Hepatocellular Carcinoma (HCC)
BSG Guidelines for the management of hepatocellular carcinoma (HCC) in adults. Published: Apr 2024.
Definition
HCC is the most common form of primary liver cancer that originates from the hepatocytes.
Epidiemoilogy
Men are 3-5 times more likely to develop HCC than women, regardless of the underlying cause of liver disease
Incidence rises steeply from 40 y/o, peaking in those >80 y/o
In the UK, incidence rates are higher in Asian and Black ethnic groups
Aetiology
90% of cases occur in the context of chronic liver disease with cirrhosis from any cause being the strongest risk factor
Major specific risk factors:
- Chronic Hepatitis B and C (accounts for >80% of HCC cases)
- Hepatitis C is most common in the Western world
- Hepatitis B is the leading cause in Asia and Africa, notably it could induce cancer even in the absence of cirrhosis by integrating into the host genome
- Alcohol-related liver disease
- MASLD
Clinical Features
HCC is often asymptomatic in early stages, and is often diagnosed incidentally via surveillance (ultrasound +/- AFP) in those with cirrhosis.
If symptomatic:
| Tumour effect |
|
| Decompensation of underlying cirrhosis |
HCC is highly vascular and can directly invade the portal vein, causing portal vein thrombosis, which worsens portal hypertension |
| Constitutional symptoms |
|
Investigation and Diagnosis
Approach:
- HCC is often detected initially via surveillance (6-monthly liver ultrasound and AFP measurement) in high-risk patients (cirrhosis and certain hepatitis B patients)
- Suspected HCC in patients with cirrhosis can be confirmed with radiological criteria alone (without the need for biopsy)
- Biopsy (pathological diagnosis) is necessary in 1) inconclusive radiological findings or 2) patients without cirrhosis
Imaging
Screening imaging modality: liver ultrasound
- If the lesion is >1 cm → refer for further imaging
- If the lesion is <1 cm → repeat ultrasound in 3 months (as the diagnostic yield with cross-sectional imaging in small lesions is low)
Imaging of choice: multiphasic CT or MRI
Diagnostic criteria (specialist-level, but included for completeness):
- For nodules ≥1 cm in a cirrhotic liver, HCC can be diagnosed if imaging shows:
- Arterial phase hyperenhancement (lesion appears very bright / vascular)
- Washout in portal venous / delayed phases (lesion appears darker / less vascular)
Biopsy
Typical biopsy findings:
- Increased cell density
- Loss of the reticulin framework
Management
Key management principles:
| HCC stage | Management approach | Key management principles |
|---|---|---|
| Localised (very early / early) | Curative intent |
|
| Locally advanced | Loco-regional control | Standard of care: TACE / TAE
Alternative:
|
| Advanced and metastatic | Systemic therapy |
|