization or thermal/radiofrequency ablation

Local-regional therapies

• Ablation: RFA, Microwave, Cryo

• Arterial Directed: transarterial bland embolization, TACE, yytrium-90 transarterial radioembolization (TARE), TACE w/ drug-eluting beads

Radiation

• intensity modulated radiation

• Stereotactic body radiation

Systemic Treatment

• 1st Line: Sorafenib

• 2nd Line: Regorafenib, Nivolumab (Child-Pugh A-B7 only)

• Chemo only in trials