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Hepatocellular Carcinoma

What is Hepatocellular Carcinoma

Hepatocellular carcinoma is the 5th most common cancer world wide, but not equally distributed. It is more common in Asia and Africa compared to Europe or the USA. Additionally it is more common in men than in women.

How does it manifest?

Usually, HCC is an accidental finding.  It presents as a nodule in the liver mostly detected by routine imaging of the liver by ultrasound.  Further CT or MRI scans typically show a liver nodule with typical behavior after application of a contrast agent: the nodule usually shows a strong uptake of the contrast agent and then a rapid outwash.

Symptoms of Hepatocellular Carcinoma

Early HCC is usually asymptomatic and, as mentioned above an accidental finding. Advanced HCC may cause symptoms like weight loss, fatigue, loss of appetite to symptoms of decompensated  liver disease like ascites or variceal bleeding.

Risk factors

The most important risk factor of HCC is chronic liver disease of all causes. Viral hepatitis B or C, chronic alcohol abuse or fatty liver disease (non alcoholic steatohepatitis, NASH) and others may cause chronic inflammation of the liver, which results in liver scaring („liver fibrosis“). There are 4 grades of fibrosis (F1-F4) and F4 reflects liver cirrhosis. The HCC risk seems to increase significantly with fibrosis grade 3, and is approximately 0.5-3% per year in patients with liver cirrhosis (F4). This is why assessment of liver fibrosis is so important – if F3 or higher is detected, the patient should undergo HCC surveillance by ultrasound of the liver every 6 months for the rest of his life. Unfortunately only few countries have established structured surveillance programs for patients with advanced fibrosis. This is why most patient are diagnosed in advanced stages of the disease, where curative treatments can not be applied anymore.

Diagnosis of Hepatocellular Carcinoma

HCC is usually diagnosed by contrast enhanced CT or MR scans in patients with liver cirrhosis. If the liver nodule shows typical behavior after application of a contrast agent  (strong uptake of the contrast agent and then a rapid outwash) the diagnosis is established. In all cases where imaging is not conclusive or no cirrhosis is present, a biopsy of there nodule for tissue collection and pathologic analysis is recommended.


Treatment of Hepatocellular Carcinoma

Treatment depends on tumor stage, liver function and general condition of the patient. Thus all treatment decisions should be  taken in an experienced interdisciplinary team that considers all these factors in the individual patient. In general, early stages of the disease can be cured by surgery (resection or liver transplantation) or radiofrequency ablation. In the so called intermediate stage we can perform transarterial chemoembolisation. In the advanced stage, systemic treatment is recommended.

Innovative treatments for this type of cancer

Until the year 2007 no systemic drug treatment was available for advanced stage HCC. Today, we have three regiments in first line treatment and another 3 drugs in second line. The greatest innovation in the last years was certainly the implementation of immunotherapy.

What is the risk of recurrence

After curative treatments like resection or ablation , the risk of recurrence is rather high- approximately  80% after 5 years. We differentiate between early recurrence within 2 years after treatment which reflects “true metastasis“  and late recurrence after >2 years  which may be attributed to de novo HCC development in the cirrhotic liver, which remains a risk factor for HCC. In contrast, the risk for recurrence after liver transplantation is only 20% after 5 years, since the cirrhotic liver is exchanged . However this low recurrence rates can only be achieved if the strict criteria for liver transplantation in terms of size and number of HCC nodules are a followed.

Liver cancer prevention

Treatment of the underlying liver disease, even if cirrhosis is already present is the best prevention of HCC. We know for example, that cure of hepatitis C, absence from alcohol, successful treatment of hepatitis B, reduces the risk of HCC dramatically. Additionally certain drugs like metformin (a diabetes drug) statins (used to decrease cholesterol levels) or aspirin e decrease the risk for HCC. Finally, there are good news for coffee lovers: 3-4 cups of coffee per day reduce the risk of HCC development in patients with liver crrhosis by up to 75%.


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