Hepatocellular carcinoma (HCC) is the fastest growing cause of cancer-related deaths in the United States. This is because of the increasing number of people with long-standing hepatitis C who have sustained severe liver fibrosis. Patients with stage 3 (bridging fibrosis) or stage 4 (cirrhosis) are at an increased risk of developing liver cancer and should be monitored twice a year with imaging studies, even after reaching a sustained viral response (SVR). Prognosis for a good outcome is better with early detection of HCC.
According to Dr. Hashem B. El-Serag, once cirrhosis is established, HCC develops at a rate of 1-4% per year. The highest incidence is in hepatitis C patients who were infected through blood transfusions or use of blood products such as hemophiliacs, and the lowest rate is in women who were infected through contaminated anti-D immune globulin. Patients who are most at risk of progression to late stage disease are of older age and they are older at time of infection. Males, diabetics, obese people, those co-infected with HBV and HIV, and people who are heavy drinkers are at increased risk for cirrhosis and therefore liver cancer.
Prognosis for HCC patients is poor with a 5 year survival rate of approximately 15%. Those diagnosed once symptoms are noticeable have a lower rate of survival. Symptoms include pain in abdomen, loss of appetite, weight loss, jaundice, fever, diarrhea, and pain in the bones. Those whose HCC is detected early, before symptoms appear, have a higher survival rate. However, most patients are diagnosed late in the course of HCC.
Physicians recommend monitoring for HCC in patients with stage 3 and 4 liver disease, every 6 months. There is no surveillance required for patients with Stage 1 and 2 liver disease. Patients who obtain an SVR but who are cirrhotic, have a much decreased risk of hepatocellular carcinoma but need to continue monitoring as risk does not fall to zero. The most commonly used lab test has been the alpha fetoprotein test (AFP). This test has a low sensitivity and should be used with imaging studies. One of the problems with the AFP test is that many patients with hepatitis have elevated AFP that is not associated with HCC. Some researchers feel that unless the level is extremely elevated (over 400) the test is not particularly useful. Fewer and fewer doctors are using the AFP test. Imaging may include the ultrasound, the MRI or the CT scan. MRI and CT are used to confirm a diagnosis, often instead of biopsy. The American Association for the Study of Liver Disease recommends the sonogram as the best tool we have at this time. They do not recommend using AFP.
Patients with HCC should be followed by a multi-disciplinary team including hepatologists, transplant surgeons, oncologists, and interventional radiologists. It is imperative that HCC patients who are candidates for transplant are referred before their lesions grow too large. Liver transplant remains the best way to achieve a cure of liver cancer. While waiting for transplant there are treatments that can be utilized to slow the progression and delay recurrence. Resection, radiofrequency ablation (RFA), or the medication sorafenib are often utilized while waiting for a liver to become available.
In patients who are not transplant candidates, there are other therapies available. One of these is called TACE, transcatheter arterial chemoembolization. This procedure is performed by the radiologist who delivers high dose chemotherapy directly to the lesion. Hopefully this will reduce tumor size and buy time. Chemotherapy dosed systemically may be used but results have not been encouraging as HCC is not very responsive to systemic treatment. There are other options but they are beyond the scope of this article.
In liver transplant patients, the rate of recurrence of HCC depends on many factors. Overall recurrence in patients with a small tumor is between 4-10%. The majority of recurrences occur within the first year after transplantation. However approximately 30% of recurrences happen later. There are no established guidelines regarding frequency of post-operative monitoring. Most physicians see patients every 3-6 months for imaging in this population.
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