History
Presenting Complaint
Most patients present with symptoms relating to the tumour or the underlying liver cirrhosis. These can include abdominal pain, nausea, bloating or fatigue. Jaundice from the tumour is uncommon as the tumour rarely invades the biliary tree; but may be present in patients with advanced cirrhotic liver disease. Acute bleeding within the tumour can cause a sudden surge in pain levels.
Past History
Most patients have a history of liver cirrhosis secondary to alcoholism or chronic hepatitis (or a combination).
Medications and Allergies
Nil specific questions. Family history is uncommon.
Social History
Patients may have difficulties with attendance due to social isolation. This is particularly true in Australia where the most common cause of hepatocellular carcinoma is alcoholism.
Examination
Hepatomegaly and ascites are common examination findings. The liver may be shrunken if there is advanced cirrhosis.
Bloods
Elevated AFP is nearly essential in the diagnosis of HCC. In combination with the typical CT findings (below) an elevated AFP can be used to confirm a diagnosis of hepatocellular carcinoma without biopsy. CA 19-9 is useful for ruling out intrahepatic cholangiocarcinoma.
Standard bloods are also important, especially liver function tests to establish the underlying health of the liver. Viral hepatitis studies can establish the cause of the hepatocellular carcinoma.
Imaging
Ultrasound
The usual first investigation for liver abnormalities. It is limited by non-specific results.
CT
CT has been the most important imaging modality for liver tumours. Hepatocellular carcinoma has a characteristic contrast enhancement in a multiphase contrast study of the liver - intense enhancement in arterial phase and a significantly reduced enhancement relative to normal liver in the venous and delayed phases.
CT of the chest, abdomen and pelvis is essential for full staging.
MRI
MRI with gadolinium contrast provides improved delineation of tumours, particularly in cirrhotic patients where the multinodular nature of the underlying illness can make interpretation difficult.
Histological Diagnosis
In patients with elevated AFP (> 400 μg/L) and characteristic imaging findings, biopsy prior to definitive resection is not required. In patients with low AFP levels, FNA biopsy of the lesion is done and is usually diagnostic.
Staging
Staging is provided by TNM. The health of the liver is 'staged' by the Childs-Pugh score.
TNM
T Stage
T1: Solitary tumour with no vascular invasion
T2: Solitary tumour with vascular invasion or multiple tumours (largest < 5 cm)
T3: Multiple tumours > 5 cm or invasion of major branch of portal/hepatic vein
T4: Invasion of adjacent structures or penetration of visceral peritoneum
N Stage
N1: Regional nodal disease (porta hepatis, hepatic ligament, hepatoduodenal ligament, inferior vena cava, hepatic artery or those along the portal vein)
M Stage
M1: Distant metastatic disease
Final Stage
| Stage | T | N | M |
|---|---|---|---|
| I | T1 | N0 | M0 |
| II | T2 | N0 | M0 |
| IIIA | T3 | N0 | M0 |
| IIIB | T4 | N0 | M0 |
| IIIC | Tany | N1 | M0 |
| IV | Tany | Nany | M1 |
Childs-Pugh
Childs-Pugh is a scoring system that judges the health of the liver in patients with cirrhosis. Higher scores are associated with worse survival:
| Marker | 1 | 2 | 3 |
|---|---|---|---|
| Bilirubin | < 34 | 34-50 | > 50 |
| Albumin | > 35 | 28-35 | < 28 |
| INR | < 1.7 | 1.71 - 2.30 | > 2.30 |
| Ascites | None | Mild | > Mild |
| Encephalopathy | None | Mild | > Mild |
Score Results:
- 5-6: Childs-Pugh A: 100% 1 year survival
- 7-9: Childs-Pugh B: 81% 1 year survival
- 10+: Childs-Pugh C: 45% 1 year survival
Multidisciplinary Team
Once the diagnosis and stage is established patients should be discussed in an MDT to decide on treatment direction. This should include an upper gastrointestinal or liver surgeon, a gastroenterologist, a medical oncologist, a radiation oncologist, and auxiliary staff.
