Hepatocellular carcinoma: Clinical sciences

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Introduction0:00–0:33

Hepatocellular carcinoma or HCC for short is primary cancer of the liver parenchyma arising from hepatocytes. Most cases occur in patients with cirrhosis from chronic liver diseases like chronic alcohol consumption or viral hepatitis infection because patients can remain asymptomatic until the tumor grows substantially.
Screening patients with risk factors is important. All right.

H&P0:33–2:05

The first step in evaluating a patient with a chief concern, suggestive of hepatocellular carcinoma is to perform a focused history and physical examination.
Let's start with screening. These patients are asymptomatic but have risk factors for HCC like cirrhosis or noncirrhotic chronic liver disease, which can include longstanding hepatitis B or C infections and non alcoholic fatty liver disease exam will likely be normal but some can have hepatomegaly and ascites.
In this case. Your next step is to obtain labs such as liver function tests or LFTs and alpha fetoprotein or AFP as well as imaging like an ultrasound of the liver.
Before we go on with the findings, let's talk about symptomatic patients. If the patient is symptomatic, they might report jaundice, anorexia, weight loss, malaise and vague upper abdominal pain history might also reveal risk factors like cirrhosis or non cirrhotic chronic liver disease on exam, you might find hepatomegaly ascites as well as jaundice of the eyes or the skin with these findings.
Your next step is to order labs including LFT S and A FP. In addition to an ultrasound of the liver.
Now, if labs are normal and the liver ultrasound is normal with no nodules, the patient likely does not have HCC and can be followed up with routine surveillance every six months.

Labs and Ultrasound2:05–3:15

If the patient was symptomatic, you will need to do additional workup to find out what is causing their symptoms for patients with normal LFT S and negative A FP.
But the liver ultrasound shows a nodule smaller than 10 millimeters. You should suspect high risk liver nodule and follow up with repeat AFP and ultrasound in 3 to 6 months.
As before symptomatic patients might need additional workup to find the cause of their symptoms. Lastly, if the patient has abnormal LFT S elevated A FP and a liver ultrasound shows a nodule that is equal to or greater than 10 millimeters, you should suspect a malignant liver nodule.
In this case. The next step is to assess Ly rads to determine the diagnosis and appropriate treatment.

CT or MRI of abdomen3:15–4:57

Ok. To do that, you need to get additional imaging with act or MRI of the abdomen to better visualize the mass.
Typically, a dedicated CT scan called triple phase liver protocol is used to make radiographic diagnosis of HCC. So liver lesions that show hyperenhancement, meaning white in the arterial phase and washout or turning gray again in the portal venous phase are consistent with hepatocellular carcinoma.
Here is a clinical pearl. The liver imaging reporting and data system or Ly Rads is a system for categorizing liver tumors based on their appearance on CT or MRI.
The categories range from LY rads. One benign lesions to LY rads five which represents HCC tumors that meet criteria for LR five are diagnostic of HCC and do not require a biopsy for confirmation.
Additionally, multiple masses in the liver are suspicious for liver metastasis from another primary cancer like colon, breast or lung cancer.
Keep in mind, metastatic lesions to the liver are more common than primary liver cancer like HCC. In these cases, refer the patient for other cancer screenings such as colonoscopy, mammogram, skin exams or chest X ray.
You can also order associated cancer markers including cea and ca 19 9 to help make your diagnosis. All right, let's talk about Ly Rads, one and two.

Benign Liver Mass4:57–5:43

If the CT or MRI of the abdomen shows a liver lesion consistent with a Ly Rads. One or two, you can diagnose a benign liver mass.
These lesions are typically simple liver cysts, hemangioma, confluent fibrosis or a focal scar. They're all considered benign with low risk for development of malignancy management includes routine surveillance to monitor for any changes with liver ultrasound and A FP every 3 to 6 months.
You can consider a follow up CT or MRI for high risk patients with a Ly rads, two lesion. Now a CT or MRI showing a ly rads, three lesion is consistent with intermediate probability for HCC.

Increased Risk for HCC5:43–6:22

These lesions are definitely not benign but also not definitely HCC management includes repeating the ultrasound CT or MRI every 3 to 6 months for two years or more monitoring for any changes in the lesion.
If there are no changes after two years, they can be routinely surveilled with liver ultrasound and a FP. Keep in mind that these patients might also need a biopsy.
Ok. Now, let's talk about ly rads four and five.

Probably HCC or Definitely HCC6:22–9:12

If you have a CT or MRI showing Ly rads four or five, you're dealing with a probable HC or a definite HCC respectively for these patients.
Your next step is to evaluate for surgical resection or transplantation. The surgical workup includes a physical exam to assess for signs of portal hypertension like varices, gastrointestinal bleeding, ascites or spontaneous bacterial peritonitis.
The next important thing here is TNM staging in which T stands for tumor N for nodes and M for metastasis. TNM staging is used to determine tumor size and invasion involvement of the regional lymph nodes around the liver and presence of distant metastasis.
This means you'll need a CT of the chest abdomen and pelvis and sometimes an MRI bone scan to look for metastatic disease.
You should also obtain labs including CBCC, MP, PTI, NR PTT and a hepatitis serology. These labs can help you calculate the meld score, which stands for model for end stage liver disease and a child Pugh score to determine the severity of the liver dysfunction.
It's very important to calculate the severity of the liver dysfunction to assure that there is enough functional reserve to tolerate resection.
Additionally, Yunos criteria which stands for United Network for organ sharing are used to evaluate for transplantation.
Here's a clinical pearl. The meld score provides a snapshot of the patient's current liver function to determine the need for a liver transplant.
To calculate the meld score, you need serum bilirubin, creatinine and PTI nr the higher the meld score, the sicker the liver.
Similarly, child Pugh uses bilirubin albumin PTI nr in the presence of ascites and encephalopathy to measure the severity of liver disease.
Typically cirrhosis in the context of patient prognosis. For child Pugh, the scores are categorized into three classes A B and C A is the least severe while C is the most severe.
Ok. Let's talk about treatment.

Stage I to III9:12–10:28

If imaging reveals that HC is confined to the liver, you're dealing with TNM stage 1 to 3 HCC. Your next step here is to determine if the liver is healthy enough to tolerate dissection.
This is where meld and child Pugh scores come in. If the score is low, the liver has enough functional reserve.
So you can proceed with surgical resection. However, a patient with high scores should be considered for a liver transplant.
Instead for large advanced HCC that is localized to the liver like TNM stage two or three. The treatment consists of chemo embolization or ablation.
Before continuing with treatment, you must make sure that you are dealing with HCC. Lyra's five masses have been confirmed radiographically.
However, all other liver masses should be confirmed with a biopsy. Keep in mind that patients who cannot tolerate surgery due to their health should proceed with systemic therapy like chemo or immunotherapy.
All right. If regional lymph nodes are involved or you find distant metastasis, we're talking about TNM stage four HCC.

Stage IV10:28–10:53

In this case, the prognosis is poor. These patients might also be candidates for systemic chemo or immunotherapy, also make sure to offer supportive care and palliative treatment.
All right. As a quick recap hepatocellular carcinoma is a primary malignancy of the liver arising from hepatocytes.

Review10:53–11:49

The mainstay of diagnosis is radiologic via ly rads. After that, you should evaluate for surgical resection or transplantation using TNM criteria, meld child Pugh score and Yunos criteria.
Depending on the findings stage. 1 to 3 HCC might be treated with resection, transplantation, chemoembolization, ablation or with systemic chemo or immunotherapy on the flip side stage four HCC has a poor prognosis and should be managed with systemic chemo or immunotherapy as well as supportive care and palliative treatment.