Hepatocellular carcinoma: updates on epidemiology, surveillance, diagnosis and treatment

Abstract

Hepatocellular carcinoma (HCC) is a major global burden, ranking as the third leading cause of cancer-related mortality. HCC due to chronic hepatitis B virus (HBV) or C virus (HCV) infection has decreased due to universal vaccination for HBV and effective antiviral therapy for both HBV and HCV, but HCC related to metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease is increasing. Biannual liver ultrasonography and serum α-fetoprotein are the primary surveillance tools for early HCC detection among high-risk patients (e.g., cirrhosis, chronic HBV). Alternative surveillance tools such as blood-based biomarker panels and abbreviated magnetic resonance imaging (MRI) are being investigated. Multiphasic computed tomography or MRI is the standard for HCC diagnosis, but histological confirmation should be considered, especially when inconclusive findings are seen on cross-sectional imaging. Staging and treatment decisions are complex and should be made in multidisciplinary settings, incorporating multiple factors including tumor burden, degree of liver dysfunction, patient performance status, available expertise, and patient preferences. Early-stage HCC is best treated with curative options such as resection, ablation, or transplantation. For intermediate-stage disease, locoregional therapies are primarily recommended although systemic therapies may be preferred for patients with large intrahepatic tumor burden. In advanced-stage disease, immune checkpoint inhibitor-based therapy is the preferred treatment regimen. In this review article, we discuss the recent global epidemiology, risk factors, and HCC care continuum encompassing surveillance, diagnosis, staging, and treatments.

Keywords: Hepatocellular carcinoma; Liver cirrhosis; Liver diseases; Liver neoplasms.

Figure 1.

(A) Incidences attributable to liver cancer from 2000 to 2021, by etiology. (B) Deaths attributable to liver cancer from 2000 to 2021, by etiology. (C) Age-standardized incidence rates attributable to liver cancer in 2021 per 100,000 population by country. (D) Agestandardized death rates attributable to liver cancer in 2021 per 100,000 population by country. (E) Proportion of incidences of liver cancer attributable to different etiologies from 2000 to 2021. (F) Proportion of deaths from liver cancer attributable to different etiologies from 2000 to 2021. ALD, alcohol-associated liver disease; HBV, hepatitis B virus; HCV, hepatitis C virus; MASH, metabolic dysfunction-associated steatohepatitis.

Figure 2.

Recent advances in the management of hepatocellular carcinoma. Created in BioRender. Hwang S (2024) https://BioRender. com/u75r972. EBRT, external beam radiation therapy; HCC, hepatocellular carcinoma; IRE, irreversible electroporatio; MWA, microwave ablation; PBT, proton beam therapy; RFA, radiofrequency ablation; SBRT, stereotactic body radiation therapy; TACE, transarterial chemoembolization; TARE, transarterial radioembolization.