Hepatocellular carcinoma: a review

Abstract

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and is a leading cause of cancer-related death worldwide. In the United States, HCC is the ninth leading cause of cancer deaths. Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, incidence and mortality continue to rise. Cirrhosis remains the most important risk factor for the development of HCC regardless of etiology. Hepatitis B and C are independent risk factors for the development of cirrhosis. Alcohol consumption remains an important additional risk factor in the United States as alcohol abuse is five times higher than hepatitis C. Diagnosis is confirmed without pathologic confirmation. Screening includes both radiologic tests, such as ultrasound, computerized tomography, and magnetic resonance imaging, and serological markers such as α-fetoprotein at 6-month intervals. Multiple treatment modalities exist; however, only orthotopic liver transplantation (OLT) or surgical resection is curative. OLT is available for patients who meet or are downstaged into the Milan or University of San Francisco criteria. Additional treatment modalities include transarterial chemoembolization, radiofrequency ablation, microwave ablation, percutaneous ethanol injection, cryoablation, radiation therapy, systemic chemotherapy, and molecularly targeted therapies. Selection of a treatment modality is based on tumor size, location, extrahepatic spread, and underlying liver function. HCC is an aggressive cancer that occurs in the setting of cirrhosis and commonly presents in advanced stages. HCC can be prevented if there are appropriate measures taken, including hepatitis B virus vaccination, universal screening of blood products, use of safe injection practices, treatment and education of alcoholics and intravenous drug users, and initiation of antiviral therapy. Continued improvement in both surgical and nonsurgical approaches has demonstrated significant benefits in overall survival. While OLT remains the only curative surgical procedure, the shortage of available organs precludes this therapy for many patients with HCC.

Keywords: cirrhosis; hepatocellular carcinoma; orthotopic liver transplantation; α-fetoprotein.

Figure 1

TACE. Notes: Pretreatment MRI of a 43-year-old male with hepatitis C shows (A) a 4-cm T2-hyperintense solitary mass (arrow [A–E]) in segment VI of the liver with enhancement features compatible with hepatocellular carcinoma. The patient was treated with TACE with drug-eluting beads (B). A follow-up MRI 6 months after TACE shows intrinsic T1 peripheral hyperintensity (C) within the treated lesion with no residual internal enhancement (D), confirmed on subtracted imaging (E). Reproduced from Cochrane Miller J. Bridging procedures prior to liver transplantation. Radiology Rounds. 2015;13(1). Abbreviations: TACE, transarterial chemoembolization; MRI, magnetic resonance imaging.

Figure 2

Typical HCC shows arterial phase hypervascularity with washout of contrast on portal venous and equilibrium phase. Note: There is delayed pseudocapsule enhancement. Abbreviation: HCC, hepatocellular carcinoma.