Hepatocellular Carcinoma

HCC Basics - Liver's Dark Side

• Definition: Primary malignancy of the liver arising from hepatocytes.
• Epidemiology: 6th most common cancer worldwide; 3rd leading cause of cancer death. Significant burden in India due to Hepatitis B (HBV) & C (HCV) prevalence.
• Risk Factors:
  • Chronic Viral Hepatitis (HBV, HCV)
  • Alcoholic Liver Disease
  • Non-alcoholic Fatty Liver Disease (NAFLD) / Non-alcoholic steatohepatitis (NASH)
  • Aflatoxin B1 exposure (e.g., contaminated groundnuts, corn)
  • Cirrhosis (present in ~80-90% of HCC cases, from any cause)
  • 📌 Mnemonic: 'HH AAN' (HBV, HCV, Alcohol, Aflatoxin, NAFLD)

⭐ Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver, accounting for approximately 75-85% of all primary liver cancers globally.

Diagnosis - Spotting the Enemy

• Screening (High-Risk: Cirrhosis, Chronic HBV/HCV):
  • Ultrasound (USG) every 6 months.
  • Serum Alpha-fetoprotein (AFP); ↑AFP > 20 ng/mL is abnormal.
• Diagnostic Imaging (Key):
  • Multiphase CT or MRI (preferred):
    • Hallmark: Arterial Phase Hyperenhancement (APHE) & Portal/Venous Phase Washout.
  • LI-RADS (Liver Imaging Reporting and Data System) used for characterization.
• Tumor Markers:
  • AFP > 400 ng/mL highly suggestive.
  • Others: AFP-L3, PIVKA-II (DCP).
• Biopsy:
  • For LI-RADS 3/4 or indeterminate lesions.
  • If imaging non-diagnostic, or in non-cirrhotic liver.
  • Risk: Needle-track seeding.

⭐ In cirrhotic patients, classic imaging features (arterial phase hyperenhancement and portal/venous phase washout) are diagnostic for HCC, often obviating biopsy.

Staging & Prognosis - Sizing Up Trouble

• Core Principle: Staging dictates therapy & predicts survival.
• BCLC (Barcelona Clinic Liver Cancer): Gold standard.

  ⭐ The Barcelona Clinic Liver Cancer (BCLC) staging system is preferred as it links stage with treatment strategy and prognosis.

• BCLC Stages & Treatment:
  • 0 (Very Early) / A (Early): Curative intent (resection, transplant, RFA).
  • B (Intermediate): TACE.
  • C (Advanced): Systemic therapy (e.g., Sorafenib, Lenvatinib).
  • D (Terminal): Best supportive care.
• Key Prognostic Factors:
  • Tumor burden: Size, number, vascular invasion (MVI).
  • Liver function reserve: Child-Pugh score.
  • Patient's overall health: ECOG performance status.
  • Serum Biomarkers: AFP levels.

Treatment - Battle Plan

• BCLC 0 & A (Very Early & Early Stage): Curative Intent
  • Surgical Resection: Child-Pugh A, adequate liver reserve.
  • Liver Transplantation: 📌 Milan Criteria: Single tumor ≤5 cm, or up to 3 tumors each ≤3 cm; no macrovascular invasion; no extrahepatic spread.
  • Ablation (RFA/MWA): For tumors <3 cm, non-surgical candidates.
• BCLC B (Intermediate Stage): Loco-regional Therapies
  • TACE (Transarterial Chemoembolization): Multinodular, preserved liver function.
  • TARE/SIRT (Y-90 Radioembolization): Alternative for TACE-unsuitable/refractory.
• BCLC C (Advanced Stage): Systemic Therapy
  • Atezolizumab + Bevacizumab (Preferred 1st line).
  • TKIs (Sorafenib, Lenvatinib).
• BCLC D (Terminal Stage): Best Supportive Care.

⭐ For advanced HCC (BCLC C), Atezolizumab-Bevacizumab is a preferred first-line systemic therapy, showing improved survival over Sorafenib monotherapy.

High‑Yield Points - ⚡ Biggest Takeaways

• Chronic Hepatitis B & C and cirrhosis are major risk factors for HCC.
• Screening in high-risk patients involves serum AFP and ultrasound every 6 months.
• Diagnosis often relies on characteristic imaging: arterial phase hyperenhancement and venous/delayed phase washout on CT/MRI.
• Milan criteria (single tumor ≤5 cm, or up to 3 tumors each ≤3 cm) are key for liver transplant eligibility.
• Surgical resection offers the best chance for cure in non-cirrhotic patients or those with well-compensated cirrhosis and solitary tumors.
• TACE (Transarterial Chemoembolization) is a primary palliative treatment for unresectable, localized HCC.
• Sorafenib and Lenvatinib are first-line systemic therapies for advanced HCC with preserved liver function.