HCC / Hepatocellular Carcinoma

In most cases, hepatocellular carcinoma does not develop in a healthy liver. It usually develops in a liver that has already been chronically damaged. In about 90% of cases, an underlying chronic liver disease is present. The most important risk factor is liver cirrhosis, regardless of its cause. Long-term inflammation, regeneration, and scarring of liver tissue can promote genetic changes in hepatocytes. This can support tumor development.

The most important known risk factors include:

• Liver cirrhosis
• Chronic hepatitis B infection
• Advanced liver fibrosis, for example due to chronic hepatitis C
• Metabolic syndrome
• Metabolic dysfunction associated steatotic liver disease, or MASLD, and MASH
• Less common causes, such as aflatoxins

The main risk factor for HCC remains liver cirrhosis. Regular follow-up checks and specific screening measures are therefore especially important in people with cirrhosis. All these risk factors can cause long-term liver damage and may promote HCC. It is important to understand that HCC often does not develop suddenly. It usually develops over many years as a result of chronic liver disease. This makes it even more important to detect, treat, and monitor known liver diseases early.

Hepatocellular carcinoma often causes no specific symptoms in its early stages. This is one reason why the disease is often found during screening. It may also be detected when advanced liver disease is already present. If symptoms occur, they are usually nonspecific at first.

Possible hepatocellular carcinoma symptoms include:

• Pressure or fullness in the right upper abdomen
• Abdominal pain in the upper abdomen, for example due to stretching of the liver capsule
• Weight loss
• Loss of appetite
• Increasing tiredness and reduced performance
• Jaundice, also called icterus
• Increasing abdominal size, for example due to ascites
• General worsening of overall health

In people who already have liver cirrhosis, HCC may also become noticeable through sudden worsening or decompensation. Possible signs include new or increasing ascites, worsening jaundice, hepatic encephalopathy, or rapidly declining liver function.

It is therefore important to know that HCC often causes no clear warning signs at first. Typical symptoms may be absent, especially in early stages. Regular checks are therefore important in people with known risk factors. These include liver cirrhosis, chronic hepatitis B, and advanced MASLD or MASH. HCC is often detected through targeted monitoring rather than through early symptoms.

The diagnosis of hepatocellular carcinoma is based on several steps. These include a detailed medical history, the identification of risk factors, imaging, and blood tests. It is important to find out whether chronic liver disease or liver cirrhosis is already present. In this context, HCC can often be detected with a high level of certainty through imaging. A suspicious lesion is often first seen during monitoring for liver cancer, usually with ultrasound. Further imaging is then used for clarification.

The most common imaging methods include contrast enhanced CT and MRI of the liver. HCC often shows typical contrast patterns. These include arterial hypervascularization followed by washout in the portal venous or delayed phase. If these features are present and the risk profile fits, HCC can often be diagnosed without a biopsy.

In addition to imaging, laboratory tests are also performed. They help assess the extent of liver disease and tumor markers. A blood test is often used to check liver values, clotting, bilirubin, albumin, and alpha fetoprotein, or AFP. However, a positive tumor marker cannot confirm the diagnosis by itself. AFP is not elevated in all people with HCC. It can also rise in other liver diseases or cancers. Tumor markers such as AFP are therefore used mainly to help classify the tumor and monitor the course of disease.

A liver biopsy may be considered in certain cases. This is especially true when imaging is unclear, when no typical risk profile is present, or when histological confirmation would affect treatment planning. Today, biopsy is used more cautiously. It is not performed routinely in every suspected case of HCC.

Hepatocellular carcinoma treatment aims to control tumor growth and spread as well as possible. It also aims to preserve liver function. Depending on the stage, treatment may try to achieve cure or slow disease progression for as long as possible. Treatment planning for HCC is usually multidisciplinary. Tumor size is important, but it is not the only factor. Liver function, possible portal hypertension, and the patient’s general condition are also crucial. These factors help decide whether local, locoregional, or systemic treatment is suitable.

In early stages, potentially curative treatments are mainly used. These include surgical resection, liver transplantation, and in selected cases radiofrequency or microwave ablation. Resection is especially useful when the tumor is limited to one area and liver function is still good. Liver transplantation is particularly important when advanced cirrhosis is also present. It treats both the tumor and the underlying diseased liver. Local ablation may be used for smaller lesions, especially when surgery is not possible or not appropriate.

In more advanced stages, locoregional treatments are often used. These include transarterial chemoembolization, or TACE. In certain situations, transarterial radioembolization may also be used. These treatments aim to slow tumor growth by reducing its blood supply. If local treatments are no longer enough, systemic therapies may be used. Today, these include immunotherapies and targeted therapies. Examples include combinations of checkpoint inhibitors or tyrosine kinase inhibitors. The choice of treatment depends on how advanced the tumor is and how well the liver is working.

The chance of cure and life expectancy in HCC depend strongly on the stage at diagnosis. If HCC is found early and resection, liver transplantation, or ablation is possible, tumor control or even cure may be possible. In more advanced stages, long-term cure is much less common. In these cases, the focus is more on slowing tumor growth, avoiding complications, and improving quality of life and life expectancy.

Complementary approaches may also be used alongside HCC treatment. They may help relieve symptoms, support the body during therapy, and improve quality of life. In supportive oncology, acupuncture is especially well established. It may help with pain, nausea, sleep disorders, and fatigue.

Hyperthermia is also increasingly being studied in oncology. Depending on the indication, different methods may be used. These include local hyperthermia and whole-body hyperthermia. In these methods, tumor tissue or the whole body is heated in a controlled way. The aim is to make tumor cells more sensitive to chemotherapy or radiation therapy. This may happen through improved blood flow and easier drug uptake in the tumor. It may also involve reduced DNA repair.

Concepts from Traditional Chinese Medicine are also being studied as supportive approaches in HCC. The focus is on immune modulating, inflammation related, and supportive effects. Some smaller clinical studies have shown partly promising results.

Nutritional supplements, including vitamins and minerals, may also be used in HCC when deficiencies are present. Their use depends on the clinical situation. In more advanced stages, B vitamins or vitamin D may be useful to correct deficiencies. They may also support muscle and bone stability and help relieve symptoms such as fatigue. Many people in these stages have malnutrition, muscle loss, reduced food intake, or neurological symptoms.

The information listed contains relevant topics and serves to improve understanding.