A Case of Hepatocellular Carcinoma

 

A patient with chronic hepatitis B carrier status and no previous treatment for such presents with a 2-month history of abdominal pain, early satiety and unintentional weight loss of 5 lbs. There is no history of alcohol abuse nor prior diagnosis of cirrhosis. An ultrasound done after these symptoms showed a large mass in right lobe of the liver. Given the working diagnosis of hepatocellular carcinoma (HCC), serum α fetoprotein (AFP) levels ordered revealed a markedly elevated value of > 25,000 μg/L. Figure 1 shows the findings of a subsequent CT scan of the liver with contrast. The constellation of findings and investigations were consistent with a diagnosis of HCC.

 

What is HCC?

HCC is the most common type of primary liver cancer. It is more common in individuals with underlying liver diseases such as cirrhosis as well as chronic viral hepatitis infections specifically B & C. Although ultrasound is an excellent tool for screening patients for HCC it has limited utility in guiding diagnosis and surgical/therapeutic intervention.  The far superior modalities are MRI and triple phase CT scan of the liver.  Triple phase CT scans ( arterial phase, a portal venous phase, and a washout phase) are highly specific but may miss small lesions. The classic findings are early enhancement of the lesion in arterial phase with rapid washout in the venous phase and the appearance of a pseudocapsule in the delayed phase. Patients with these findings and on imaging and an elevated AFP do not require a biopsy. Biopsy may be considered in patients with a low AFP value and lesion > 2cm in size.

 

hcc-formatted
Figure 1: A triple phasic CT scan of the liver. The non-contrast coronal view shows an irregular border of the inferior right lobe liver with consistent attenuation (top left). Enhancement of this vascular mass in the inferior right lobe of liver in the arterial phase of contrast (top right). A rapid washout of contrast from this mass during the portal venous phase of this scan is noted in this image (bottom left). Delayed phase showing a pseudocapsule distinct from from liver border in the inferior right lobe of liver (bottom right). 

 

 

HCC screening
Figure 2: Diagnostic approach and algorithm to lesions suspicious for HCC.Bruix & Sherman 2011

 

house-clipart-7iaqaoaiaTake Home Points

  • Patients with underlying chronic hepatitis B & C infections,  liver cirrhosis and other chronic liver diseases are at increased risk for developing HCC.
  • Be sure to arrange for abdominal ultrasounds every 6 months for populations at risk for developing HCC [1].
    • If a nodule of <1cm is noted on ultrasound, arrange ultrasounds every 3 months to assess for rapid interval increase.
    • If nodule is  >1 cm, then arrange for MRI/Contrast CT scan to assess for hypervascularity.

 

References:

  1. Multidisciplinary Canadian concensus recommendations for the management and treatment of hepatocellular carcinoma.

  2. Bruix J, Sherman M on behalf of the American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology 2011;53:1020–2.

 

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