Hepatocellular Carcinoma

How good is AFP? 
AFP has a sensitivity of 40-65% and specificity of 80-94% according to a systematic review of studies of hep C patients. (Annals, July 1, 2003 vol. 139 no. 1 46-50).

   AFP is also elevated in tumors of gonadal origin, pregnancy, sometimes even just chronic hepatitis.


Risk factors for HCC: chronic hep B or C*, cirrhosis for any reason, ETOH*, NASH, aflatoxin B (*our patient).

*Pearl: You do not have to have cirrhosis to develop HCC.

HCC screening:
Our patient had no health care for several years before presenting to us. If he had, as Gaurav pointed out, he would have had AFP and US screening for HCC every 6 months. There are no strict guidelines for HCC screening, however in high risk patients, most advocate for this approach. The US can't tell you it is HCC versus another solid tumor but it can assess patency of PV.


Treatment options for HCC
Transplant candidates:
-One lesion<5cm
-Up to 3 lesions<3cm
-Any childs score
-No gross vascular invasion

Surgical resection candidates:
-No cirrhosis
-Childs A
-Single lesion
-No Mets

Not a surgical candidate:
-Comorbid factors
-Four lesions
-Gross vascular invasion
+LN or mets
--> systemic chemo, TACE, RFA etc

Triphasic CT Scan:
“Triphasic” is a somewhat general term but usually refers to CT scan with contrast timed to capture arterial, venous and washout phases. This is helpful in assessing for HCC because the lesions are hypervascular and “light up” (hyper-intense) during the arterial phase. The venous phase allows you to assess the underlying liver parenchyma, which can be helpful in assessing for cirrhosis. In the case of HCC you want to know if the portal vein is involved, which would negate transplant candidacy.

Palliative management of HCC:
Our patient chose palliative management of her HCC. This involves managing the above complications of ESLD and the malignancy itself.
Sorafenib may be used in metastatic HCC. See table attached or follow this link:
http://www.uptodate.com.laneproxy.stanford.edu/online/content/image.do?imageKey=ONC%2F17937
1. Prevention of GIB- screening EGD, ligation of varices, BB to reduce risk of bleed
2. Prevention of Encephalopathy-lactulose to reduce absorption of GI neurotoxins (nitrogenous products of glutamine breakdown), rifaximin for gut decontamination which also reduces these toxins. Neomycin and metronidazole are also used by have greater toxicities. Low protein diet is controversial due to nutritional needs. Zn is similarly controversial but has been reported to improve HE in case reports
3. Minimize Ascites- lasix, spironolactone, low salt diet
4. Prevention of SBP- oral fluoroquinolones, bactrim most often used to prevent recurrence in cirrhotics with h/o SBP, GIB or low ascitic fluid protein. The issue of when, how long, and what antibiotic is debatable. Beware resistant organisms after using broad antibiotic for extended time!

(Ellen Eaton MD, 9/13/10)

(Katharine Cheung MD, 11/4/10)