2. Hepatocellular Carcinoma from the ACC to Med E Paul M. Johnson Department of Internal Medicine University of North Carolina Hospitals February 12, 2010

3. Overview Incidence Diagnosis Treatment Surveillance

4. HCC: A growing problem… Incidence: 4.1/100K in US male to female ratio 3:1 much higher risk abroad mortality rate = incidence Above: Average yearly, age-adjusted incidence of HCC in US. Left: Cumulative incidence of HCC among veteran patients between 1985 and 1990. Gastroenterology 2004; 127: S27

5. Who gets HCC in the US? Hep C: 2-8% annual incidence Hep B: 0.5% annual incidence Cirrhosis due to other causes – EtOH, and others (Wilson’s, α1AT-def, hemochromatosis, NASH) Gastroenterology 2004; 127: S27-234

6. Diagnosis History – wt loss, early satiety = advanced mass Physical Exam – decompensation of cirrhosis ascites, jaundice, splenomegaly bruit over liver? paraneoplastic Labs – nonspecific, but indicative of liver disease Alpha-fetoprotein – sensitivity/spec is poor Imaging – key point: U/S, CT, and MRI all work well Biopsy – not always needed – risk of seeding (2.5 % in one review) Gut 2008; 57: 1592-6

7. Treatment of HCC 1.Resectable or not 2.Transplantable or not 3.Small, local disease or severe disease 1.If small and local, can pursue RFA, TACE (chemoembo), or PEA 2.If severe disease, pursue systemic therapy 1.Sorafenib vs. clinical trails Am J Med 2007; 120: 194-202 A simplified approach to treatment of HCC.

8. A word on surveillance…. There is no definitive evidence that screening for HCC improves survival* USPSTF and ACS do not have guidelines for screening for HCC, but the AASLD does.

9. …however, look for HCC when… Surveillance is recommended for the following groups of patients Hepatitis B carriers Asian males > 40/females >50 Family history of HCC All cirrhotic Hep B carriers* Africans >20 Non Hepatitis B cirrhosis Hepatitis C Alcoholic cirrhosis Genetic hemochromatosis Primary billiary cirrhosis Though at high risk, there is no data for Alpha 1- AT def, NASH, autoimmune hepatitis Surveillance Plan for HCC Alpha-fetoprotein – at cutoff 20 ng/mL, 60% sens, 80% spec – inadequate Ultrasound – sens 65-80%, spec 90% Interval – 6-12 months, but no data Use ultrasound to screen at 6-12 month intervals – (level II evidence) Hepatology 2005; 42: 1208-1233

10. Diagnosis Hepatology 2005; 42: 1208-1233

11. Key Points HCC is increasing in incidence. Screen selected patients with ultrasound q 6 months. Select HBV carriers, HCV and others patients with cirrhosis If the patient is symptomatic with HCC on presentation, the 5-year survival is 10%. Lancet 2003; 62: 1907-1917.

12. References Wands, JR.Prevention of Hepatocellular Carcinoma. NEJM 2004; 351: 1567. Parikh, S, and Hyman, D. Hepatocellular Cancer: A Guide for the Internist. Am J Med 2007; 120: 194-202. El-Seag, HB. Hepatocellular Carcinoma: Recent Trends in the United States. Gastroenterology 2004; 127: S27-234. Bruix, J, Sherman, M. Management of Hepatocellular Carcinoma. AASLD Guideline. Hepatology 2005; 42: 1208-1233. Silva, AU, Hegab, B. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta- analysis. Gut 2008; 57: 1592-6. Llover, JM, Burroughs, A. Hepatocellular carcinoma. Lancet 2003; 62: 1907-1917. Schwartz, JM, Carithers, RL. Hepatocellular carcinoma. www.uptodate.com. Accessed 2/11/2010.