Hepatocellular cancer

Epidemiology
US incidence is increasing (8,000 - 10,000 cases per year)
8th most common cancer worldwide

Risk factors
HBV/HCV infection (HR~100); infection with both viruses synergistically increases risk of HCC
Any kind of cirrhosis (EtOH, hematochromatosis, Wilson's disease, viral, etc.)
Aflatoxin
Thorotrast
Hereditary liver disease

Clinical
No biopsy needed in patients with AFP higher than 200 and a liver mass
Consider screening with AFP and u/s in patients with cirrhosis and particularly HBV/HCV
Biopsy tract seeded in 2 - 5% of patients

Prognostic factors
Size and number of tumors
N/M stage
Underlying liver function
Presence of vascular invasion

Pathologic subtypes
Fibrolamellar: more favorable
Hepatoblastoma: most common liver tumor in children; associated with FAP phenotype
Rare liver tumors: Angiosarcoma (associated with thorotrast exposure); leiomyosarcoma (most commonly occurring sarcoma in the liver)

Treatment
Surgical resection or liver transplant is the only curative therapy
Criteria for transplant: one tumor smaller than 5cm or 2-3 tumors, each smaller than 3cm

Liver tolerance to radiation: dose and volume dependent; lower if pre-existing impairment
100% -- 35Gy
70% -- 42Gy
50% -- 50Gy
30% -- 70Gy

Radiation induced liver disease
RUQ pain
Ascites and hepatomegaly
No jaundice
Increased alk phos, AST; bilirubin is usually normal
Pathology: central veno-occlusive disease with secondary necrosis of hepatocytes