Hepatocellular Carcinoma (Malignant Hepatoma)

 

Hepatocellular Carcinoma (Malignant Hepatoma)

Definition:

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, originating from hepatocytes. It is a major global health concern, especially in regions with high hepatitis B and C prevalence.

Etiology / Risk Factors

• Chronic Hepatitis B Virus (HBV) infection
• Chronic Hepatitis C Virus (HCV) infection
• Liver cirrhosis (from any cause)
• Alcoholic liver disease
• Non-alcoholic steatohepatitis (NASH)
• Aflatoxin B1 exposure
• Hemochromatosis
• Alpha-1 antitrypsin deficiency
• Wilson’s disease
• Diabetes mellitus, obesity, smoking

Pathophysiology

HCC develops in the background of chronic liver injury and regeneration. Mutations accumulate in hepatocytes leading to dysplasia, angiogenesis, and transformation into malignant clones. Tumors can be solitary, multifocal, or infiltrative.

Clinical Presentation

• Right upper quadrant pain or discomfort
• Weight loss and fatigue
• Abdominal distension (due to ascites)
• Jaundice (late stage)
• Palpable liver mass
• Portal hypertension and variceal bleeding (in cirrhotics)
• Paraneoplastic syndromes (hypoglycemia, erythrocytosis, hypercalcemia)

Diagnosis

• Laboratory Tests:
  • Elevated alpha-fetoprotein (AFP) > 400 ng/mL (in ~60% of cases)
  • Liver function tests (ALT, AST, ALP, bilirubin)
  • HBV and HCV serology
• Imaging:
  • Ultrasound (screening)
  • Triphasic CT or MRI with contrast — shows arterial enhancement and venous washout
• Biopsy: Generally avoided if diagnosis is established radiographically. May be required in uncertain cases.

Staging

The Barcelona Clinic Liver Cancer (BCLC) staging system is widely used to determine treatment and prognosis, integrating tumor burden, liver function (Child-Pugh score), and performance status.

Treatment Options

• Curative Intent:
  • Surgical Resection (in non-cirrhotic or compensated cirrhotics with preserved liver function)
  • Liver Transplantation (Milan criteria: single tumor <5 cm or up to 3 tumors each <3 cm)
• Locoregional Therapies:
  • Radiofrequency ablation (RFA)
  • Transarterial chemoembolization (TACE)
  • Transarterial radioembolization (TARE)
• Systemic Therapy:
  • Targeted therapy: Sorafenib, Lenvatinib
  • Immunotherapy: Atezolizumab + Bevacizumab, Nivolumab
• Palliative care for advanced or metastatic disease

Prognosis

Highly variable depending on stage and liver function. Without treatment, median survival is 6 months. With early detection and curative therapy, 5-year survival can exceed 70%.

Surveillance

For high-risk individuals (cirrhosis, HBV), perform surveillance using ultrasound every 6 months with or without AFP testing.

Recent Advances

• Combination immunotherapies showing improved survival
• Liquid biopsy under research for early detection
• Genomic profiling for personalized medicine

References & Guidelines

• AASLD Guidelines for HCC Management
• ESMO Clinical Practice Guidelines
• Harrison's Principles of Internal Medicine 21st Edition
• Current Medical Diagnosis and Treatment (Lange Series)

Prepared for: Medical Students and Clinical Trainees
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