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Harrison's Podclass - Episode 123- A 65-Year-Old Male with Hepatocellular Carcinoma (HCC)
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Harrison's Podclass - Episode 123- A 65-Year-Old Male with Hepatocellular Carcinoma (HCC)
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T00H07M15S
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Upload Date:
2025-07-18T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi everyone. Welcome back to Harrison's Podclass. We're your co-hosts. I'm Dr. Cathy Handy. [Dr. Wiener] And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. [music continues] [Dr. Handy] Welcome to episode 123: a 65-year-old man with hepatocellular carcinoma.
[Dr. Wiener] Hey, Cathy. So today's patient is a 65-year-old man who was recently diagnosed with hepatocellular carcinoma. He's a recent immigrant from Bangladesh where he lived in a rural setting with minimal primary healthcare. His physical examination is only notable for him being thin with a palpable liver. His granddaughter, who grew up in the US, is in clinic with him today and is wondering if she is also at risk for cancer.
And the question's going to ask about risk factors for his current malignancy. [Dr. Handy] Well, we know that hepatitis B and hepatitis C are the most common risk factors for the development of cirrhosis and hepatocellular carcinoma, but I'm guessing that that's not going to make it to the answer/questions and it'll be harder than that. [Dr. Wiener] Yeah, I'm not going to make it that easy.
So the question asks, which of the following is the most likely risk factor for his current hepatocellular carcinoma? And the options are A, aluminum; B. arsenic; C. cadmium; D. lead; or E. mercury. [Dr. Handy] Okay. So it sounds like today we're talking about heavy metals, an excellent and not often discussed topic. [Dr. Wiener] You're stalling. [Dr. Handy chuckles] All right. The answer is B. arsenic.
[Dr. Wiener] You saw "Arsenic and Old Lace," the famous Carrie Grant movie? Tell me more. What do you know about arsenic? [Dr. Handy] Arsenic has been clearly linked with an increased risk for many cancers. And this is even at moderate levels of exposure. So in addition to hepatocellular carcinoma, it's also been linked to cancers of the skin, bladder, the renal pelvis, ureter, and kidney.
[Dr. Wiener] Outside of the movies, where do people get exposed to arsenic these days? [Dr. Handy] Exposure to arsenic can derive from smelting in microelectronics industries, wood preservatives, pesticides, herbicides, fungicides, bulk remedies sometimes, or incinerators that burn these products. For this gentleman, it's possible that he was exposed due to well water contamination. It's been well known that deep water wells are sources of arsenic but more recently, shallow tube wells for drinking water in Bangladesh and Western India have shown to have high levels of arsenic too.
And this is problematic because for millions, this is their major source of potable water. [Dr. Wiener] Does arsenic have any other risks besides malignancies? [Dr. Handy] Yes. More bad news on this front. Recent studies in community-based populations have generated strong evidence that arsenic exposure is also a risk factor for an increased risk of hypertension, coronary heart disease and stroke, lung function impairment, acute respiratory tract infections, respiratory symptoms, and non-malignant lung disease mortality.
The association with cardiovascular disease may hold at levels of exposure in drinking water that are below the WHO provisional guideline value of 10 micrograms per liter. Evidence has also continued to build indicating that low-level arsenic is a likely cause of neurodevelopmental delays in children and also likely contributes to the development of diabetes. [Dr. Wiener] I'm glad we're discussing this, but I've also heard that seafood is a source of arsenic.
[Dr. Handy] Seafood and fish contain organic arsenic, which is non-toxic. What we're talking about today is inorganic arsenic. The toxic metal that we worry about in fish is mercury. [Dr. Wiener] Okay, well, in someone who has potential chronic arsenic toxicity, how do we diagnose it and how do we treat it? [Dr. Handy] The best test for chronic toxicity is to measure arsenic in the hair or fingernails, which represents deposition over 6 to 12 months.
You can also measure levels in the blood or urine for more acute exposures. Chronic arsenic exposure is also associated with hyperkeratosis, exfoliative dermatitis, and Mees' lines on the nails. Treatment is chronic chelation with Dimercaprol. [Dr. Wiener] Okay. I do want to get back to "Arsenic and Old Lace," the movie. You've talked about chronic arsenic exposure.
What are the symptoms of acute arsenic poisoning? [Dr. Handy] All right, acute arsenic poisoning results in necrosis of intestinal mucosa with hemorrhagic gastroenteritis, fluid loss, hypotension, delayed cardiomyopathy, acute tubular necrosis, and hemolysis. [Dr. Wiener] Got it. So we now understand acute and chronic arsenic but let's finish up with the typical clinical manifestations for our other choices in this question. [Dr. Handy] Okay. Aluminum contributes to the encephalopathy in patients with severe renal disease who are undergoing dialysis.
Serious cadmium poisoning from the contamination of food and water by mining effluents in Japan contributed to the 1946 outbreak of itai-itai disease, so named because of cadmium-induced bone toxicity that led to painful bone fractures. Modest exposures from environmental contamination have been associated in some studies with a lower bone density, a higher incidence of fractures, and a faster decline in height in both men and women, effects that may be related to cadmium's calciuric and other toxic effects on the kidney.
[Dr. Wiener] So, itai-itai apparently means "ouch ouch." And I love that we have a disease called "ouch ouch." What about lead and mercury? [Dr. Handy] Lead has gotten a lot of publicity in the United States in recent years. It's associated with a host of cognitive and developmental problems in children and young adults. Less well-known is the strong association between chronic lead toxicity or exposure and increased cardiovascular morbidity and mortality, hearing loss, Parkinson's disease, and amyotrophic lateral sclerosis as well.
With respect to pregnancy-associated risks, high maternal bone lead levels were found to predict lower birth weight, head circumference, birth length, and neurodevelopmental performance in the offspring by age two years. [Dr. Wiener] And mercury, you already mentioned, it could be found in some fish. [Dr. Handy] Yeah, the concern is neurobehavioral performance in the offspring of mothers that ingested mercury-contaminated fish.
The current recommendation is for pregnant women to avoid fish known to have high levels of mercury contamination, and that would include fish like swordfish, king mackerel, and some varieties of tuna. Notably, salmon, sardines, and shellfish have low mercury levels. [Dr. Wiener] Okay, so today's teaching points are that heavy metals can cause acute and chronic toxicity.
Chronic arsenic exposure, often through drinking water in parts of the world that are at risk, can place patients at high risk of a variety of medical disorders including malignancies. [Dr. Handy] And you can find this question and questions like it in the Harrison's Review Questions book and online, and more about heavy metals in the chapter on heavy metals. Visit the show notes for links to helpful resources, including related chapters and review questions from Harrison's.
And thank you so much for listening. If you enjoyed this episode, please leave us a review so we can reach more listeners just like you. [upbeat outro music]
