HCC

Hepatocellular carcinoma (HCC) is a growing concern. Currently, it is listed in the top ten most common cancers worldwide amongst both men and women, and is continuing to increase. The majority of cases are in the setting of viral hepatitis, where hepatitis B makes up nearly 50%  of cases. Any causes of cirrhosis can theoretically lead to HCC, and rarely, HCC can develop in the absence of cirrhosis (10%). The burden of hepatitis C has been driving HCV in North America, where HCV related liver cancer is the fastest growing cause of cancer related death in the US.

Patients with HCC tend to present with symptoms of cirrhosis. Jaundice, ascites, GI bleeding and so forth. HCC should be considered in those presenting with acutely decompensated cirrhosis, as it can precipitate worsening liver disease through tumor extension. As an internist, it's also interesting to recognize the various paraneoplastic symptoms of HCC; erythrocytosis, hypoglycemia, sign of leser trelat, hypercalcemia, and diarrhea are recognized phenomenon. 

The diagnosis is based on imaging and possible need for biopsy. MRI or CT can be very helpful and when patients have predisposing conditions (HBV), a tumour of 2 cm or greater with typical radiographer pattern in pathognemonic for HCC. Early arterial enhancement and delayed venous washout on a multiphasic scan are suggestive, and indicate tumor vascularity. Tumours less than 1cm. Are difficult to biopsy and require serial scans for monitoring. Intermediate size nodules with atypical pattern should be followed with consideration of biopsy for definitive diagnosis. There are guidelines available on how to approach these nodules which can be very helpful. Alpha-fetoprotein (AFP), when over 500 mcg/L is diagnostic for HCC but intermediate levels can be seen in cirrhosis alone and results need to be taken in context. Levels over 200 mcg/L in the appropriate context have a specificity of over 95%.

Monitoring for HCC is suggested to include liver ultrasound and AFP every 6-12 months in those at risk. This is based on a study published in 2004, where nearly nearly 19,000 Chinese patients with HBV underwent this surveillance. They found a reduction on mortality of 37%. However, A study performed the year prior found no benefit. That being said, this is recommended by the current guidelines. patients that should be monitored include: 

1. Asians men over 40 with HBV
2. Asian women over 50 with HBV
3. Patients with HBV and cirrhosis
4. Blacks with HBV 
5. Family history of HCC and HBV
6. Any patient with cirrhosis

It is less clear when to start screening Caucasians with HBV, and some recommend initating at similar times to the Asian population, despite a lower risk of developing HCC. It may less cost effective to screen in those with cirrhosis from alcohol given a lower risk of HCC, but the epidemiology is not well described. Attached below is a nice NEJM review which contains many of the resources with above information.

HCC review