• Clinical science

Hepatocellular carcinoma


Hepatocellular carcinoma (HCC) is a malignant, most often solitary tumor of the liver, which occurs primarily in patients with preexisting liver cirrhosis or chronic hepatitis. Typically, it is an incidental diagnosis in these high-risk patients that is made either via ultrasound or an increase in the hepatic tumor marker alpha-fetoprotein. Most patients typically present with symptoms caused by underlying disease (e.g., ascites, jaundice) rather than the tumor itself. Potentially curative treatment options include tumor resection, liver transplantation, and ablative therapies. Unfortunately, it is usually not possible to remove all tumor tissue, which explains the poor prognosis of HCC. In western countries, the five-year survival is less than 50%.


  • Fifth most common malignancy worldwide
  • Highest incidence in Southeast Asia and Africa
  • Peak incidence in the US: 70–75 years
  • >


Epidemiological data refers to the US, unless otherwise specified.


Aflatoxins are considered one of the most potent carcinogens!


Clinical features

  • Usually asymptomatic apart from symptoms of the underlying disease (mostly cirrhosis or hepatitis)
  • Metastasis is uncommon and usually only occurs in advanced stages
  • Possible symptoms in advanced disease
    • Weight loss, cachexia
    • Hepatomegaly and right upper quadrant tenderness
    • Ascites and jaundice



Laboratory tests

In patients with cirrhosis of the liver or chronic hepatitis B/C infection, AFP is used as a screening test for HCC!


Contrast-enhanced studies using ultrasound, MRI, or CT are most useful in the evaluation of a liver mass

  • Ultrasound: first test
    • Irregular mass borders
    • Echogenicity ranging from homogeneous to inhomogeneous and from hypoechoic to hyperechoic
    • Vascular invasion of the tumor may be visible (e.g., portal vein thrombosis)
    • Underlying cirrhosis may be seen
  • Abdominal CT (confirmatory test): typically shows a single hypodense lesion with irregular borders and possible local invasion
    • Alternative: MRI

Liver biopsy

  • Can provide a definitive diagnosis but carries the risk of bleeding and tumor spread
  • Recommended when both lab and imaging studies are inconclusive


Differential diagnoses

Malignant liver tumors

Benign liver tumors


The differential diagnoses listed here are not exhaustive.


  • Curative therapeutic options: potentially for patients with retained liver function
    • Surgical resection
    • Liver transplantation
    • Ablative therapies (mostly palliative, but can also be curative) result in shrinking and scarring of the tumor
  • Follow-up:
  • Palliative care: primarily for decompensated disease, unresectable, multinodular disease, or metastatic disease