Hepatocellular carcinoma: a look at the most common primary liver cancer | Hartford Hospital


January 03, 2022

By Dr Oscar K. Serrano
Liver transplant and hepatobiliary surgeon
Hartford Hospital Transplant Program and Complete Liver Center

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, accounting for nearly one million cases worldwide. HCC is the sixth most common cancer in the world and the third leading cause of cancer-related death. In the United States, it has been estimated that approximately 42,230 new cases will be diagnosed and 30,230 people will die from the disease in 2021.

The most important risk factor for HCC is chronic liver disease or cirrhosis. Globally, the majority of HCC cases are confined to sub-Saharan Africa and East Asia, where there is a high prevalence of hepatitis B virus (HBV) infection. In the United States and Europe, the main risk factors for HCC are infection with the hepatitis C virus (HCV) and alcohol abuse.

More recently, the increase in non-alcoholic fatty liver disease has become an important risk factor for the development of cirrhosis and HCC in the western world. Other risk factors include diabetes and metabolic syndrome, smoking, and human immunodeficiency virus (HIV) coinfection.

Unfortunately, for many patients, the presence of cirrhosis is unknown until it reaches an advanced stage. It is imperative that at-risk populations seek testing to avoid the consequences of late-stage disease. Patients with a known history of HCV or HBV infection, history of intravenous drug use, unprotected sex, alcohol abuse, obesity, diabetes, or syndrome metabolic rate should seek screening for liver disease from their primary care provider.

Unfortunately, patients with HCC may not show any symptoms, especially when detected early in the disease, as part of a formal screening program. Other patients may experience abdominal pain, unexplained weight loss, weakness or fatigue, jaundice (yellowing of the skin or eyes), or a hard lump under the right rib cage, but these patients are in the minority.

Once a patient is deemed at risk for HCC and is enrolled in a monitoring program, serial abdominal imaging and blood tests are the cornerstone of the diagnosis. Typically, a screening ultrasound will be obtained annually in patients at risk. The α-fetoprotein tumor marker is also used as a screening tool to probe patients at high risk for HCC. Abnormalities in any of these tests will require additional imaging, especially abdominal MRI (preferred) or CT scan. HCC is usually diagnosed radiologically with characteristic arterial enhancement and delayed lavage, avoiding the need for a biopsy.

After confirmation of the diagnosis of HCC, the most important prognostic factor is the stage of the disease. CHC is classified according to the Barcelona Clinic Liver Cancer Classification System (BCLC), which is useful for making recommendations on treatment options. The BCLC system classifies HCC based on the characteristics and size of the tumor, the patient’s native liver function and performance status, and cancer-related symptoms.

BCLC step groups include:

  • Very early stage (BCLC 0): Patients with a single tumor of less than 2 centimeters, who do not have underlying liver disease and whose performance index is excellent. Surgical resection is generally recommended. Average survival is generally over five years.
  • Early stage (BCLC A): Patients with a single tumor or multiple tumors, each less than 3 centimeters tall and with liver dysfunction. Patients may be candidates for liver transplantation, surgical resection, or regional treatments. Average survival is generally over five years.
  • Intermediate stage (BCLC B): Patients with a large tumor or with several tumors and certain hepatic dysfunctions. Patients are candidates for regional therapies. Average survival is usually 2-3 years.
  • Advanced level (BCLC C): Patients with a tumor that has invaded the portal vein or has spread to other parts of the body, such as the lymph nodes, lungs, and bones. Treatment is usually systemic. Average survival is usually one year.

The treatment of HCC is diverse and strongly depends on the stage of presentation of the BCLC, the patient’s performance status and the treatment goals. Surgery (liver resection or transplantation) has long been the backbone of curative therapies for HCC, giving the best results, with a five-year survival of over 80 percent.

For patients who may not be suitable surgical candidates, who have significant underlying liver disease, or who do not meet criteria for liver transplantation, various locoregional therapies can serve as a gateway to liver transplantation, palliative treatments, or for prolong life. These include microwave or radiofrequency ablation, chemo or transarterial radioembolization, or external beam radiation therapy.

Finally, systemic treatment of HCC has recently developed as our understanding of the molecular footprint of these tumors has improved, which has led to the development of biological agents including monoclonal antibodies, pathway inhibitors. molecular and immunomodulators.

Treatment of HCC is complex and requires a full team of providers from a variety of backgrounds, including hepatology, oncology, surgery, radiation oncology, diagnostic and interventional radiology, and transplantation. Patients with HCC should be referred to a center specializing in liver disease and liver transplantation.

At the Hartford Hospital Transplant Program and Comprehensive Liver Center, we work collaboratively to provide each patient with cutting-edge diagnostic and treatment options that encompass all facets of care, including the most effective screening modalities, the latest locoregional therapies and a minimum of invasive surgical techniques and the possibility of participating in clinical trials that exploit new therapeutic targets in addition to standard treatment. Patients considered at risk for HCC should be followed closely with an active surveillance plan to improve the chances of detecting an early lesion.


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