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Hepatocellular carcinoma
Treat primary liver cancer before
it's too late
BY Tom Guzowski, MD
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Mrs. L. is a 64-year-old convenience
store clerk. She's originally from Vietnam, and moved to Canada to
stay with her family 5 years ago. She presents to her family doctor
with vague abdominal pain over the last 3 months that's been getting
progressively worse. She has a longstanding history of hepatitis B
(hep B) infection.
Presentation
Physical examination
- bulging flanks consistent with mild-to-moderate
ascites
- spider nevi and splenomegaly
- no other stigmata of chronic liver
disease
Investigations
- alanine aminotransferase (ALT): 45
U/L
- aspartate aminotransferase (AST):
50 U/L
- albumin: 39 g/L
- international normalized ratio (INR):
1.1
- platelet count: 115 x 109/L
- hep B surface antigen (HBsAg): +
- hepatitis 'e' antigen (HBeAg): +
- a-fetoprotein (AFP): 5,500 µg/L
- gadolinium-enhanced MRI of the abdomen:
5.7 cm encapsulated hepatic mass in left hepatic lobe with
heterogeneous enhancement in the hepatic arterial phase
and washout in portal/venous phase, most in keeping with
hepatocellular carcinoma (HCC)
Diagnosis and treatment
Mrs. L. was diagnosed with HCC, which
developed on the background of her chronic active hepatitis.
Based on the Milan criteria, she was not a transplant candidate.
The patient was referred for chemoembolization. One year later,
she's still alive.
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Making the case
HCC is the fourth most common cancer and third most frequent cause
of death from cancer worldwide. It's responsible for 500,000-1,000,000
deaths per year. The incidence in North America has been increasing
in the last 30 years, possibly due to hep C virus (HCV) infection
and nonalcoholic fatty liver disease. Eighty percent of patients
with HCV develop chronic hepatitis and of those, 20% will progress
to cirrhosis in 20 years. Of cirrhotics, 2-5% per year get HCC.
Despite recent advances in treatment and surveillance, overall survival
figures remain poor.
Signs and symptoms
In its early stages, HCC is generally silent, with only 18% of patients
presenting with tumours that are still small enough for surgical
resection. Symptoms might include anorexia, vague upper abdominal
pain, and early satiety. Patients commonly have cirrhosis. They
may also show signs of acute decompensation -- intractable ascites,
encephalopathy, variceal bleeding or jaundice. Obstructive jaundice,
bone pain and dyspnea due to metastases are not uncommon. Intraperitoneal
bleeding due to tumour rupture results in acute abdominal pain.
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