Methods of diagnosis in HCC have evolved with the improvement in medical imaging. The evaluation of<unk> oth asymptomatic patients and those with symptoms of liver disease involves<unk> lood testing and imaging evaluation. Although historically a<unk> iopsy of the tumor was required to prove the diagnosis, imaging (especially MRI) findings may<unk> e conclusive enough to obviate histopathologic confirmation. Screening HCC remains associated with a high mortality rate, in part related to initial diagnosis commonly at an advanced stage of disease. As with other cancers, outcomes are significantly improved if treatment is initiated earlier in the disease process.<unk> ecause the vast majority of HCC occurs in people with certain chronic liver diseases, especially those with cirrhosis, liver screening is commonly advocated in this population. Specific screening guidelines continue to evolve over time as evidence of its clinical impact<unk> ecomes available. In the United States, the most commonly observed guidelines are those published<unk> y the American Association for the Study of Liver Diseases, which recommends screening people with cirrhosis with ultrasound every 6 months, with or without measurement of<unk> lood levels of tumor marker alpha-fetoprotein (AFP). Elevated levels of AFP are associated with active HCC disease, although inconsistently reliable. At levels >20 sensitivity is 41–65% and specificity is 80–94%. However, at levels >200 sensitivity is 31, specificity is 99%. On ultrasound, HCC often appears as a small hypoechoic lesion with poorly defined margins and coarse, irregular internal echoes. When the tumor grows, it can sometimes appear heterogeneous with fibrosis, fatty change, and calcifications. This heterogeneity can look similar to cirrhosis and the surrounding liver parenchyma. A systematic review found that the sensitivity was 60% (95% CI 44–76%) and specificity was 97% (95% CI 95–98%) compared with pathologic examination of an explanted or resected liver as the reference standard. The sensitivity increases to 79% with AFP correlation. Controversy remains as to the most effective screening protocols. For example, while some data support decreased mortality related to screening in people with hepatitis<unk>  infection, the AASLD notes. “there are no randomized trials for screening in Western populations with cirrhosis secondary to chronic hepatitis C or fatty liver disease, and thus there is some controversy surrounding whether surveillance truly leads to a reduction in mortality in this population of patients with cirrhosis.” Higher risk people In a person where a higher suspicion of HCC exists, such as a person with symptoms or abnormal<unk> lood tests (i.e. alpha-fetoprotein and des-gamma carboxyprothrombin levels), evaluation requires imaging of the liver<unk> y CT or MRI scans. Optimally, these scans are performed with intravenous contrast in multiple phases of hepatic perfusion to improve detection and accurate classification of any liver lesions<unk> y the interpreting radiologist. Due to the characteristic<unk> lood flow pattern of HCC tumors, a specific perfusion pattern of any detected liver lesion may conclusively detect an HCC tumor. Alternatively, the scan may detect an indeterminate lesion and further evaluation may<unk> e performed<unk> y obtaining a physical sample of the lesion. Imaging Triphasic contrast CT of hepatocellular carcinoma. Ultrasound, CT scan, and MRI may<unk> e used to evaluate the liver for HCC. On CT and MRI, HCC can have three distinct patterns of growth: * A single large tumor * Multiple tumors * Poorly defined tumor with an infiltrative growth pattern A systematic review of CT diagnosis found that the sensitivity was 68% (95% CI 55–80%) and specificity was 93% (95% CI 89–96%) compared with pathologic examination of an explanted or resected liver as the reference standard. With triple-phase helical CT, the sensitivity was 90% or higher,<unk> ut these data have not<unk> een confirmed with autopsy studies. However, MRI has the advantage of delivering high-resolution images of the liver without ionizing radiation. HCC appears as a high-intensity pattern on T2-weighted images and a low-intensity pattern on T1-weighted images. The advantage of MRI is that it has improved sensitivity and specificity when compared to ultrasound and CT in cirrhotic patients with whom it can<unk> e difficult to differentiate HCC from regenerative nodules. A systematic review found that the sensitivity was 81% (95% CI 70–91%) and specificity was 85% (95% CI 77–93%) compared with pathologic examination of an explanted or resected liver as the reference standard. The sensitivity is further increased if gadolinium contrast-enhanced and diffusion-weighted imaging are combined. MRI is more sensitive and specific than CT. Liver image reporting and data system (LI-RADS) is a classification system for the reporting of liver lesions detected on CT and MRI. Radiologists use this standardized system to report on suspicious lesions and to provide an estimated likelihood of malignancy. Categories range from LI-RADS (LR) 1 to 5, in order of concern for cancer. A<unk> iopsy is not needed to confirm the diagnosis of HCC if certain imaging criteria are met. Pathology Micrograph of hepatocellular carcinoma. Liver<unk> iopsy. Trichrome stain. Macroscopically, liver cancer appears as a nodular or infiltrative tumor. The nodular type may<unk> e solitary (large mass) or multiple (when developed as a complication of cirrhosis). Tumor nodules are round to oval, gray or green (if the tumor produces<unk> ile), well circumscribed<unk> ut not encapsulated. The diffuse type is poorly circumscribed and infiltrates the portal veins, or the hepatic veins (rarely). Microscopically, the four architectural and cytological types (patterns) of hepatocellular carcinoma are: fibrolamellar, pseudoglandular (adenoid), pleomorphic (giant cell), and clear cell. In well-differentiated forms, tumor cells resemble hepatocytes, form trabeculae, cords, and nests, and may contain<unk> ile pigment in the cytoplasm. In poorly differentiated forms, malignant epithelial cells are discohesive, pleomorphic, anaplastic, and giant. The tumor has a scant stroma and central necrosis<unk> ecause of the poor vascularization. A fifth form – lymphoepithelioma like hepatocellular carcinoma – has also<unk> een described. File:Histopathology of well-differentiated hepatocellular carcinoma.Well-differentiated HCC File:Histopathology of moderately differentiated hepatocellular carcinoma.Moderately differentiated HCC. File:Histopathology of poorly differentiated hepatocellular carcinoma.Poorly differentiated HCC Staging<unk> CLC Staging System The prognosis of HCC is affected<unk> y the staging of the tumor and the liver's function due to the effects of liver cirrhosis. A number of staging classifications for HCC are available; however, due to the unique nature of the carcinoma to fully encompass all the features that affect the categorization of the HCC, a classification system should incorporate tumor size and number, presence of vascular invasion and extrahepatic spread, liver function (levels of serum<unk> ilirubin and albumin, presence of ascites, and portal hypertension) and general health status of the patient (defined<unk> y the ECOG classification and the presence of symptoms). Of all the staging classification systems available the<unk> arcelona Clinic Liver Cancer staging classification encompasses all of the above characteristics. This staging classification can<unk> e used to select people for treatment. +<unk> arcelona Clinic Liver Cancer classification Stage Description Child-Pugh class ECOG performance status 0 (very early stage) Single nodule, < 3 cm A 0 A (early stage) 1–3 nodule, all < 3 cm A or<unk> <unk>  (intermediate stage) Multi-nodular tumor C (advanced stage) Portal invasion and extra-hepatic spread 1 or 2 D (terminal stage) Severe liver damage C 3 or 4 Important features that guide treatment include: * size * spread (stage) * involvement of liver vessels * presence of a tumor capsule * presence of extrahepatic metastases * presence of daughter nodules * vascularity of the tumor MRI is the<unk> est imaging method to detect the presence of a tumor capsule. The most common sites of metastasis are the lung, abdominal lymph nodes, and<unk> one.
complications of Hepatitis B
complications of Hepatitis A
complications of Hepatitis E
medical cause of Hepatitis
medical cause of Liver cancer
symptom of Hepatitis B
complications of Amoebiasis
complications of Cholera