Hepatocellular Carcinoma (HCC)

What is Hepatocellular Carcinoma (HCC) according to the summary?

The most common primary liver malignancy in adults, often affecting patients with preexisting liver disease. Summary 1

How does Hepatocellular Carcinoma (HCC) typically manifest in terms of tumor structure?

It often manifests as a solitary tumor. Summary 2

What is the typical symptom presentation of early-stage Hepatocellular Carcinoma (HCC)?

Commonly asymptomatic in the early stage. Summary 3

How do patients with Hepatocellular Carcinoma (HCC) commonly present clinically?

Typically present with features of the underlying liver disease (e.g., ascites, jaundice). Summary / Clin Feat 4

What are symptoms associated with advanced Hepatocellular Carcinoma (HCC)?

Nonspecific features of abdominal pain, weight loss, and anorexia. Summary / Clin Feat 5

What surveillance is recommended for individuals at risk of developing Hepatocellular Carcinoma (HCC)?

Regular (6-monthly) surveillance with abdominal ultrasound, with or without serum AFP levels. Summary / Screening 6

What findings on HCC screening warrant further investigation (e.g., multiphase imaging)?

Liver lesion ≥10 mm OR AFP ≥ 20 ng/mL. Summary / Diagnosis 7

How is the diagnosis of Hepatocellular Carcinoma (HCC) usually confirmed after suggestive screening?

Confirmed with multiphase imaging and, if needed, a liver biopsy. Summary / Diagnosis 8

What factors determine the management approach for Hepatocellular Carcinoma (HCC)?

Management is based on tumor burden, the patient's performance status, and the severity of liver dysfunction. Summary / Treatment 9

What are potentially curative treatment options for Hepatocellular Carcinoma (HCC)?

Tumor resection, liver transplantation, and ablative therapy (most commonly radiofrequency ablation - RFA). Summary / Treatment 10

What treatment options exist for patients with advanced Hepatocellular Carcinoma (HCC)?

Noncurative locoregional therapy (LRT) such as transarterial chemoembolization (TACE), or systemic chemotherapy. Summary / Treatment 11

What is the general prognosis for Hepatocellular Carcinoma (HCC) and why?

Generally poor, as HCC mostly occurs in patients with advanced underlying liver disease. Summary / Prognosis 12

What is the worldwide rank of Hepatocellular Carcinoma (HCC) among common malignancies?

Fifth most common malignancy worldwide. Epidemiology 13

What is the most common primary liver malignancy in adults?

Hepatocellular carcinoma (HCC). Epidemiology 14

Where is the incidence of Hepatocellular Carcinoma (HCC) highest globally?

Highest incidence in Southeast Asia and Africa. Epidemiology 15

What is the peak age of incidence for Hepatocellular Carcinoma (HCC) in the US vs. Africa/Asia?

US: 70-75 years; Africa and Asia: 30-40 years. Epidemiology 16

What is the sex predilection for Hepatocellular Carcinoma (HCC)?

Males > Females (♂ > ♀). Epidemiology 17

What underlying liver condition is present in about 80% of Hepatocellular Carcinoma (HCC) cases?

Liver cirrhosis. Etiology 18

What chronic viral infections are major risk factors for Hepatocellular Carcinoma (HCC)?

Chronic hepatitis B or C virus infection. Etiology 19

Besides viral hepatitis and cirrhosis, name three other risk factors for Hepatocellular Carcinoma (HCC).

Alcohol-associated liver disease, MASH, hemochromatosis, Wilson disease, Alpha-1 antitrypsin deficiency, autoimmune hepatitis, schistosomiasis, aflatoxin ingestion. (Any 3) Etiology 20

What carcinogen produced by Aspergillus flavus is a risk factor for Hepatocellular Carcinoma (HCC)?

Aflatoxin. Etiology 21

What specific gene mutation is associated with aflatoxin exposure causing Hepatocellular Carcinoma (HCC)?

G:C → T:A transversion in codon 249 of the TP53 gene (inactivating mutation). Etiology 22

Apart from underlying disease symptoms, what are possible symptoms of advanced Hepatocellular Carcinoma (HCC)?

Weight loss, anorexia, hepatomegaly, right upper quadrant tenderness, jaundice, ascites. Clinical Features 23

What is the preferred initial imaging modality for suspected Hepatocellular Carcinoma (HCC)?

Ultrasound abdomen. Diagnosis 24

What finding on initial ultrasound warrants further imaging for suspected Hepatocellular Carcinoma (HCC)?

A lesion ≥ 10 mm. Diagnosis 25

What serum AFP level, if measured alongside an ultrasound finding a lesion, warrants further imaging?

AFP ≥ 20 ng/mL (with a lesion of any size). Diagnosis 26

When is a liver biopsy typically performed for suspected Hepatocellular Carcinoma (HCC)?

If multiphase imaging is inconclusive, OR for liver lesions suspicious for HCC in patients without cirrhosis. Diagnosis 27

Is a liver biopsy routinely required to confirm HCC in patients with cirrhosis and characteristic imaging?

No, not routinely required if imaging findings are characteristic. Diagnosis 28

What are supportive ultrasound findings for Hepatocellular Carcinoma (HCC)?

Solid nodule(s) ≥10 mm, varying echogenicity/homogeneity, irregular borders; possible portal vein infiltration/thrombosis; signs of cirrhosis may be present. Diagnosis / Imaging 29

What imaging modalities are typically used for multiphase diagnostic confirmation of HCC?

CT or MRI abdomen with IV contrast. (Contrast-enhanced ultrasound is an alternative). Diagnosis / Imaging 30

What is the characteristic enhancement pattern of Hepatocellular Carcinoma (HCC) on multiphase imaging?

Arterial phase hyperenhancement followed by nonperipheral washout in the portal venous or delayed phase. Diagnosis / Imaging 31

What additional finding on multiphase imaging supports an HCC diagnosis?

Enhancing capsule. Diagnosis / Imaging 32

What system standardizes reporting of liver imaging findings for suspected Hepatocellular Carcinoma (HCC)?

Liver Imaging Reporting and Data System (LI-RADS). Diagnosis / Imaging 33

What blood test finding may indicate paraneoplastic erythrocytosis in Hepatocellular Carcinoma (HCC)?

Elevated hemoglobin/hematocrit on CBC (though thrombocytopenia is more common with cirrhosis). Diagnosis / Labs 34

What tumor marker is typically elevated in Hepatocellular Carcinoma (HCC)?

Serum alpha-fetoprotein (AFP). Diagnosis / Labs 35

Name two paraneoplastic syndromes that can occur with Hepatocellular Carcinoma (HCC).

Hypoglycemia, hypercalcemia, hypercholesterolemia, erythrocytosis. (Any 2) Diagnosis / Labs 36

What are the main risks associated with liver biopsy for suspected Hepatocellular Carcinoma (HCC)?

Bleeding and tumor seeding. Diagnosis / Biopsy 37

What staging system is recommended by AASLD for Hepatocellular Carcinoma (HCC)?

Barcelona Clinic Liver Cancer (BCLC) staging system. Staging 38

What three main factors does the BCLC staging system for HCC assess?

Tumor burden, liver function (Child-Pugh score), and ECOG performance status. Staging 39

What defines Very Early Stage (BCLC Stage 0) Hepatocellular Carcinoma (HCC)?

Single tumor ≤ 2 cm, AND Child-Pugh A, AND ECOG PS 0-1. Staging 40

What defines Early Stage (BCLC Stage A) Hepatocellular Carcinoma (HCC)?

Single tumor > 2 cm or 2-3 tumors ≤ 3 cm, AND Child-Pugh A or B, AND ECOG PS 0-1. Staging 41

What defines Intermediate Stage (BCLC Stage B) Hepatocellular Carcinoma (HCC)?

3 tumors OR 2-3 tumors (any > 3 cm), AND Child-Pugh A or B, AND ECOG PS 0-1. Staging 42

What defines Advanced Stage (BCLC Stage C) Hepatocellular Carcinoma (HCC)?

Portal vein invasion OR Nodal/extrahepatic metastasis, AND Child-Pugh A or B, AND ECOG PS 0-2. Staging 43

What defines End-Stage (BCLC Stage D) Hepatocellular Carcinoma (HCC)?

Child-Pugh C liver function OR ECOG PS > 2 (regardless of tumor burden). Staging 44

What is the primary curative treatment for early-stage HCC in patients with minimal liver disease?

Surgical resection. Treatment 45

What is the primary curative treatment for early-stage HCC in patients with significant liver disease?

Liver transplantation (if Milan criteria are met). Treatment 46

What are the Milan criteria for liver transplantation in Hepatocellular Carcinoma (HCC)?

1 tumor ≥ 2 cm and ≤ 5 cm OR 2-3 tumors measuring ≥ 1 cm and ≤ 3 cm each. Treatment 47

What is the first-line ablative therapy technique for Hepatocellular Carcinoma (HCC)?

Radiofrequency ablation (RFA). Treatment 48

When is ablative therapy indicated for Hepatocellular Carcinoma (HCC)?

Early-stage HCC in non-surgical candidates; downstaging or bridge to transplant. Treatment 49

What type of therapy is typically used for intermediate-stage (BCLC Stage B) Hepatocellular Carcinoma (HCC)?

Locoregional therapy (LRT). Treatment 50

Name two common locoregional therapy (LRT) techniques for Hepatocellular Carcinoma (HCC).

Transcatheter arterial chemoembolization (TACE) and Transarterial radioembolization (TARE). Treatment 51

When is systemic chemotherapy indicated for Hepatocellular Carcinoma (HCC)?

Advanced-stage (BCLC Stage C) HCC or patients who progress after LRT. Treatment 52

What is the preferred first-line systemic targeted therapy regimen for advanced HCC?

Atezolizumab/bevacizumab. Treatment 53

What are alternative first-line targeted therapies for advanced Hepatocellular Carcinoma (HCC)?

Sorafenib or lenvatinib. Treatment 54

Is adjuvant therapy routinely recommended after potentially curative treatment for HCC?

No, adjuvant treatment is not routinely recommended as it has not been shown to be effective. Treatment 55

What is the most common malignant liver lesion overall?

Metastatic liver disease (not primary HCC). Differential Dx 56

What are typical primary tumor sites that metastasize to the liver?

Gastrointestinal tract (colon, stomach, pancreas), lung, and breast. Differential Dx 57

What is the typical appearance of liver metastases on ultrasound?

"Bulls-eye" or target sign (hyperechoic center, hypoechoic periphery). Differential Dx 58

What is the recommended imaging modality for suspected liver metastases?

CT abdomen with IV contrast. Differential Dx 59

What environmental exposures are associated with hepatic angiosarcoma?

Vinyl chloride, arsenic, or thorium dioxide. Differential Dx 60

What histological marker is positive in hepatic angiosarcoma?

PECAM-1 (CD31). Differential Dx 61

What are risk factors for primary hepatic lymphoma?

HIV, hepatitis B, hepatitis C, and chemical exposure. Differential Dx 62

Name two benign liver tumors that are differential diagnoses for Hepatocellular Carcinoma (HCC).

Hepatic cyst, liver hemangioma, focal nodular hyperplasia, hepatocellular adenoma, hepatic lipoma. (Any 2) Differential Dx 63

Are liver lesions more often benign or malignant, even in patients with known cancer elsewhere?

Liver lesions are most often benign. Differential Dx 64

What vascular complication can Hepatocellular Carcinoma (HCC) cause?

Budd-Chiari syndrome (hepatic vein thrombosis). Complications 65

Does Hepatocellular Carcinoma (HCC) commonly metastasize?

Hematogenous metastasis is rare and usually only occurs in advanced stages. Complications 66

What is the approximate 5-year survival rate for early-stage Hepatocellular Carcinoma (HCC)?

70%. Prognosis 67

What is the approximate 5-year survival rate for advanced Hepatocellular Carcinoma (HCC)?

Approximately 20%. Prognosis 68

Name two strategies for primary prevention of Hepatocellular Carcinoma (HCC).

Hepatitis B immunization, treatment of chronic HBV/HCV, limiting alcohol intake, managing obesity/MASH. (Any 2) Primary Prevention 69

Which patients are considered high-risk and recommended for Hepatocellular Carcinoma (HCC) screening?

Patients with cirrhosis (any cause), or chronic hepatitis B with specific risk factors (active infection, family hx, older Asian pts, African pts ≥ 20). Screening 70

What is the recommended screening interval for high-risk patients for Hepatocellular Carcinoma (HCC)?

Every 6 months. Screening 71

What is the preferred screening modality for Hepatocellular Carcinoma (HCC)?

Abdominal ultrasound. Screening 72

How should a liver lesion < 10 mm found on HCC screening ultrasound be managed?

Repeat ultrasound in 3-6 months. Screening 73

How should a liver lesion ≥ 10 mm found on HCC screening ultrasound be managed?

Perform further imaging (typically multiphase CT or MRI). Screening 74