Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most prevalent form of primary liver cancer, accounting for approximately 75% of all liver cancer cases. As the incidence of HCC continues to rise globally, understanding its causes, risk factors, and treatment options is crucial for healthcare providers and patients alike. This article aims to provide a comprehensive overview of hepatocellular carcinoma, highlighting its diagnosis, staging, radiological assessments, risk factors, symptoms, causes, and treatment modalities.

What is Hepatocellular Carcinoma?

Hepatocellular carcinoma originates from hepatocytes, the primary cells of the liver. It typically arises in the context of chronic liver disease and cirrhosis, although it can also develop in non-cirrhotic livers. The progression of HCC is often insidious, with symptoms manifesting only in advanced stages, complicating early diagnosis and treatment.

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Hepatocellular Carcinoma Symptoms

In its early stages, HCC is often asymptomatic, delaying diagnosis. As the disease progresses, patients may experience:

Abdominal pain and swelling
Unexplained weight loss
Jaundice (yellowing of the skin and eyes)
Fatigue and weakness
Loss of appetite
Nausea and vomiting

Hepatocellular Carcinoma Causes

The pathogenesis of HCC is multifactorial, involving a complex interplay between genetic, environmental, and lifestyle factors. Chronic liver inflammation and regeneration cycles contribute to genetic mutations and cellular dysplasia, setting the stage for malignant transformation.

Hepatocellular Carcinoma Risk Factors

Several risk factors contribute to the development of HCC, with chronic liver disease being the most significant. Key risk factors include:

Chronic Hepatitis B and C Infections: These viral infections lead to chronic liver inflammation and fibrosis, significantly increasing the risk of HCC.
Cirrhosis: Regardless of aetiology, cirrhosis predisposes individuals to HCC, with an annual incidence of 1-8%.
Alcohol Consumption: Excessive alcohol intake contributes to liver cirrhosis and subsequently elevates HCC risk.
Non-Alcoholic Fatty Liver Disease (NAFLD): The rising prevalence of NAFLD and its progression to non-alcoholic steatohepatitis (NASH) is an emerging risk factor for HCC.
Aflatoxin Exposure: This mycotoxin, commonly found in improperly stored grains and nuts, is a potent carcinogen linked to HCC development.
Genetic Disorders: Conditions such as hemochromatosis and Wilson's disease increase the likelihood of liver cancer.

Hepatocellular Carcinoma Diagnosis

Clinical Evaluation

The diagnosis of HCC begins with a thorough clinical evaluation, which includes a detailed medical history and physical examination. Clinicians should be vigilant for signs suggestive of liver disease, such as jaundice, ascites, and hepatomegaly.

Laboratory Tests

Laboratory tests play a pivotal role in the diagnosis of HCC. Elevated levels of alpha-fetoprotein (AFP) serve as a tumour marker for HCC, though not all patients exhibit elevated AFP levels. Additional liver function tests, including bilirubin, transaminases, and alkaline phosphatase, provide insight into liver health and disease progression.

Imaging Techniques

Radiological assessments are integral to diagnosing and staging HCC. Ultrasound is often the first-line imaging modality, given its accessibility and non-invasive nature. However, contrast-enhanced imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) offer superior sensitivity and specificity in detecting liver lesions and evaluating tumour vascularity.

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Hepatocellular Carcinoma Staging

Accurate staging of HCC is imperative for guiding treatment decisions and prognostication. The Barcelona Clinic Liver Cancer (BCLC) staging system is widely utilized, incorporating tumour characteristics, liver function, and performance status. Other staging systems include the TNM (Tumor, Node, Metastasis) classification and the American Joint Committee on Cancer (AJCC) system, which provide additional insights into tumour burden and spread.

Hepatocellular Carcinoma Treatment

Surgical Interventions

Surgical resection remains the cornerstone of curative treatment for HCC, particularly in patients with localized tumours and preserved liver function. Liver transplantation is an option for patients with early-stage HCC and underlying cirrhosis, offering the dual benefit of tumour removal and restoration of liver function.

Locoregional Therapies

For patients ineligible for surgery, locoregional therapies provide effective alternatives. These include:

Radiofrequency Ablation (RFA): RFA uses thermal energy to destroy cancer cells, which is suitable for small tumors.
Transarterial Chemoembolization (TACE): TACE involves the selective delivery of chemotherapy agents and embolic particles to tumor-feeding arteries, inducing ischemia and tumor necrosis.
Selective Internal Radiation Therapy (SIRT): SIRT administers radioactive microspheres directly to the tumour site, minimizing systemic exposure.

Systemic Therapies

Systemic treatment options for advanced HCC have expanded significantly with the advent of targeted therapies and immunotherapy. Sorafenib, a multi-kinase inhibitor, was the first agent approved for advanced HCC and remains a cornerstone of systemic treatment. Recent advancements include immune checkpoint inhibitors such as nivolumab and pembrolizumab, which have demonstrated promising efficacy in clinical trials.

Palliative Care

For patients with advanced, unresectable HCC, palliative care focuses on symptom management and improving quality of life. Interventions may include pain management, nutritional support, and psychological counselling.

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