How hepatocellular carcinoma is diagnosed

Hepatocellular carcinoma (HCC) is a primary malignant tumor of the liver derived from the parenchymal cells. HCC is one of the most frequent cancer types worldwide.

Clinical presentation

At the early stages, the disease is usually asymptomatic, although the diagnosis is often made at an advanced stage when the tumor is large and local symptoms are common. Individuals with HCC complain of dull pain in the right upper quadrant of the abdomen, that sometimes irradiates to the shoulder.  

Examination

During the physical examination masses or lumps in the liver as well as enlarged abdomen due to the fluid accumulation may be detected. The liver and sometimes the spleen is swollen.

Blood tests and liver function tests

Alpha-fetoprotein is considered a serum marker for HCC, although its levels appear increased only in 60% of individuals with HCC and therefore normal AFP values do not exclude HCC. On the other hand, AFP levels may rise in case of active hepatitis B and C when the virus replicates fast, toxic hepatitis. When the diagnosis is already established serial measurements may be used to control the disease progression and response to treatment.  

Carcinoembryonic antigen (CEA),  vitamin  B12,  ferritin, and antimitochondrial antibodies should be measured. Prothrombin time (PT), partial thromboplastin time (PTT), albumin, transaminases, γ-glutamyl transpeptidase, and alkaline phosphatase should be measured to estimate the liver function and disease severity.

  • Low hemoglobin is suggestive of possible bleeding from the varices;
  • Significant portal hypertension and related to it splenomegaly may be suspected in case of the low platelet blood count;
  • Active liver damage causes increased liver enzymes and increased bilirubin levels;
  • Prolonged prothrombin time (PT)/INR re characteristic for the impaired liver function;
  • Serum creatinine appears elevated when the kidney function is impaired;
  • Platelet count and white blood cells may be decreased due to hypersplenism.

Serologic tests to identify hepatitis  A,  B and  C should be performed.

Ultrasound

Ultrasound examination is commonly used as a screening tool. Lesions may appear from hypoechoic to hyperechoic depending on the fatty infiltration of the liver. The tumor is characterized by the increased vascularity and significantly higher blood supply of the mass in comparison to the other tissues.

CT/MRI

CT scan of the abdomen and pelvis should be performed to detect the lesion and estimate its size and spread.

Biopsy

A liver biopsy is the most accurate method used to confirm the diagnosis. A sample of the liver may be taken during the laparoscory, when the lesion is resected or when the fine needle biopsy is performed. Then the tissues are examined under the microscope to detect whether there are the cancer cells.

The lesion appears as a solitary tumor or a multicentric tumor with a bigger central lesion and multiple satellite neoplasms. Sometimes HCC looks like yellowish-white nodules with areas of hemorrhages and dead tissues. The differentiated lesions are comprised of large hepatocytic cells. Undifferentiated tumors contain various cells with different size and shape.  The tumor may spread into the portal vein. Lymph node metastases are common, whilst lung and bone metastases are rare.