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Hepatocellular carcinoma

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
Last reviewed: 24 May 2025
Last updated: 04 Mar 2025

Summary

Definition

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 exposure
  • thorium dioxide radioactive contrast exposure
  • hemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cholangitis (PBC)
  • primary sclerosing cholangitis (PSC)
  • use of androgenic steroids
  • use of 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

MD

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

VA

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

NH

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

TX

Disclosures

NS declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Singal AG, Llovet JM, Yarchoan M, et al. AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology. 2023 Dec 1;78(6):1922-65.Full text  Abstract

Vogel A, Cervantes A, Chau I, et al. Hepatocellular carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29 (suppl 4):iv238-55.Full text  Abstract

European Association for the Study of the Liver. EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2018 Jul;69(1):182-236.Full text  Abstract

Su GL, Altayar O, O'Shea R, et al. AGA clinical practice guideline on systemic therapy for hepatocellular carcinoma. Gastroenterology. 2022 Mar;162(3):920-34.Full text  Abstract

Gordan JD, Kennedy EB, Abou-Alfa GK, et al. Systemic therapy for advanced hepatocellular carcinoma: ASCO guideline update. J Clin Oncol. 2024 May 20;42(15):1830-50.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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  • 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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