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Updated: Dec 27 2021

Hepatocellular Carcinoma

  • Snapshot
    • A 58-year-old man presents to his primary care physician for a routine follow-up. He was diagnosed with hepatitis C infection, complicated by hepatic cirrhosis. He reports that he currently feels well with no acute complaints. Abdominal ultrasound demonstrates a focal hepatic lesion. He underwent a multi-phase contrasted abdominal CT scan, which demonstrated an enhancing focal hepatic mass during the arterial phase with rapid washout during the portal venous phase.
  • Introduction
    • Overview
      • primary malignancy affecting hepatocytes
      • may result in a paraneoplastic syndrome
        • hypoglycemia
        • erythrocytosis
        • hypercalcemia
        • severe diarrhea
  • Epidemiology
    • Risk factors
      • cirrhosis (80-90% of cases)
      • chronic hepatitis B infection
      • chronic hepatitis C infection
      • aflatoxin, produced by Aspergillus species
      • alcohol use
      • hereditary hemochromatosis
      • α1 antitrypsin deficiency
      • obesity
      • diabetes mellitus
      • non-alcoholic fatty liver disease
    • Pathophysiology
      • β-catenin activation and inhibition of p53 play a role in the development of hepatocellular carcinoma
  • Presentation
    • Symptoms/physical exam
      • right upper quadrant pain
      • weight loss
      • ascites
      • obstructive jaundice
      • however, patients can be asymptomatic and be incidentally found to have HCC due to routine screening in patients with cirrhosis
  • Imaging
    • Abdominal ultrasound
      • indication
        • monitoring lesions < 1 cm every 3-6 months for up to 2 years
        • can be used as a screening imaging study in patients with cirrhosis
          • if there are findings concerning for HCC, then confirmatory imaging (or possibly biopsy) is needed
      • findings
        • masses with poorly defined margins
        • irregular echoes
    • Multi-phase contrasted CT abdomen
      • indication
        • a confirmatory imaging study
      • findings
        • typically a focal nodule with early enhancement (in the arterial phase) and rapid contrast washout (in the portal venous phase)
    • Multi-phase contrasted MRI abdomen
      • indication
        • a confirmatory imaging study
      • findings
        • enhancement in the arterial phase with rapid contrast washout
  • Studies
    • Serum labs
      • α-fetoprotein (AFP)
        • if elevated > 400-500 ng/mL
          • may be suggestive of HCC
          • may be seen in patients with active liver disease (e.g., HCV or HBV infection)
        • a normal value does not exclude HCC
  • Differential
    • Hepatic adenoma
      • differentiating factor
        • benign liver tumor seen in patients with prolonged contraception use, anabolic steroid use, glycogen storage disorders, and pregnancy
  • Treatment
    • Surgical
      • resection
        • indication
          • recommended if the lesion is resectable and the patient has good performance status
      • liver transplantation
        • indication
          • recommended based on the patient's performance status and that the tumor is unresectable
      • liver-directed therapies
        • indication
          • in patients with local disease who are not candidates for resection or liver transplantation
            • may potentially down-stage the tumor, enabling the possibility of transplantation or resection
        • modalities
          • radioablation
            • delivers local radiofrequency thermal energy
          • transarterial chemoembolization (TACE)
            • delivers high-dose chemotherapy (e.g., cisplatin and doxorubicin) to local areas in the liver
              • therefore, this decreases the risk of developing systemic toxicities
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