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Liver cancer
Written by Jeffrey R. Waggoner, MD   
Hepatocellular carcinoma (HCC) is associated with alcohol abuse, viral hepatitis, and metabolic liver disease. The incidence of HCC has increased dramatically in the last two decades because of the increased incidence of hepatitis C. This cancer may take three forms of growth—solitary mass, multifocal or nodular pattern, and diffuse small foci. HCC produces alpha-fetoprotein (AFP) as well as other serum proteins.  Most HCC patients die within one year of diagnosis. Surgical cure is possible in less than 5% of cases. The most common cause of death is bleeding from esophageal varices and cachexia. (1)

The most significant factor associated with HCC is cirrhosis, regardless of cause. The major causes of cirrhosis are alcohol, hepatitis C infection, and hepatitis B infection, and these are also associated with HCC.

50% of alcoholics have evidence of HCC on autopsy. The risk of HCC in patients with decompensated alcoholic cirrhosis is approximately 1% per year.

Chronic hepatitis B infection (HBV) in the setting of cirrhosis increases the risk of HCC by a factor of 1000. Hepatitis C virus (HCV) is associated with a 5% risk of developing HCC. It appears that treatment with antivirals decreases the risk of HCV patients developing HCC.

Hemochromatosis, particularly when associated with cirrhosis, increases the incidence of HCC. 30% of deaths in hemochromatosis are associated with HCC. Aflatoxin, a byproduct of fungal contamination of foodstuffs in sub-Saharan Africa and East and Southeast Asia, is also associated with an increased risk of developing HCC. Rarer causes are primary biliary cirrhosis, androgenic steroids, primary sclerosing cholangitis, 1-antitrypsin deficiency, Thorotrast radioactive contrast, oral contraceptives, and porphyria cutanea tarda. (2)

When patients present with HCC, they may present with jaundice, pruritus, splenomegaly, variceal bleeding, cachexia, bloating and increased abdominal girth from ascites, right upper quadrant pain, abdominal mass, and hepatic encephalopathy. Lab values of importance are total bilirubin, aspartate aminotransferase (AST), alkaline phosphatase, albumin, and prothrombin time to show results consistent with cirrhosis. These are an assessment of the extent of cirrhosis. (3)

Alpha-fetoprotein (AFP) is elevated in 75% of cases of HCC, and the levels are inversely correlated with the disease’s prognosis. If a level is noted to be greater than 400 ng/mL, there is a 95% association with the presence of HCC. (4)

A variety of imaging techniques have been used in the evaluation of HCC. Regardless of the associated debates, it would appear that multiple-phase abdominal CT is the imaging procedure of choice. The most accurate protocol consists of three phases: “1. scanning before the intravenous bolus of contrast is given, 2. scanning shortly after contrast administration, and 3. routine portal venous phase scanning of the entire abdomen, including the liver. Hepatocellular carcinoma is seen most commonly in the second--the hepatic arterial--phase, because the lesions are often hypervascular. (5) Treatment of HCC is changing on a constant basis and encompasses chemotherapy, angiographic administration of chemical agents, partial hepatectomy, and even liver transplant. In America, the latter is limited to very specific circumstances. (6)
 
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