Hepatocellular Carcinoma Associated with Hepatic Venous Outflow Tract Obstruction (HVOTO-HCC): Is it Different from HCC of Viral Etiology?

Abstract

Background and Aims: Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and the third leading cause of cancer related mortality worldwide. More than 80%–90% of HCC has underlying cirrhosis. Advances in non-surgical treatment options for hepatic venous outflow tract obstruction (HVOTO) has led to a dramatic decline in mortality rates leading to the emergence of the entity of HVOTO-HCC. We illustrate the differences with regard to the demography, clinical profile and imaging features of HVOTO-HCC, a rare entity, and compare the features with the garden variety of HCC of viral origin. Methods: HVOTO-HCC presenting to our hospital from 1992 to 2013, were enrolled. Their clinical presentation, demographic profile, biochemical parameters, and imaging characteristics were studied at length and staging of the cancer was done following Barcelona Clinic staging of Liver Cancer (BCLC) criteria. Imaging with ultrasonography (USG) and multiphase CT scan (MPCT) was performed. The masses were evaluated on the basis of their number, size, attenuation on unenhanced CT scan and characteristics of enhancement on post contrast arterial as well as venous phase. For comparison, BCLC stage matched patients of HCC of viral etiology (HCC-viral) presenting to us during the same period were studied and the differences assessed. Results: Total of 129 patients with HCC were evaluated (15 with HVOTO and 114 with viral hepatitis). HVOTO-HCC patients were younger (mean age 38.5 ± 12.5 years); predominantly females (male: female 6:9) and had significantly high levels of serum alpha fetoprotein [AFP (mean 30014 ± 58287ng/ml, P < 0.001)]. In contrast, Viral-HCC patients were older (51.4 ± 12.1 years); had male predilection (97:17 male: female) with mean AFP of 8100.9 ± 31933 ng/ml. In both entities, pain was a common symptom; however, it was more frequently seen in HVOTO-HCC (73.3% vs 38.6%, P = 0.04). On MPCT, HVOTO-HCC in comparison with Viral- HCC was usually solitary (40% vs 18.4%), predominantly exophytic (46.6% vs 18.4%, P < 0.01) and had necrosis more frequently (53.3% vs 23.7%, P = 0.04). Enhancement patterns of HCC in both entities were comparable. Conclusion: It is important to be familiar with HVOTO related HCC, a rare entity, which has definite characteristic features helping in differentiating from HCC of viral origin.