Hepatoma (Hepatocellular Carcinoma)
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Hepatoma, also known as hepatocellular carcinoma (HCC), is the most common primary malignant tumor of the liver, arising from hepatic parenchymal cells (hepatocytes); 80% are associated with underlying chronic liver disease, most commonly cirrhosis related to hepatitis B and C (exception: rare fibrolamellar type).
- Second leading cause of cancer-related death worldwide
- Fifth most common malignancy worldwide, >700,000 new cases per year worldwide (1)[A]
- 4 to 5 new cases/100,000/year of the U.S. population; 120 new cases/100,000/year in Asia and sub-Saharan Africa
- Among known cirrhotics, 2 to 5 cases/100 cirrhotics/year
- Incidence increasing since 1980s in the United States (due to increase in hepatitis C infection)
- In the United States, estimate is 28,720 new cases of primary liver cancer were diagnosed in 2012 and 20,550 deaths.
- Male > female (mean 3.7:1 for incidence and 2:1 for deaths)
- Asians/Pacific Islanders > African Americans > Native American > Hispanics > Caucasians
- Predominant age: median age 65 years in the West, 4th to 5th decades in Asia and Africa
- Predominant sex: male > female (3 to 4:1)
Etiology and Pathophysiology
- Cirrhosis accounts for 80–90% of HCC. Alcoholic cirrhosis is most common in the Western world. Reported risk in patients with alcoholic cirrhosis is 3–10% with micronodular pattern.
- Hepatitis B virus (HBV) and hepatitis C virus (HCV) are independent and synergistic risk factors for HCC.
- Associated with >70% of cases worldwide
- Most important factor in Africa and Asia
- Chronic alcohol use
- Obesity, type 2 DM, and nonalcoholic fatty liver disease (NAFLD)
- Chronic tobacco abuse
- Betel nut chewing (common in Asia)
- Mycotoxins (aflatoxins): metabolite of the fungus Aspergillus flavus that contaminates foods
- Vinyl polymers associated with angiosarcoma and, less commonly, HCC
No known genetic pattern
- 80–90% of HCC associated with cirrhosis (2)[B]
- Cirrhosis can be from any etiology: hepatitis B and C, alcoholism, hemochromatosis, nonalcoholic steatohepatitis (NASH), α1antitrypsin deficiency, biliary cirrhosis, autoimmune hepatitis, Wilson disease, glycogen storage disease.
- Fungal aflatoxins (contaminants of grain in Africa and Asia): synergistic effect with other causes of liver disease
- Vinyl chloride
- Thorium dioxide
- Anabolic steroids
- NAFLD/NASH (3)[C]
- For fibrolamellar type: no identified risk factors
- For angiosarcoma: vinyl chloride
- The major risk factor for HCC is cirrhosis. Prevention of cirrhosis and tumor surveillance in patients with or at risk for cirrhosis is key.
- Prevent HBV and HCV infection through safe sexual practices, avoidance of shared IV drug paraphernalia, and HBV vaccination.
- Treat chronic HBV and HCV with lamivudine, adefovir, entecavir, tenofovir, or ribavirin/pegylated interferon, according to guidelines.
- Avoid excessive alcohol use.
- Treatment of obesity, NAFLD, NASH
- Drink >3 cups of coffee per day (4)[A].
- Statin use is associated with decreased risk of HCC.
- High-risk individuals
- Chronic hepatitis with HBV or HCV
- Alcoholic cirrhosis
- Genetic hemochromatosis
- Exposure to vinyl chloride >10 years (screen every 6 months)
- Primary biliary cirrhosis
- Morbid obesity
- Screen high-risk patients by ultrasound (US) and α-fetoprotein (AFP) every 6 to 12 months (5)[B].
- HCC progresses from dysplastic nodules to vascular invasion (after tumor is >2 cm in diameter).