Makindo Medical Notes

🌍 Hepatocellular carcinoma (HCC) is the most common primary liver cancer, frequently arising in patients with cirrhosis. Biannual ultrasound ± alpha-fetoprotein (AFP) screening is recommended in high-risk groups to allow diagnosis at an early stage when potentially curative therapies are feasible.

📖 About

• HCC is a leading cause of cancer deaths worldwide.
• Highest incidence: Southeast Asia & sub-Saharan Africa 🌏.
• Not all cases arise in cirrhosis — HBV can predispose directly via viral DNA integration.

⚠️ Risk Factors

• Chronic hepatitis B or C infection 🦠
• Alcoholic liver disease 🍺
• Non-alcoholic steatohepatitis (NASH, metabolic syndrome link) 🍔
• Haemochromatosis 🩸
• Aflatoxin B exposure (contaminated grains/nuts in endemic regions) 🌽
• Primary biliary cholangitis (rare cause)

🩺 Clinical Features

• Systemic: Weight loss, anorexia, fever, fatigue.
• Hepatic: Right upper quadrant pain, hepatomegaly, jaundice in late disease.
• Background of cirrhosis (ascites, varices, encephalopathy).

🔎 Screening

• Surveillance: Ultrasound ± AFP every 6 months for cirrhotics or HBV carriers at risk.
• Helps detect subclinical disease when resection/transplant is feasible.

🧪 Investigations

• Bloods: FBC, U&E, LFTs, coagulation, CRP.
• Tumour marker: Alpha-fetoprotein (AFP), though not diagnostic alone.
• Ultrasound: Initial modality to detect lesions.
• Triple-phase CT / MRI: Gold standard to confirm arterial enhancement & venous washout.
• Biopsy: Usually avoided due to seeding risk unless diagnosis uncertain.

🛠️ Management

• Resection: Best for solitary tumours with preserved liver function (Child-Pugh A, no portal hypertension).
• Liver Transplantation: For unresectable cases meeting Milan criteria (single tumour ≤5 cm or ≤3 tumours ≤3 cm, no vascular invasion/metastases).
• Ablation (RFA/Microwave): Effective for small lesions; less so for large or deep tumours.
• Transarterial chemoembolisation (TACE): Used for multifocal disease without vascular invasion/extrahepatic spread.
• Systemic therapy: Sorafenib (tyrosine kinase inhibitor), Lenvatinib (non-inferior alternative), Regorafenib for progression. Newer immunotherapies (atezolizumab + bevacizumab) showing survival benefit 🌟.

📚 References

• Hepatocellular Carcinoma – Lancet Review