Chapter 088. Hepatocellular Carcinoma (Part 4)

Physical Signs Hepatomegaly is the most common physical sign, occurring in 50–90% of patients. Abdominal bruits are noted in 6–25%, and ascites occurs in 30–60% of patients. Ascites should be examined by cytology. Splenomegaly is mainly due to portal hypertension. Weight loss and muscle wasting are common, particularly with rapidly growing or large tumors. Fever is found in 10–50% of patients, from unclear cause. The signs of chronic liver disease may be present, including jaundice, dilated abdominal veins, palmar erythema, gynecomastia, testicular atrophy, and peripheral edema. Budd-Chiari syndrome can occur due to HCCinvasion of the hepatic veins; it should...
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Chapter 088. Hepatocellular Carcinoma (Part 4) Chapter 088. Hepatocellular Carcinoma (Part 4) Physical Signs Hepatomegaly is the most common physical sign, occurring in 50–90% ofpatients. Abdominal bruits are noted in 6–25%, and ascites occurs in 30–60% ofpatients. Ascites should be examined by cytology. Splenomegaly is mainly due toportal hypertension. Weight loss and muscle wasting are common, particularlywith rapidly growing or large tumors. Fever is found in 10–50% of patients, fromunclear cause. The signs of chronic liver disease may be present, includingjaundice, dilated abdominal veins, palmar erythema, gynecomastia, testicularatrophy, and peripheral edema. Budd-Chiari syndrome can occur due to HCCinvasion of the hepatic veins; it should be suspected in patients with tense ascitesand a large tender liver (Chap. 302). Paraneoplastic Syndromes Most paraneoplastic syndromes in HCC are biochemical abnormalitieswithout associated clinical consequences. They include hypoglycemia (also causedby end-stage liver failure), erythrocytosis, hypercalcemia, hypercholesterolemia,dysfibrinogenemia, carcinoid syndrome, increased thyroxin-binding globulin,changes in secondary sex characteristics (gynecomastia, testicular atrophy, andprecocious puberty), and porphyria cutanea tarda. Mild hypoglycemia occurs inrapidly growing HCC as part of terminal illness, and profound hypoglycemia mayoccur, although the cause is unclear. Erythrocytosis occurs in 3–12% of patients,and hypercholesterolemia in 10–40%. A high percentage of patients havethrombocytopenia or leukopenia not caused by cancer infiltration of bone marrow,as in other tumor types. Staging Although the TNM (primary tumor, regional nodes, metastasis) stagingsystem set up by the American Joint Commission for Cancers (AJCC) issometimes used, the newer Cancer of the Liver Italian Program (CLIP) system isnow popular as it takes cirrhosis into account, as does the Okuda system (Table88-4). Other staging systems have been proposed and a consensus is needed. Thebest prognosis is stage I, solitary tumor Variables 0 1 2 i. Tumor number Single Multiple — Hepatic replacement by Okuda Classification Tumor Sizea Ascites Albumin Bilirubin (g/L) (mg/dL) ≥50 ≥3 <% 0 3 3 (+) (–) (+ ( (+ (– (+ (– ) –) ) ) ) ) Okuda stages: stage 1, all (–); stage 2, 1 or 2 (+); stage 3, 3 or 4 (+). a Extent of liver occupied by tumor. Note: CLIP, Cancer of the Liver Italian Program.