SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2023 | VOLUME 21 | ISSUE 1 | 12 Discussion HCC in pregnancy remains a rare condition with less than 100 cases reported in the literature with most patient reports coming from Asia and Sub-Saharan Africa. 1, 4, 5 It is, however, a devastating diagnosis with an overall 1-year survival of only 23%. 1 Up to 20% of women have distant metastasis at diagnosis with an even worse 1-year survival of <10%. 3 HCC in pregnancy is reported to have a more aggressive disease course and thus carries a worse prognosis. This is likely secondary to the direct effect of estrogen accelerating tumour growth and the relative immune-suppressed state of pregnancy. 1, 2, 5 There is also a state of hyperperfusion due to increased cardiac output during pregnancy, which may drive the higher rate of distant metastasis at diagnosis. 1, 3, 6 Risk factors for HCC in pregnancy include previously well-described risk factors such as HBV, HCV, cirrhosis, a family history of HCC, exposure to aflatoxin B1 and obesity. 7 Oestrogen as a driver of more severe disease is also considered a risk factor and as such long-term use of the combined oral contraceptive pill and multiparity may further increase the risk. 1, 4-6 With the availability of lower- dose COC formulations, this may be less of a factor. Early diagnosis remains one of the biggest challenges. According to WHO, antenatal screening for HBV should be carried out in all areas where the prevalence of HBV is >2%. 8 Many women with chronic HBV infection, however, are unaware of their status and thus not enrolled in surveillance programs nor receiving treatment. 9 Imaging with CT or MRI remains diagnostic in most patients with HCC. In pregnancy, this may present a challenge due to concerns related to foetal radiation, particularly in the first trimester. 1 Ultrasound provides an excellent screening tool and is safe in all trimesters. 3 MRI remains the modality of choice when further imaging is needed for diagnosis or for further prognostication and treatment planning in all trimesters. Gadolinium contrast does cross the placenta and can accumulate resulting in concerning inflammatory side effects. Risk-benefit needs to be assessed in each situation as one endeavours to treat both the mother and the foetus. 3, 10 Treatment remains a significant challenge and is affected by many factors, including the gestational age of the foetus and the stage of the tumour. As the disease course may be more aggressive, there are increased risks of complications and paraneoplastic effects, including hypoglycaemia, and up to 10% of patients may complicate with tumour rupture which carries a dismal prognosis. 3, 4 Most centres would recommend termination of pregnancy if the diagnosis is made within the first trimester in order to ensure optimal treatment of the mother. 3 If the diagnosis is made in the second or third trimester, the patient should be managed by an experienced multidisciplinary team including obstetrics, hepatobiliary surgeons, oncologists and hepatologists, to provide an individualized treatment plan in discussion with the patient. A number of procedures may be offered as either palliative or bridging therapy including bland arterial embolization and ethanol injection. 1 Resection remains the best option of cure if the tumour and patient characteristics allow it. 1-3 Conclusion Hepatocellular carcinoma in pregnancy remains a devastating diagnosis with poor outcomes for both mother and baby. In this instance, earlier screening and linkage to care may have potentially avoided this outcome. The reality is that many opportunities existed to test this woman for hepatitis B. This did not happen and underpins the challenge we have in eliminating hepatitis B. Until screening is prioritized, such cases will unfortunately remain. References 1. Esike Chidi OU, E.P.O., Umeora Odidika UJ, Anozie Okechukwu B, Ajayi Nnennaya A, Ajah Leonard O, Iyare Festus E, Ukaegbe Chukwuemeka I,, Hepatocel- lular carcinoma in pregnancy, a rare cancer in preg- nancy that still occurrs - a review of the literature. Int J Clin Obstet Gynaecol, 2020. 4: p. 04-06. 2. Cobey, F.C. and R.R. Salem, A review of liver mass- es in pregnancy and a proposed algorithm for their diagnosis and management. The American journal of surgery, 2004. 187(2): p. 181-191. 3. Choi, K.K., et al., Hepatocellular carcinoma during pregnancy: is hepatocellular carcinoma more aggres- sive in pregnant patients? J Hepatobiliary Pancreat Sci, 2011. 18(3): p. 422-31. 4. Ndububa, D., et al., Case Report: Hepatocelluar Car- cinoma In Pregnancy And Postpartum Period: A Study Of 6 Cases In Nigerian Women. Nigerian Journal of Clinical Practice, 2004. 7(1): p. 46-49. 5. Lau, W.Y., et al., Hepatocellular carcinoma during pregnancy and its comparison with other pregnan- cy-associated malignancies. Cancer, 1995. 75(11): p. 2669-2676. 6. De Maria, N., M. Manno, and E. Villa, Sex hormones and liver cancer. Molecular and cellular endocrinology, 2002. 193(1-2): p. 59-63. 7. Spearman, C. et al, Towards the elimination of hepatitis B and hepatocellular carcinoma. SAMJ: South African Medical Journal, 2018. 108(8): p. 13-16. 8. Organization, W.H., Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations. 2022: World Health Or- ganization. 9. Spearman, C.W., et al., Hepatitis B in sub-Saharan Af- rica: strategies to achieve the 2030 elimination targets. The lancet gastroenterology & hepatology, 2017. 2(12): p. 900-909. 10. Ray, J.G., et al., Association between MRI exposure during pregnancy and fetal and childhood outcomes. Jama, 2016. 316(9): p. 952-961. CASE STUDY