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Essentials of Diagnosis
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General Considerations
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Hepatocellular carcinoma: malignant neoplasm of the liver that arises from parenchymal cells (accounting for 85% of liver cancers)
Contrast cholangiocarcinoma: malignant neoplasm that originates in the ductular cells (≤ 15% of liver cancers)
Rare tumors of the liver include angiosarcoma and lymphoma
Hepatocellular carcinoma risk factors
Cirrhosis in general, including nonalcoholic fatty liver disease, and hepatitis B or C in particular
Hepatitis B in Africa and Asia
Hepatitis C and alcoholic cirrhosis in the West and Japan
High levels of HBV replication, HBV genotype C, hepatitis D coinfection
Elevated serum ALT levels in persons with chronic hepatitis B (antiviral therapy to suppress HBV replication appears to reduce the risk)
HCV infection with lack of response to antiviral therapy
HCV genotype 1b
Hemochromatosis, aflatoxin exposure (associated with mutation of the TP53 gene), alpha-1-antiprotease (alpha-1-antitrypsin) deficiency, tyrosinemia, and radiation exposure
In patients with cirrhosis, additional risk factors include
Male sex
Age > 55 years
Hispanic or Asian ethnicity
Family history in a first-degree relative
Tobacco use
Diabetes mellitus, hypothyroidism, overweight
Alcohol use (especially in combination with obesity)
HCV infection
HBsAg and anti-HBc positivity
Elevated serum transferrin saturation
Prolonged prothrombin time
Low platelet count
Fibrolamellar variant of hepatocellular carcinoma
Occurs in young women
Characterized by a distinctive histologic picture, absence of risk factors, unique genomic profiles, and indolent course
Staging in the TNM classification
T0: there is no evidence of primary tumor
T1a: solitary tumor ≤ 2 cm
T1b: solitary tumor > 2 cm without vascular invasion
T2: solitary tumor > 2 cm with vascular invasion or multiple tumors none > 5 cm
T3: multiple tumors with at least one > 5 cm
T4: single or multiple tumors of any size involving a major branch of the portal or hepatic vein or with direct invasion of adjacent organs other than the gallbladder or with perforation of the visceral peritoneum
N1, regional lymph node metastasis
M1, distant metastasis
F0, no to moderate hepatic fibrosis
F1, severe hepatic fibrosis to cirrhosis
The BCLC (Barcelona Clinic Liver Cancer) staging system is preferred
Includes the Child-Pugh stage, tumor stage, and liver function
Has the advantage of linking overall stage with preferred treatment modalities and with an estimation of life expectancy
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Worldwide, hepatocellular carcinomas are the fourth most common cause of cancer-related deaths and the sixth most common cancer in incidence
In Africa and most of Asia, hepatitis B virus (HBV) infection is a major etiologic factor
In the United States and other Western countries, because of the increasing prevalence of cirrhosis caused by chronic hepatitis C virus (HCV) infection and nonalcoholic fatty liver disease, incidence rates have risen rapidly (over twofold since 1978 with some ...