(I) Pathology
1.Typing (1) giant mass type >10cm; (2) nodular type: about 5cm; (3) diffuse type; (4) small cancer type. Liu Hongbo, Department of Radiotherapy, Zhumadian First People’s Hospital
2. Metastatic pathways: (1) hematogenous metastasis, the earliest and most common; (2) lymphatic metastasis mostly to hepatoportal lymph nodes; (3) implantation metastasis.
(II) Clinical manifestations
Primary liver cancer starts insidiously and lacks typical symptoms in early stage. Symptoms of middle and late stage liver cancer are as follows.
1. Pain in the liver area is mostly persistent swelling pain or dull pain. Liver pain is caused by the liver envelope being pulled by the fast-growing tumor. If the lesion invades the diaphragm, the pain may involve the right shoulder. When the cancer nodules on the liver surface rupture, the necrotic cancer tissue and blood flow into the abdominal cavity, severe pain may occur suddenly, extending from the liver area to the whole abdomen.
2.hepatomegaly liver is progressively enlarged, with hard texture, uneven surface, nodules or giant lumps of different sizes, blunt and uneven edges, and often with different degrees of pressure pain. When liver cancer is protruding under the right costal arch or the subserous process, the epigastrium may show local elevation or fullness. The cancer nodules located under the costal arch are the most easily palpable. Sometimes, if the cancer compresses the blood vessels, a blowing sound can be heard in the corresponding abdominal wall area.
3.Jaundice appears in late stage, usually due to hepatocellular damage or due to compression or invasion of bile ducts near hepatoportal by cancer mass, or due to obstruction of bile ducts caused by shedding of cancer tissue or blood mass.
4.Signs of cirrhosis with cirrhotic portal hypertension may include splenomegaly, ascites, formation of venous collateral circulation and other manifestations. Ascites increases quickly and is usually leaking fluid. (Candidates should keep in mind whether it is mostly leakage or exudate, and can review the point of differentiation of exudate and leakage accordingly). There may be bloody ascites, mostly caused by the cancer invading the peritoneum or breaking down into the abdominal cavity.
5.The systemic manifestations of malignant tumor include progressive wasting, loss of appetite, fever, weakness, malnutrition and cachexia. Spontaneous hypoglycemia and erythrocytosis are more common, while other rare ones include hyperlipidemia, hypercalcemia, carcinoid syndrome, etc. (What is concomitant cancer syndrome, very important terminology explanation).
6.Metastasis symptoms are early in intrahepatic hematogenous metastasis, most of them metastasize to lung, adrenal gland, bone, thorax, brain and other parts causing corresponding symptoms, thoracic turn to shift the right side is more common, there can be pleural fluid sign.
(C) Ancillary tests
1.AFP measurement is important to judge the condition of hepatocellular carcinoma, postoperative recurrence and estimate the prognosis. Criteria: ①AFP>500μg/L for 4 weeks ②AFP gradually increases from low to non-decreasing ③AFP at a moderate level of 200μg/L or more for 8 weeks.
2.Serum enzyme measurement: GGT?II (γ-glutamyl transpeptidase isoenzyme II) has a positive rate of 90% in primary and metastatic hepatocellular carcinoma.
3.B-type ultrasound imaging can show tumors with a diameter of 2 cm or more.
4.Electronic computerized X-ray tomography (CT) can show tumors with diameter of 2cm or more. If combined with hepatic arteriography (CTA) or hepatic arteriography with iodine oil injection (1ipoidol-CTA), the detection rate of tumors below 1cm can reach more than 80%, which is the best method to diagnose small and micro hepatocellular carcinoma.
5.X-ray hepatic angiography, selective abdominal artery and hepatic artery angiography can show cancer nodules with diameter above 1cm, with positive rate of 87%, combined with AFP, positive results, can be used to diagnose small hepatocellular carcinoma. DSA (digital subtraction hepatic arteriography) can show small hepatocellular carcinoma with 1 or 5cm diameter.
(IV) Diagnosis
For any middle-aged, especially male patients with a history of liver disease who have unexplained pain in the liver area, wasting and progressive hepatomegaly, AFP assay and the above tests should be performed. Strive for early diagnosis. AFP testing combined with ultrasonography once or twice a year in high-risk groups is a basic measure to detect early hepatocellular carcinoma. persistent low-level increase in AFP but normal transaminases is often the main manifestation of subclinical hepatocellular carcinoma. The diagnosis of primary hepatocellular carcinoma can be confirmed when AFP>500μg/L for 1 month or AFP>200μg/L for 8 weeks, in addition to excluding active liver disease, pregnancy and embryonal tumor.
(V) Differential diagnosis
1.Secondary hepatocellular carcinoma has extrahepatic tumor manifestation, with slower development and milder symptoms, and the AFP test is usually negative. The key to confirm the diagnosis is pathological examination and finding the evidence of extrahepatic primary cancer.
2.Cirrhosis if there are obvious cases of cirrhosis with large liver, large hard nodules or liver atrophy and deformation and imaging examination reveals occupying lesions, there is a high possibility of hepatocellular carcinoma.
If: (1) the dynamic curves of AFP and ALT are parallel or synchronously increased, or ALT is continuously increased to several times of normal, the possibility of active liver disease is high; (2) the two curves are separated, and AFP is increased while ALT is normal or decreased from high, then more consideration should be given to primary liver cancer.
4.Hepatic abscess generally has obvious clinical manifestations of inflammation, the surface of the enlarged liver is smooth without nodules, and the tenderness is obvious. The white blood cell count is elevated. Ultrasonography can detect a liquid dark area in the liver. In case of diagnostic difficulties, diagnostic puncture can be performed under ultrasound guidance. Anti-amoebic and anti-bacterial tests may be performed for treatment.
5. Extrahepatic tumors adjacent to the liver area with retroperitoneal soft tissue swelling, and tumors from the kidney, adrenal glands, pancreatic structures, etc. may also present masses in the abdomen. Ultrasonography can help to distinguish the site and nature of the mass, and AFP test should be negative. If it is difficult to distinguish, abdominal dissection is needed to confirm the diagnosis.
6. Non-cancerous occupying lesions of liver such as hepatic hemangioma, polycystic liver, encapsulated liver disease, etc. can be diagnosed by CT radionuclide blood pool scan, MRI and ultrasonography, and sometimes abdominal dissection is required.
(vi) Treatment
Surgical treatment is the best method. Indications for surgery are: (1) clear diagnosis; estimated lesions limited to one lobe or half of the liver, (2) good liver function compensation, prothrombin time not less than 50% of normal, no obvious jaundice, ascites or distant metastases, (3) good cardiopulmonary and renal function, able to tolerate surgery.
Hepatic artery embolization chemotherapy (TAE) is the preferred non-surgical method.