1、,Complain: right quadrant pain intermittently for 2 months. Concomitant : anorexia usually and diarrhea occasionally P.E: no special sign Blood-RT: normal Stool-RT: normal Past-H: HBV infection for 20 ys. Family-H: mother died of HBV-cirrhosis,Diagnosis ?,A case:,Male, 41 y.o.,Hepato-Cellular Carcin

2、oma (HCC) !,Hepato-Cellular Carcinoma (HCC),Chang-qing Yang, MD 9(2):281-5 Gastroenterology. 2004; 127(5 Suppl 1):S79-86,Minor risk factors,As many as 45% of persons who suffer from hereditary hemochromatosis develop into HCC This complication was thought to occur only in the presence of cirrhosis P

3、atients with Wilson disease occasionally develop into HCC, although only in the presence of cirrhosis Other inherited metabolic disturbances predispose to that HCC may also induced by cirrhosis (1antitrypsin deficiency),Minor Risk Factors,In patients with the use of contraceptive steroids, the risk

4、is related directly to the duration of use Controversy exists over whether cigarette smoking,Pathology,Gross appearance Microscopic appearance Well-Differentiated appearance Moderate-Differentiated appearance Undifferentiated appearance Fibrolaminar hepatocellular carcinoma,Gross appearance,Nodular

5、or =5cm, most common form most prone to rupture Diffuse It is rare, may be difficult to distinguish from regenerating nodules of cirrhosis,Gross appearance,Nodular Type,Gross appearance,Massive Type,Gross appearance,Diffuse Type,Small HCC,3cm Well differentiated, low grade malignancy Usually encapsu

6、lated cancer embolism rate is low with relative good liver function,Microscopic appearance,Hepatocyte (90%) Bile duck cell (less) Mixed (least),Metastasis of HCC,Intrahepatic metastasis: through portal vein Extrahepetic metastasis : through hepatic vein or lymph route 5 most common sites of HCC meta

7、stasis are: (1) regional lymph nodes (2) lung (3) adrenal glands (4) bone (5) peritoneal surface,Metastasis of HCC,Intrahepatic metastasis:,Metastasis of HCC,Extrahepetic metastasis:,Tumor embolus in inferior cava vein,HCC,Clinical manifestation,Symptoms Prevalence(%) Abdominal pain 59-95 Weight los

8、s 34-71 Weakness 22-53 Abdominal swelling 28-43 Nonspecific 25-28 Gastrointestinal symptoms common,Clinical manifestation,Physical signs Prevalence(%) Hepatomegaly 54-98 Hepatic bruit 6-25 Ascites 35-61 Splenomegaly 27-42 Jaundice 4-35 Wasting 25-41 Fever 11-54,Paraneoplastic Syndromes associated wi

9、th HCC,Hypoglycemia Polycythemia (erythrocytosis) Hypercalcemia Osteoporosis Polymyositis Neuropathy,Sexual changes: gynecomastia feminization,Clinical stages,Stage I (subclinical stage): High risk factors, hepatitis history or HBsAg + over 5 years No specific symptoms Elevated AFP Single or multipl

10、e nodules, size = 5cm No vascular invasion,Clinical stages,Stage IIa Present some symptoms or signs of HCC Abnormal laboratory findings Single or double nodules 510cm No portal vein cancerous embolism No lymph nodes enlargement No distant metastasis,Clinical stages,Stage IIb Single or double nodules

11、 10cm or triple 10cm in one hepatic lobule Single or double nodules 510 cm in two hepatic lobule Portal vein cancerous embolism,Clinical stages,Stage III More advanced than stage IIb or with vascular invasion or with intrahepatic invasion or with peritoneal lymph nodes enlargement or distant metasta

12、sis,Complications,Hepatic encephalopsy end stage deadly complication, 1/3 death cause Gastrointestinal bleeding esophageal varices, erosive GI mucosa Rupture of hepatic cancer mass accounts for 914% Secondary infection,Laboratory tests and others,Tumor markers of HCC Radiologic investigations Needle

13、 biopsy,Tumor markers, -Fetoprotein (AFP) Glutamyl Transferase ( -GT) L-Fucosidase (ALF) Des- -Carboxy Prothrombin (D - CP),-Fetoprotein (AFP),high concentration in fetal serum, in normal adult usually500g/L) is a strong pointer to the diagnosis of HCC Below this level may be found in patients with

14、variety of acute and chronic benign hepatic disease or GI tumor with liver metastasis,Glutamyl Transferase ( -GT),Normal serum contains as many as 10 isoenzymes of -GT Three isoenzymes may be present in serum from patients with HCC: -GT- I 27% -GT -II 60% -GT-III 30%,Des- -Carboxy Prothrombin,It is

15、raised in the majority of patients with HCC 250g /L is considered positive,L-Fucosidase (ALF),It was first reported to have a sensitivity of 75% and specificity 90% in HCC In a subsequent study, it failed to distinguish between cirrhosis and HCC In black Africans, this marker is less sensitive, less

16、 specific and has lower predictive value than alpha-fetoprotein,Tumor markers,Sensitivity(%) Specificity (%) Advantages Disadvantages AFP 8090(high) 90 Relatively quick Relative easy to measure expansive D- CP 58-91 84 Easy and quick Far more to measure expansive ALF 75 70-90 Easy and quick to measu

17、re, relative inexpansive -GT-II 60 96 Relatively easy and Expansive quick to measure,Hepatic imaging,Ultrasonography (U-S) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Hepatic Arteriography (DSA) Position emission computed tomography (PECT),Ultrasonography,Detects tumor which size 2cm S

18、hows the size, sharp, site and its relationship with vessel Identifies the hepatic vein, portal vein cancerous embolism Doppler sonography are useful,Ultrasonography,Ultrasonography,CT,It usually shows the tumor size greater than 2.0 cm It may detect small HCC (1.0 cm) by using contrast materials It

19、 is the best method for detecting small and micro HCC,CT,CT,MRI,Useful for detecting both primary and tumor spread Useful in distinguishing between small HCC and small hemangiomas uncovered during surveillance,MRI,MRI,Hepatic arteriography,It is the best modality for detecting the tumor site It may

20、show tumor with 0.5cm1.0cm,Hepatic arteriography,Hepatic arteriography,PET(positron emission tomography),Peritoneoscopy,(Laparoscopy),Liver biopsy,Diagnosis,Diagnosis,HCC markers,Hepatic imaging,HCC !,Risk Factors,Clinical Manifestation,Diagnosis,HCC markers,Hepatic imaging,Sub-clinical HCC !,Risk F

21、actors,Clinical Manifestation,Differential Diagnosis,Hepatic cirrhosis/hepatitis Secondary liver cancer Benign hepatic tumors Liver abscess,Treatment,Treatment,Surgical resection Alcohol injection Embolization and chemoembolization(TACE) Chemotherapy Physiotheropy Liver transplantation,Surgical rese

22、ction,Offers the best chance for cure of HCC,Surgical resection,Alcohol Injection,also called percutaneous ethanol injection (PEI) too small to be suitable for resection or because they are multiple or because their special position in the liver or because of the severe hepatic dysfunction It carries the risk of disseminating the tumor,Alcohol injection,Embolization / TACE,Embolization with lipiodol and anticancer drugs has been used to reduce the viable tumor mass before surgery Patients receiving TACE (transarter