The Specter of Hepatocellular Carcinoma
When we think of liver disease, we immediately picture the damage caused by alcohol, hepatitis C, and cirrhosis. Similarly, when we hear the word “cancer,” it’s hard to think past the devastation of breast, lung, and colon cancer. After reading this month’s Top Paper1, you will now find it hard to minimize the impact of hepatocellular carcinoma (HCC). This month’s column offers a thorough understanding of what health care professionals increasingly face as the number of individuals with hepatitis C and cirrhosis rise.
HCC is the fifth most common cancer in men and seventh in women.2 It is a consequence of cirrhosis, which is a prevalent cancer in 80% to 90% of those afflicted. The author of this paper concludes: As hepatitis C infections increase, HCC cancer will also rise in prominence.
Knowing that cirrhosis is the stage HCC cancer acts on, surveillance of cirrhotic individuals is essential and cost-effective when performed every 6 months. The recommended testing includes a measure of alpha-fetoprotein levels and an ultrasonography; a combination of the two equates to a 90% sensitivity in detecting HCC.1
This can be either curative intent or palliation only. Curative therapies are comprised of surgical resection, liver transplantation, and radiofrequency ablation.
One would surmise that surgical resection of the tumor would be a good approach. However, it can only be performed for early stage cancer in persons without cirrhosis or well-compensated cirrhosis. Resecting a substantial portion of the liver in a cirrhotic can be fatal.
Another curative approach is liver transplantation—where the tumor and the cirrhotic liver are removed. If this sounds too good to be true, it probably is. Due to an organ shortage, many people die from HCC while waiting for a donated organ. Candidates for transplant are deemed eligible by the Milan criteria: A single nodule is <5 cm in diameter or up to 3 nodules, with the largest <3 cm in diameter without vascular invasion or metastases.
Sorafenib, an oral anti-angiogenic agent, is HCC-specific chemotherapy for palliative care. However, in patients with advanced stage HCC and only Child-Turcotte-Pugh A cirrhosis, it only extended life for 3 months.
The number of individuals with Hepatitis C is on the rise. Presumably, many of these individuals will progress to cirrhosis and as such, the grim specter of HCC will grow. Having a handle on surveillance and treatment will be important to primary care practitioners. This column is only a short summary of the primary care information in this month’s Top Paper, which I would recommend as an easy-to-read reference for all health care professionals. ■
1.Murali AR, Romero-Marrero C, Aucejo F, Menon KV. Hepatocellular carcinoma: options for diagnosing and managing a deadly disease. Cleve Clin J Med. 2013;80:645-653.
2.Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893-2917.
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.