SeminarHepatocellular carcinoma
Section snippets
Incidence
The burden of HCC is irregularly distributed in the world, for the most part following the prevalence of the hepatitis B virus. Of the estimated 350 000 new cases per year, one-third occur in China and another third elsewhere in Asia. There are about 30 000 cases per year in Europe and 23 000 in Japan; the USA has about 7000 cases per year and there are at least six times that number in Africa. Men are afflicted at least twice as often as women. Although HCC ranks eighth in frequency among
Presymptomatic trauma
Small HCCs (<2 cm) are histologically well-differentiated and arranged in a thin trabecular pattern without a capsule.18 These tumours are distinct from both the large cell and small cell dysplasias which at one time were thought to be the preneoplastic lesions of HCC.19, 20 The stepwise development of HCC is now thought to proceed from adenomatous hyperplasia through atypical hyperplasia to early hepatocellular carcinoma.21 However, because no consistent diagnostic criteria have been
Surgical resection
When HCC is diagnosed the first question faced by the patient and the clinician is—Can it be resected? A simple history and physical examination will exclude many patients from consideration for resection. Because most HCCs occur in cirrhotic liver, patients are in danger of decompensation or liver failure if an overaggressive resection is attempted. Most surgeons will attempt resection only if the patient has cirrhosis of Child-Pugh class A and a single definable tumour.34 Despite progress in
Screening
Because HCC tends to occur in a definable population (those with chronic hepatitis or cirrhosis) and because the outlook with advanced disease is so poor, it is tempting to postulate that screening of cirrhotic patients might yield individuals who could receive early and successful therapy. Patients with cirrhosis screened for HCC have an annual conversion rate of about 3% in western patients and 6% in Japanese patients.51, 52 Suggested strategies for screening have included periodic ultrasound
Prevention
The best news in HCC research is that the disease can be prevented. The strongest data come from Taiwan where, in 1984, neonatal vaccination began. For the first two years, only the children of HBsAg-positive mothers were vaccinated against HBV but after 1986 vaccination was universal. The rate of HCC in children aged 6–9 years decreased from 5·2 million before the programme to 1·3 per million in the first vaccinated cohort.54 Mass vaccination programmes in Hong Kong, Thailand, Indonesia, and
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