hepatic and biliary disorders
Hepatocellular Carcinoma
Diagnosis of Hepatocellular Carcinoma
Alpha-fetoprotein (AFP) measurement Imaging (CT, ultrasonography, or MRI) Clinicians suspect hepatocellular carcinoma (HCC) if They feel an enlarged liver. Unexplained decompensation of chronic liver disease develops. An imaging test detects a mass in the right upper quadrant of the abdomen during an examination done for other reasons, especially if patients have Cirrhosis . However, screening programs enable clinicians to detect many HCCs before symptoms develop. Diagnosis is based on AFP measurement and an Imaging Tests of the Liver and Gallbladder . In adults, AFP signifies dedifferentiation of hepatocytes, which most often indicates HCC; 40 to 65% of patients with the cancer have high AFP levels ( Depending on local preferences and capabilities, the first imaging test may be contrast-enhanced CT, ultrasonography, or MRI. Contrast imaging must be ordered as a triple-phase protocol because the third, or delayed-contrast phase is essential for a radiographic diagnosis of hepatocellular carcinoma. Hepatic arteriography is occasionally helpful in equivocal cases and can be used to outline the vascular anatomy when ablation or surgery is planned. Radiographic criteria known as the LI-RADS (liver imaging reporting and data system) are used to diagnosis HCC with high sensitivity with key radiographic features, including presence of arterial hyperenhancement, pseudocapsule around the lesion, washout of contrast on delayed-phase imaging, and interval growth of the lesion from the prior scan ( Diagnosis references ). If imaging shows characteristic findings and AFP is elevated, the diagnosis is clear. However, rarely, Liver Biopsy , often guided by ultrasonography or CT, is indicated for definitive diagnosis. If a HCC is diagnosed, staging evaluation usually includes chest CT without contrast and imaging of the portal vein (if not already done) by MRI or CT with contrast to exclude thrombosis. In instances of significant alkaline phosphatase or AFP elevation or tumor well outside of Milan criteria, a bone scan is often employed to rule out bone metastases. Various systems can be used to stage HCC; none is universally used. One system is the TNM system, based on the following (see table): T:How many primary tumors, how big they are, and whether the cancer has spread to adjacent organs N:Whether the cancer has spread to nearby lymph nodes M:Whether the cancer has metastasized to other organs of the body Numbers (0 to 4) are added after T, N, and M to indicate increasing severity. Other scoring systems include the Okuda and the Barcelona–Clinic Liver Cancer staging systems. In addition to tumor size, local extension, and metastases, these systems incorporate information about the severity of liver disease. An increasing number of hepatocellular carcinomas are being detected through screening programs. Screening patients with Cirrhosis is reasonable, although this measure is controversial and has not been shown to reduce mortality. One common screening method is ultrasonography every 6 or 12 months. However, in obese patients, because sensitivity of ultrasonography is limited in them, alternating ultrasonography with MRI or CT should be considered for screening. Many experts advise screening patients with long-standing hepatitis B even when cirrhosis is absent. Patients with 1.Mitchell DG, Bruix J, Sherman M, et al: LI-RADS (liver imaging reporting and data system): Summary, discussion, and consensus of the LI-RADS Management Working Group and future directions.Hepatology61(3):1056-1065. 2015. doi: 10.1002/hep.27304 2.Galle PR, Forner A, Llovet JM, et al: EASL clinical practice guidelines: Management of hepatocellular carcinoma.J Hepatol69:182-236, 2018. 