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Chapter 15: Hepatocellular Carcinoma

Tim Greten; Nadine Abi-Jaoudeh

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INTRODUCTION

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Epidemiology

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Epidemiology
Incidence✫: 16 cases per 100,000 population worldwide: 626,000 cases per year Stage at presentation
Stage A: 35%
Deaths (worldwide): 598,000 per year Stage B: 25%
Median age✫ (Asia and Western Europe): 50–60 years Stage C: 10%
Male to female ratio: ~2.4:1 Stage D: 30%

✫The incidence and age of hepatocellular carcinoma vary widely according to geographic location. The distribution also differs among ethnic groups and regions within the same country

 

Forner et al. Lancet 2012;379:1245–1255

Llovet JM et al. J Natl Cancer Inst 2008;100:698–711

Parkin DM et al. CA Cancer J Clin 2005;55:74–108

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Work-up

  1. Alpha-fetoprotein (AFP)

  2. Liver function test (see Child-Pugh classification)

  3. Ultrasound and abdominal/chest spiral CT and/or dynamic liver MRI

  4. Specific clinical scenarios such as selection for liver transplantation may also require bone scintigraphy to exclude bone metastases, but there are no robust data supporting the cost-efficiency of this policy

 

Diagnostic Criteria for HCC: Non-invasive criteria (Restricted to cirrhotic patients)

  1. Radiological criteria: (arterial hypervascularization/washout in portal phase)

    Two coincident imaging techniques, nodule <2 cm

    One imaging technique, nodule >2 cm

  2. Combined criteria: one imaging technique associated with AFP

    Focal lesion >2 cm with arterial hypervascularization

 

Bruix J, Sherman M. Hepatology 2005;42:1208–1236

Forner A et al. Hepatology 2008;47:97–104

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Pathology

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Pathology
Hepatocellular carcinoma 99%
Fibrolamellar hepatocellular carcinoma <1%

Nakashima T, Kojiro M. Hepatocellular Carcinoma. Tokyo, Japan: Springer Verlag, 1987

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Staging

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Staging

Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Solitary tumor without vascular invasion
T2 Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
T3a Multiple tumors more than 5 cm
T3b Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein
T4 Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum
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Staging

Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
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Staging

Distant Metastasis (M)
M0 No distant metastasis (no pathologic M0; use clinical M to complete stage group)
M1 Distant metastasis
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Staging

Staging
  T N M
I T1 N0 M0
II T2 N0 M0
IIIA T3a N0 M0
IIIB T3b N0 M0
IIIC T4 N0 M0
IVA any T N1 M0
IVB any T any N M1

Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010
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