CHAPTER 62
Hepatocellular carcinoma

Jorge A. Marrero and Nicole E. Rich

University of Texas Southwestern Medical Center, Dallas, TX, USA

Hepatocellular carcinoma (HCC) is one of the most common solid malignancies worldwide, with the highest incidence rates in East Asia and Africa. Although the incidence of HCC is lower in the United States and Europe, it has increased over the last two decades due to the burden of chronic hepatitis C virus (HCV) infection and nonalcoholic fatty liver disease (NAFLD) cases (Figure 62.1). Moreover, the death rates are close to the incidence rates, indicating an aggressive tumor with poor prognosis. Prognosis for patients with HCC depends on tumor stage at diagnosis, with curative options only available for patients diagnosed at an early stage.

An important aspect of HCC is the male predominance for this disease (Figure 62.2). The male‐to‐female ratio for the incidence of HCC among patients with cirrhosis is 2–3:1. Further studies are needed to elucidate the mechanism for this difference in incidence of HCC, which has implications for early detection and prevention strategies.

Despite the availability of efficacious surveillance tests, most HCC patients continue to be diagnosed at an advanced stage. Abdominal ultrasound forms the backbone of HCC surveillance testing and is efficacious for early tumor detection (Figure 62.3). HCC surveillance has been associated with significantly improved rates of early tumor detection, curative treatment, and overall survival in several cohort studies. The diagnosis of HCC can be made radiographically using multiphase computed tomography (CT) or gadolinium contrast‐enhanced magnetic resonance imaging (MRI) in the majority of patients. Characteristic imaging criteria for HCC include arterial phase enhancement and portal venous/delayed phase hypointensity (“washout”) in a liver mass exceeding 1 cm in diameter. Although most diagnoses can be established using imaging alone, biopsy should be considered in patients with noncharacteristic imaging. Histological variants of HCC include trabecular, pseudoglandular, scirrhous, and fibrolamellar types.

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