Hepatocellular Carcinomafrom the ACC to Med E

Paul M. JohnsonDepartment of Internal Medicine

University of North Carolina HospitalsFebruary 12, 2010

Overview

HCC: A growing problem…• Incidence: 4.1/100K in US• male to female ratio 3:1• much higher risk abroad• mortality rate =

incidence

Above: Average yearly, age-adjusted incidence of HCC in US.

Left: Cumulative incidence of HCC among veteran patients between 1985 and 1990.

Gastroenterology 2004; 127: S27

Who gets HCC in the US?

• Hep C: 2-8% annual incidence

• Hep B: 0.5% annual incidence

• Cirrhosis due to other causes– EtOH, and others

(Wilson’s, α1AT-def, hemochromatosis, NASH)

Gastroenterology 2004; 127: S27-234

Diagnosis• History

– wt loss, early satiety = advanced mass

• Physical Exam– decompensation of cirrhosis

• ascites, jaundice, splenomegaly• bruit over liver?• paraneoplastic

• Labs– nonspecific, but indicative of

liver disease

• Alpha-fetoprotein– sensitivity/spec is poor

• Imaging– key point: U/S, CT, and

MRI all work well

• Biopsy– not always needed– risk of seeding (2.5 % in

one review)

Gut 2008; 57: 1592-6

Treatment of HCC1. Resectable or not2. Transplantable or not3. Small, local disease or

severe disease1. If small and local, can

pursue RFA, TACE (chemoembo), or PEA

2. If severe disease, pursue systemic therapy

1. Sorafenib vs. clinical trails

Am J Med 2007; 120: 194-202A simplified approach to treatment of HCC.

A word on surveillance….

There is no definitive evidence that screening for HCC improves survival*

USPSTF and ACS do not have guidelines for screening for HCC, but

the AASLD does.

…however, look for HCC when…Surveillance is recommended for the following groups of patientsHepatitis B carriers•Asian males > 40/females >50•Family history of HCC

•All cirrhotic Hep B carriers*•Africans >20

Non Hepatitis B cirrhosis•Hepatitis C•Alcoholic cirrhosis

•Genetic hemochromatosis•Primary billiary cirrhosis

Though at high risk, there is no data for Alpha 1- AT def, NASH, autoimmune hepatitis

Surveillance Plan for HCC• Alpha-fetoprotein

– at cutoff 20 ng/mL, 60% sens, 80% spec

– inadequate

• Ultrasound– sens 65-80%, spec 90%

• Interval– 6-12 months, but no data

• Use ultrasound to screen at 6-12 month intervals – (level II evidence)

Hepatology 2005; 42: 1208-1233

Diagnosis

Hepatology 2005; 42: 1208-1233

Key Points

• HCC is increasing in incidence.• Screen selected patients with ultrasound q

6 months.• Select HBV carriers, HCV and others patients

with cirrhosis

• If the patient is symptomatic with HCC on presentation, the 5-year survival is 10%.

Lancet 2003; 62: 1907-1917.

References

• Wands, JR.Prevention of Hepatocellular Carcinoma. NEJM 2004; 351: 1567.

• Parikh, S, and Hyman, D. Hepatocellular Cancer: A Guide for the Internist. Am J Med 2007; 120: 194-202.

• El-Seag, HB. Hepatocellular Carcinoma: Recent Trends in the United States. Gastroenterology 2004; 127: S27-234.

• Bruix, J, Sherman, M. Management of Hepatocellular Carcinoma. AASLD Guideline. Hepatology 2005; 42: 1208-1233.

• Silva, AU, Hegab, B. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis. Gut 2008; 57: 1592-6.

• Llover, JM, Burroughs, A. Hepatocellular carcinoma. Lancet 2003; 62: 1907-1917.

• Schwartz, JM, Carithers, RL. Hepatocellular carcinoma. www.uptodate.com. Accessed 2/11/2010.