Hepatocellular Carcinoma

from the ACC to Med E

Paul M. Johnson
Department of Internal Medicine
University of North Carolina Hospitals
February 12, 2010
Overview
 HCC: A growing problem
Incidence: 4.1/100K in
US
male to female ratio
3:1
much higher risk
abroad
mortality rate =
incidence

Above: Average yearly, age-

adjusted incidence of HCC in US.

Left: Cumulative incidence of

HCC among veteran patients
between 1985 and 1990.

Gastroenterology 2004; 127: S27

 Who gets HCC in the US?
Hep C: 2-8%
annual incidence
Hep B: 0.5%
annual incidence
Cirrhosis due to
other causes
EtOH, and others
(Wilsons, 1AT-def,
hemochromatosis,
NASH)

Gastroenterology 2004; 127: S27-234

 Diagnosis
History Alpha-fetoprotein
wt loss, early satiety = sensitivity/spec is
advanced mass
poor
Physical Exam
decompensation of
Imaging
cirrhosis key point: U/S, CT,
ascites, jaundice, and MRI all work well
splenomegaly
bruit over liver? Biopsy
paraneoplastic not always needed
Labs risk of seeding (2.5
nonspecific, but % in one review)
indicative of liver disease

Gut 2008; 57: 1592-6

 Treatment of HCC
1. Resectable or not
2. Transplantable or
not
3. Small, local disease
or severe disease
1. If small and local,
can pursue RFA,
TACE (chemoembo),
or PEA
2. If severe disease,
pursue systemic
therapy
1. Sorafenib vs. clinical
A simplified approach to treatment of HCC. Am J Med 2007; 120: 194-202
trails
 A word on surveillance.

There is no definitive evidence

that screening for HCC
improves survival*

USPSTF and ACS do not have

guidelines for screening for
HCC, but the AASLD does.
 however, look for HCC
when
Surveillance is Surveillance Plan for HCC
recommended for the Alpha-fetoprotein
following groups of at cutoff 20 ng/mL, 60%
patients sens, 80% spec
inadequate
Hepatitis B carriers
Asian males > All cirrhotic
Ultrasound
40/females >50 Hep B carriers* sens 65-80%, spec 90%
Family history Africans >20 Interval
of HCC
6-12 months, but no data
Non Hepatitis B cirrhosis
Use ultrasound to
Hepatitis C Genetic screen at 6-12 month
Alcoholic hemochromatos
cirrhosis is intervals
Primary billiary (level II evidence)
cirrhosis
Though at high risk, there is no Hepatology 2005; 42: 1208-1233
Diagnosis

Hepatology 2005; 42: 1208-1233

 Key Points
HCC is increasing in incidence.
Screen selected patients with
ultrasound q 6 months.
Select HBV carriers, HCV and others
patients with cirrhosis
If the patient is symptomatic with
HCC on presentation, the 5-year
survival is 10%.
Lancet 2003; 62: 1907-1917
 References
Wands, JR.Prevention of Hepatocellular Carcinoma. NEJM
2004; 351: 1567.
Parikh, S, and Hyman, D. Hepatocellular Cancer: A Guide
for the Internist. Am J Med 2007; 120: 194-202.
El-Seag, HB. Hepatocellular Carcinoma: Recent Trends in
the United States. Gastroenterology 2004; 127: S27-234.
Bruix, J, Sherman, M. Management of Hepatocellular
Carcinoma. AASLD Guideline. Hepatology 2005; 42:
1208-1233.
Silva, AU, Hegab, B. Needle track seeding following biopsy of
liver lesions in the diagnosis of hepatocellular cancer: a
systematic review and meta-analysis. Gut 2008; 57: 1592-6.
Llover, JM, Burroughs, A. Hepatocellular carcinoma.
Lancet 2003; 62: 1907-1917.
Schwartz, JM, Carithers, RL. Hepatocellular carcinoma.
www.uptodate.com. Accessed 2/11/2010.