Hepatocellular Carcinoma
On this page
Direct answer
A liver nodule in a cirrhotic patient is hepatocellular carcinoma until proven otherwise, and in India the cirrhosis beneath it is most often hepatitis B, hepatitis C or alcohol-related, with aflatoxin exposure adding risk in stored-groundnut regions. Surveillance — twice-yearly abdominal ultrasound with alpha-fetoprotein in every cirrhotic — exists because early tumours are silent, and imaging criteria (arterial-phase enhancement with washout on portal venous/delayed phases) can diagnose HCC by radiology alone in high-risk livers, biopsy reserved for indeterminate lesions. Staging by the Barcelona Clinic Liver Cancer algorithm drives treatment: very early and early tumours in preserved-liver patients earn curative therapy — resection for single tumours with adequate liver reserve, radiofrequency ablation for small (especially under 3 cm) nodules, and transplantation applying the Milan criteria (single tumour up to 5 cm, or up to 3 nodules each up to 3 cm); intermediate-stage multinodular disease receives transarterial chemoembolisation, and advanced disease systemic therapy.
What you must remember
- Risk bases in India: chronic hepatitis B (the leading cause), hepatitis C, alcohol, non-alcoholic steatohepatitis and aflatoxin B1-contaminated food; hepatitis B vaccination is the preventive cornerstone.
- Surveillance standard: ultrasound plus serum AFP every six months in cirrhotics; a rising AFP or new nodule triggers multiphase CT or MRI.
- Imaging diagnosis: arterial hypervascularity with washout on contrast CT/MRI is diagnostic in a cirrhotic liver — no biopsy needed for typical lesions; biopsy risks seeding and bleeding.
- BCLC mapping: stage 0/A — curative (resection, RFA, transplant); stage B — TACE; stage C — systemic (sorafenib historically; lenvatinib; atezolizumab plus bevacizumab in suitable patients); stage D — best supportive care.
- Resection fitness: single tumour, no portal hypertension (or well-compensated), adequate future liver remnant and Child-Pugh A status; decompensated livers point to transplantation instead.
- Milan criteria: one lesion up to 5 cm, or up to three lesions each up to 3 cm, without vascular invasion or extrahepatic spread.
- RFA niche: tumours up to about 3 cm, especially in non-resectable candidates, with ablation success comparable to resection at that size.
- TACE logic and limits: embolisation with doxorubicin for unresectable multinodular disease in compensated cirrhosis; contraindicated by decompensation, portal vein occlusion (relative) and poor performance status.
- Rupture presentation: spontaneous haemoperitoneum with abdominal pain and shock — stabilise, control bleeding by embolisation, then stage.
How to work through a surveillance-detected nodule
During a routine six-monthly check, a 56-year-old man with Child-Pugh A hepatitis B cirrhosis is found to have a 2.8 cm liver segment V nodule and AFP of 220 ng/mL. Multiphase CT shows arterial enhancement with delayed washout — the radiological signature of HCC in a cirrhotic liver, so no biopsy is taken. His portal pressure is acceptable and remnant volume sufficient, so the tumour committee offers either anatomical segmentectomy or radiofrequency ablation, both curative at this size; he undergoes segmental resection and remains on surveillance. Now rerun the case with three tumours of 2, 2.5 and 2.5 cm in a Child-Pugh B liver: within Milan, so liver transplantation is the correct curative answer. Change the film to bilobar multifocal disease with a patent portal vein and Child-Pugh A function: TACE is the treatment. Change it again to lung deposits with portal vein invasion: systemic therapy and supportive care. Four patients, one algorithm — the BCLC stage, not the surgeon's enthusiasm, assigns the treatment.
Where students slip
Candidates forget that diagnosis in cirrhotic livers can be radiological — reaching for "biopsy" as the confirmatory answer in a classic enhancement-washout lesion loses the mark. The second slip is offering resection to a decompensated cirrhotic: without portal hypertension assessment and Child-Pugh grading, the patient dies of liver failure, not tumour. Third, mixing up TACE with RFA indications — chemoembolisation suits multinodular intermediate disease, ablation suits small discrete tumours — is a recurring single-best-answer discrimination.
Frequently asked questions
What surveillance detects hepatocellular carcinoma early?
Abdominal ultrasound with serum alpha-fetoprotein every six months in patients with cirrhosis or chronic hepatitis B at high risk.
When can HCC be diagnosed without biopsy?
In a high-risk liver, a nodule showing arterial-phase hyperenhancement with washout on portal venous or delayed phases on contrast CT or MRI meets radiological diagnostic criteria.
What are the Milan criteria for transplantation?
A single tumour up to 5 cm, or up to three tumours each up to 3 cm, with no vascular invasion or extrahepatic disease.
Which patients tolerate liver resection?
Child-Pugh A patients with single tumours, no clinically significant portal hypertension and an adequate future liver remnant.
What is the role of transarterial chemoembolisation?
Palliative control of unresectable, multinodular HCC in patients with preserved liver function, exploiting the tumour's hepatic-arterial blood supply.