Hepatocellular carcinoma

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 27 Aug 2024

Last updated: 25 Sep 2024

Hepatocellular carcinoma (HCC) usually arises in patients with liver cirrhosis due to any cause.

A significant number of patients may be asymptomatic and are diagnosed following screening.

Patients at risk of HCC should receive surveillance with an ultrasound of the liver and alpha fetoprotein at 6-month intervals.

Treatment is guided by staging and prognosis. Treatment options include resection, transplantation, percutaneous ablation therapy, chemoembolization, and systemic immunotherapy.

Atezolizumab plus bevacizumab, or durvalumab plus tremelimumab are the first-line agents for advanced-stage HCC.

Definition

Hepatocellular carcinoma (HCC), also known as hepatoma, is a primary cancer arising from hepatocytes in predominantly cirrhotic liver. However, some patients may not have cirrhosis before developing HCC, especially patients with chronic hepatitis B virus or metabolic dysfunction-associated steatotic liver disease.

History and exam

Key diagnostic factors

history of cirrhosis
history of chronic hepatitis B (HBV) or C (HCV)
history of chronic heavy alcohol use
history of diabetes or obesity
family history of liver cancer
older age
hepatomegaly

Full details

Other diagnostic factors

abdominal distension
esophageal or gastric variceal bleeding
right upper quadrant abdominal pain
early satiety
weight loss
lower extremity edema
hepatic encephalopathy
cachexia
jaundice
splenomegaly
asterixis
spider nevi
palmar erythema
periumbilical collateral veins
fetor hepaticus
diarrhea
paraneoplastic syndrome
bone pain
severe abdominal pain
obstructive jaundice
enlarged hemorrhoidal veins
vascular bruit

Full details

Risk factors

cirrhosis
chronic hepatitis B (HBV) infection
chronic hepatitis C (HCV) infection
chronic heavy alcohol use
diabetes
obesity
family history of liver cancer
aflatoxin
thorium dioxide radioactive contrast
hemochromatosis
cigarette smoking
alpha-1-antitrypsin deficiency
porphyria cutanea tarda
primary biliary cholangitis (PBC)
primary sclerosing cholangitis (PSC)
androgenic steroids
oral contraceptives
male sex

Full details

Diagnostic tests

1st tests to order

complete blood count
basic metabolic panel
liver function tests
prothrombin time/INR
viral hepatitis panel
alpha fetoprotein (AFP)
ultrasound of liver

Full details

Tests to consider

contrast CT scan of abdomen
contrast MRI of abdomen
liver biopsy
computed tomography scan of chest
bone scan

Full details

Treatment algorithm

ACUTE

Barcelona Clinic Liver Cancer (BCLC) stage 0-A (very early 0 or early disease A): possible surgical candidate (good liver function)

BCLC stage 0-A (very early 0 or early disease A): nonhepatic resection candidate

BCLC stage B: intermediate disease

BCLC stage C: advanced disease

BCLC stage D: end-stage disease

ONGOING

recurrence

Contributors

Authors

Doan Y Dao, MD

Assistant Professor of Medicine

Director, Center of Excellence for Liver Disease in Vietnam

Johns Hopkins School of Medicine

Department of Medicine

Division of GI & Hepatology

Baltimore

Disclosures

DYD receives grants from Roche, Fujifilm Medical System, and DELFI Diagnostics; serves as Guest Director of Hepatology for Tech University; and is a member of the Data and Safety Monitoring Board of IQVIA.

Ngoc-Thai Truong, MD, MS

Research Assistant

Vietnam Viral Hepatitis Alliance

Reston

Disclosures

NTT declares that he has no competing interests.

Acknowledgements

Dr Doan Y Dao and Dr Ngoc-Thai Truong would like to gratefully acknowledge Dr Qingyao Daniel Huang, Dr Margaret Li Peng Teng, Dr Poh Seng Tan, Dr Badar Muneer, and Dr Smruti R. Mohanty, previous contributors to this topic.

Disclosures

QDH declares that he has no competing interests. MLPT declares that she has no competing interests. PST has received sponsorship/honorarium from Bayer (South East Asia) Pte Ltd and Sirtex for attending conferences, delivering lectures, and participating in advisory board meetings. BM declares that he has no competing interests. SRM serves as a speaker for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewers

Srikrishna Nagri, MD

Gastroenterologist

Dartmouth-Hitchcock Nashua

Nashua

Disclosures

SN declares that he has no competing interests.

Ned Snyder, MD, FACP

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch

Galveston

Disclosures

NS declares that he has no competing interests.

Differentials
- Cholangiocarcinoma
- Hepatic adenoma
- Hemangioma of liver
More Differentials
Guidelines
- NCCN clinical practice guidelines in oncology: hepatocellular carcinoma
- NCCN clinical practice guidelines in oncology: management of immunotherapy-related toxicities
More Guidelines
Calculators
Child Pugh classification for severity of liver disease
MELD Score for End-Stage Liver Disease (NOT appropriate for patients under the age of 12)
More Calculators
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Hepatocellular carcinoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

Barcelona Clinic Liver Cancer (BCLC) stage 0-A (very early 0 or early disease A): possible surgical candidate (good liver function)

BCLC stage 0-A (very early 0 or early disease A): nonhepatic resection candidate

BCLC stage B: intermediate disease

BCLC stage C: advanced disease

BCLC stage D: end-stage disease

recurrence

Contributors

Authors

Doan Y Dao, MD

Disclosures

Ngoc-Thai Truong, MD, MS

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Srikrishna Nagri, MD

Disclosures

Ned Snyder, MD, FACP

Disclosures

Differentials

Guidelines

Calculators

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