HEPATOCELLULAR CARCINOMA (HCC) Hepatocellular Carcinoma(HCC)is macroscopically classified into four categories,which may be correlated with clinical,histologic and prognostic patterns: (a)typeI-nodular form with single or multiple nodules with apseudocapsule. (b)typeII-adominant mass with satellite nodules. (c)typeIII-adiffuse form with extensive tumor infiltration in parenchymal tissue. (d)typeIV-invading adjacent structures such as the diphram and stomach.

*Epidemiology: -Hepatocellular Carcinoma(HCC) is the most common primary malignancy of the liver. -Hcc has avariable geographical distribution around the world.Especially in Saudi Arabia,liver cancer acounts for 6-9% of all newly diagnosed cancer according to the most recent cancer. -Male to Female ratio is 3:1 of all liver cancer,hepatocellular carcinoma accounts for 88% in Saudi Arabia. The median age at diagnosis is 65 years for Males and 60 years for Females. -The incidence of Hcc is expected to increase dramatically in the kingdome in the next 30 years.

Statics:

*Risk Factor: -Hepatitis B is considered the strongest risk factor associated with Hcc in the majority of countries,but more important in Asia and Africa. -The annual incidence of Hcc in hepatitis B patients with cirrhosis exceeds 2%. -Hepatitis B virus is thought to be carcinogenic both directly and indirectly,because HBV DNA is integrated into cellular DNA of host and can be demonstrated in Hcc cells in 95% of the cases..*FIGURE:This woman is suffering from liver cancer caused by Hepatitis B.

-Hepatitis C is considered the most important risk factor for Hcc in different countries. -Almost all Hcc in patients with hepatic C occurs in patients who have dvelop cirrhosis. -This suggests that hepatic disease plays amajor role in the development of cancer in this disease.

-Cirrhosis is the major risk factor for the development of Hcc regardless of the cause. -The annual incidence of Hcc in patients of cirrhosis is about 3%. -Male sex,age,and duration of cirrhosis are associated with increased risk of Hcc in patients with cirrhosis. Hepatitis BHepatitis C Cirrhosis HCC

*other risk factor: -Alcohol is the risk factor of Hcc is increase up to 40%,in astudy,the risk of Hcc was found to be 13 times greater in drinkers than in non-drinkers. -Alfatoxin B1 is an important risk factor for Hcc in parts of Africa and Asia. -Smoking are conflicting but this is probably Aminor risk factor.

*The classic features of Hcc: -Weight loss. -Weakness. -Abdominal swelling. -Acute deterioration of liver function,in patient with stable cirrhosis and acute intra-abdominal bleeding.

-Physical finding: *Stage of disease. *Mass of tumor. *Hcc is known to cause many paraneoplastic syndromes. *Hypoglycemia may be seen early in the disease. *Polycythemia may be seen in less than 10% of patients. *Hypercalcemia may also be seen in the absence of bone invasion.

How is hepatocellular carcinoma diagnosed? In addition to a complete medical history and physical examination, diagnostic procedures for hepatocellular carcinoma may include: 1-biopsy - a sample of tissue removed from the tumor and examined under a microscope; the surgeon may also look at the liver using an instrument called a laparascope, a small tube with a light on the end

2-complete blood count (CBC) - a measurement of size, number, and maturity of different blood cells in a specific volume of blood. 3-additional blood tests - may include blood chemistries, evaluation of liver and kidney functions, and genetic studies. 4-multiple imaging studies, including:

(a)computerized tomography scan (also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

(b)x-ray – a diagnostic test which uses invisible electromagnetic nergy beams to produce images of internal tissues, bones, and organs onto film

(c)magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

(d)ultrasound (also called sonography) - a diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.

(e)liver scans - pictures or x-rays taken of the liver after a dye has been injected that is absorbed by liver tissue. These are used to detect tumors and liver abnormalities. 5 -alpha-fetoprotein (AFP) test - alpha-fetoprotein (AFP) levels in the blood can be used to diagnose and follow response to treatment

*Management: -Hepatic resection,major advanced in the field of hepatobililary surgery have occured. Although tumor resection removes the visible portion of the cancer,it is clearly inferior to transplantation in that it can not guarantee the removal of invisible tumors seeding,in that it leaves the remaining portions of the liver which is at high risk of malignancy, and in that it doesn’t improve hepatic function. -We feel that the best treatment option in a cirrhotic with large tumor is probably chemoemobilization rather than surgical resection.

-Even if it’s technically feasible,and surgical resection should be preserved for patients who are not cirrhotic or patients with compensated cirrhosis with small tumors. -We feel that in patients with no liver cirrhosis or early liver cirrhosis(indicate by normal billirubin and no signs of portal hypertension),liver resection should be considered.

- Ablation :this could be done by either chemical means(absolute alcohol or trichlroacetic acid)or physical means(radiofrequancy ablation). -In RFA, thermal destruction is achieved with an electric current that passes to the tumors tissues via an electrode tip under imaging guidance,resulting in heat generation and coagulation necrosis.This technique seems to be very effective with low recurrence rate.

*Prevention of infection: -Vaccination is a very powerful measure to reduce the infection rate with hepatitis B and hence reduce the incidence Hcc. -No effective vaccine is available for hepatitis C.