HEPATOCELLULAR CARCINOMA



Although hepatocellular carcinoma is rare in the United States (accounting for less than 2.5 per cent of all malignancies), in other areas of the world, including sub-Sahara Africa, China, Japan,and Southeast Asia, it is one of the most frequent malignancies and is an important cause of mor­tality, particularly in middle-aged males. Hepa­tocellular carcinoma usually arises in a cirrhotic liver and is closely associated with chronic hep­atitis B virus infection, particularly in those parts of the world, enumerated above, where infants ac­quire persistent infection with hepatitis B from chronically infected mothers at birth. The advent and widespread use of vaccination to prevent in­fection with hepatitis B virus is expected to re­duce markedly the incidence of this disease. The risk of hepatocellular carcinoma is low in cirrho­sis associated with primary biliary cirrhosis and Wilson’s disease and intermediate in cirrhosis due to alcohol. Other risk factors for development of hepatocellular carcinoma, as well as its clinical manifestations, are listed in Table 48-1. Diagnosis of small, potentially treatable lesions, even in high-risk areas, is difficult, as the efficacy of screening for elevated a-fetoprotein levels has been mixed. Most patients present with wide­spread, often multifocal disease, and the median survival from the time of diagnosis is less than six months. Hepatic resection can be attempted in pa­tients with small, solitary lesions if the remaining liver is not cirrhotic. Chemotherapy, radiation