CAUSES ;
β’ Cirrhosis - accounts for 60 to 80% of cases. Alcoholic cirrhosis most important in western world. Reported risk of hepatoma in alcoholic cirrhosis is 3-10% with micronodular pattern.
β’ Hepatitis B virus infection - associated with > 70% of cases worldwide. Most important factor in Africa and Asia but less important in western countries. In USA, HBsAg is positive in 20% cases of this tumor.
β’ Hepatitis C virus infection - 50-70% of HBsAg negative patients are positive for anti-HCV antibody, an important factor in hepatoma patients not due to HBV infection.
β’ Mycotoxins (aflatoxins) - metabolite of fungus Aspergillus flavus that contaminates foods. Two series, B1 and derivatives and G1 and derivatives. B1 being the most potent carcinogen, important in Sub-Saharan Africa and Southeast Asia, no signifi cant role in USA.
β’ Vinyl polymer, but not the fi nished product, produces angiosarcoma
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DIFFERENTIAL DIAGNOSIS :
β’ Early asymptomatic tumor - underlying liver conditions, e.g., cirrhosis, chronic hepatitis; benign liver nodules, hamartoma, hemangioma, metastatic adenocarcinoma, gallstones, or gallbladder polyp
β’ Late symptomatic tumor with hepatomegaly - hepatic cyst, adenoma, hemangioma, abscess, metastatic malignancy of liver, cirrhosis with activity, infarction of liver, fatty infiltration, thrombosis of hepatic veins, portal vein, inferior vena cava, active viral hepatitis, alcoholic
hepatitis
β’ Ruptured tumor - all causes of acute abdomen, traumatic hemoperitoneum
. Erythrocytosis, elevated Ca, low glucose
. Liver function test abnormalities
. Tumor markers
. Alpha-fetoprotein (AFP) - single most important lab test for screening and diagnosis of hepatoma - 70%.
Negative in angiosarcoma, cholangiocarcinoma and fibrolamellar carcinoma. Level > 400 ng/mL (> 400 MCg/L) is diagnostic, level does not correlate with
prognosis.
. Other markers - des-gamma-carboxyprothrombin, gamma glutamyl transferase, carcinoembryonic antigen (CEA), variant alkaline phosphatase, isoferritins
* ASCITIC FLUID ASPIRATION FOR ROUTINE & CELL CYTOLOGY TEST
* HEPATIC ARTRY ANGIOGRAPHY
* TECNNETIUM SCAN
* IMAGING
β’ Plain x-ray - useful to demonstrate metastatic involvement to lung and bone
β’ Ultrasound - best diagnostic imaging technique, capable of detecting tumor > 1 cm, and may be positive when AFP is normal. Has been useful in serially following cases of cirrhosis to identify hepatocellular cancer when under 2 cm and curable.
β’ CT scan - valuable in determining extrahepatic spread of the disease; diagnostic of fibrolamellar
β’ MRI - helpful in delineating the details of tumor, and invasion of vessels
β’ Hepatic arteriography - mostly done to see the anatomy of hepatic vessels and extent of tumor while considering resection, embolization, dearterialization or intra-arterial infusion of cytotoxic agents. Most useful in detecting angiosarcoma, separating benign vs. malignant.
β’ Lipoidal angiography and CT - lipoidal is readily taken up by tumor cells, this technique can detect even millimeter sized lesions. Lipoidal also serves as a vehicle to deliver chemotherapeutic or radioactive agents to the tumor.
DIAGNOSTIC PROCEDURES
β’ Tissue diagnosis must be made for appropriate treatment
β’ Liver biopsy - usually US or CT guided when nodules not palpable
β’ Laparoscopic occasionally used to evaluate extent in cirrhosis
* SMALL PERCENTAGE OF PTS HAVE PARANEOPLASTIC SYNDROME, HAVING INCREASED ERYTHROCYTES, HYPERCALCEMIA, HYPERCHOLESTEROLEMIA, HYPOGLYCEMIA , DYSFIBROGENEMIA, CRYOFIBROGENEMIA & ACQUIRED PORPHYRIA.