AKT · Gastroenterology/Liver

Hepatocellular carcinoma

Primary liver cancer arising in chronic liver disease (cirrhosis, hepatitis B/C)

Overview

The commonest primary liver cancer, arising almost always in a background of CHRONIC LIVER DISEASE/cirrhosis (hepatitis B — even without cirrhosis, hepatitis C, alcohol, MASLD, haemochromatosis, aflatoxin). Often detected on surveillance (USS ± AFP 6-monthly) or presents with decompensation/weight loss/RUQ pain. Diagnosed on characteristic imaging (arterial enhancement + washout) ± biopsy; treated by resection/transplant/ablation/TACE or systemic therapy.

Recognise

Often asymptomatic (found on surveillance) or: weight loss, RUQ pain/mass, worsening/decompensation of known liver disease, raised AFP
Background of cirrhosis/chronic hepatitis B or C; hepatomegaly, ascites
Imaging: arterial-phase hyperenhancement with venous washout (diagnostic on CT/MRI in a cirrhotic liver)

Red flags

New decompensation or a liver lesion in a cirrhotic → urgent imaging (HCC)
Rupture/bleeding; portal vein invasion

Differentials & how to tell them apart

Liver metastasescommoner than primary HCC overall; usually multiple, no cirrhosis background, primary elsewhere

Cholangiocarcinomabiliary origin, different enhancement; PSC association

Hepatic adenoma/haemangioma/FNHbenign lesions — characteristic imaging, no cirrhosis

Hepatocellular carcinoma — arterially-enhancing liver lesion on CT in a cirrhotic liver
Zhenyu Pan, Guozi Yang et al / CC BY 4.0 — Wikimedia Commons

Investigations

6-monthly surveillance USS ± AFP in at-risk patients; multiphase CT/MRI (arterial enhancement + washout — diagnostic); biopsy if imaging equivocal; staging (BCLC); assess liver function (Child-Pugh).

Management

Resection/transplant/ablation (early) → TACE → systemic therapy (per BCLC stage)

1Diagnose on characteristic imaging in a cirrhotic (arterial enhancement + washout). Stage (BCLC) and assess liver function. Treatment is stage- and liver-function-dependent.Gate: SURVEILLANCE (6-monthly USS ± AFP) in cirrhosis and chronic hepatitis B is what catches curable early HCC — and hepatitis B causes HCC even WITHOUT cirrhosis (so those patients are surveilled too)
2Early → resection/transplant (Milan criteria)/ablation; intermediate → TACE; advanced → systemic therapy (immunotherapy); best supportive care; treat the underlying liver disease.

Curative: resection / liver transplant / ablation — for early disease with preserved liver function (BCLC/Milan criteria for transplant)

Transarterial chemoembolisation (TACE) — intermediate-stage disease

Systemic therapy (atezolizumab + bevacizumab; sorafenib/lenvatinib) — advanced disease

Key points

New lesion/decompensation in a cirrhotic = HCC until excluded → multiphase imaging (arterial enhancement + washout). Surveillance saves lives. Hepatitis B causes HCC even without cirrhosis.

Monitor & prognosis

Surveillance imaging/AFP; treatment response.

Curable if early/surveillance-detected; poor if advanced.

Source: NICE; EASL; BCLC staging