Gastroenterology & Nutrition

Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a primary hepatocyte cancer usually arising in cirrhosis or chronic hepatitis B; early detection and treatment must account for both tumour burden and the reserve of the underlying liver.

In a nutshell

HCC usually arises in cirrhosis, but hepatitis B can cause it without cirrhosis. At-risk people need six-monthly ultrasound surveillance; add AFP according to the NICE hepatitis B pathway. A suspicious lesion is assessed with multiphasic CT or MRI, and classic enhancement/washout can establish HCC in the right at-risk liver without biopsy. Treatment is an MDT decision balancing BCLC stage, liver reserve and fitness: resection, transplant or ablation may cure early disease; TACE/TAE suits selected intermediate disease; advanced disease has current NICE immunotherapy options.

Classic presentation

A person with cirrhosis has a new lesion on six-monthly surveillance ultrasound, or develops unexplained weight loss, right upper quadrant pain or new decompensation.

Key points

Cirrhosis is the main risk state; hepatitis B can cause HCC without cirrhosis.
Offer six-monthly ultrasound for cirrhosis. NICE recommends ultrasound with or without AFP for cirrhosis without hepatitis B, while hepatitis B surveillance includes AFP in significant fibrosis/cirrhosis.
AFP is neither sensitive nor specific enough to diagnose or exclude HCC alone.
Arterial phase hyperenhancement with later washout on multiphasic CT/MRI can diagnose HCC non-invasively in an appropriate at-risk liver.
Early HCC may be treated with resection, transplantation or ablation; treatment depends on liver reserve as well as tumour size and number.
TACE/TAE is for selected intermediate disease with preserved liver function; avoid it in decompensation, macroscopic vascular invasion or extrahepatic spread.
NICE lists atezolizumab plus bevacizumab and durvalumab plus tremelimumab as options for untreated advanced or unresectable HCC, subject to eligibility and current commissioning arrangements.

First-line investigation

Multiphasic contrast CT or MRI of the liver after a suspicious surveillance ultrasound, with AFP and full liver-function/staging assessment; refer atypical cases to the specialist MDT.

Management

Recognise rupture or severe decompensation

Admit and involve hepatology, interventional radiology/surgery and critical care as appropriate for shock, peritonism, suspected tumour rupture, rapidly worsening liver failure or another acute complication.^1,7

Confirm and stage through the specialist MDT

Use multiphasic CT/MRI, baseline liver assessment, chest/extrahepatic staging and BCLC; biopsy atypical lesions or when histology is required for the treatment pathway.^1,4

Select resection, transplant or ablation for early disease

Select treatment according to tumour extent, portal hypertension, liver reserve, remnant liver and fitness; transplantation is especially important for decompensated cirrhosis within accepted criteria.^1,9

Use transarterial therapy selectively

TACE/TAE is used for selected intermediate disease with preserved liver function and performance status, not for decompensation, macroscopic vascular invasion or extrahepatic spread.¹

Use current systemic options or supportive care

For untreated advanced or unresectable HCC, discuss current NICE options including atezolizumab/bevacizumab or durvalumab/tremelimumab with specialist oncology; use supportive and palliative care when active treatment is unlikely to help.^5,6,1,11

Continue specialist surveillance and safety-netting

Follow the MDT imaging and blood-test plan after treatment, manage cirrhosis and treatment toxicity, and advise urgent review for new pain, bleeding, jaundice, ascites, encephalopathy, fever or rapid functional decline.^1,11

Exam traps

A normal AFP does not exclude HCC and a raised AFP does not diagnose it.
Do not describe every liver lesion as HCC: classic radiology is diagnostic only in the appropriate clinical setting; atypical or non-cirrhotic cases may need biopsy.
Milan criteria are useful exam shorthand, but transplant listing uses current specialist-centre criteria and assessment.
TACE is not appropriate for decompensated liver disease, macroscopic vascular invasion or extrahepatic spread.
New portal-vein thrombosis in an at-risk liver may be tumour invasion and requires specialist imaging review.
Advanced HCC systemic therapy is not a simple drug choice: liver function, performance status, bleeding risk and current NICE eligibility matter.

Illustrations

HCC on multiphase CT (arterial enhancement and washout)Multiphase contrast CT showing a liver nodule with bright arterial-phase enhancement and washout on the portal-venous or delayed phase, with labels explaining why this pattern matters in an at-risk liver.Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong, Wikimedia Commons · CC-BY-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.