What is the liver?

The liver is one of the largest organs in the body, located in the upper right portion of the abdomen. The liver has many important functions, including clearing toxins from the blood, metabolizing drugs, making blood proteins, and making bile which assists digestion.

What is hepatocellular carcinoma (HCC)?

Hepatocellular carcinoma is a cancer that arises in the liver. It is also known as hepatoma or primary liver cancer.

How common is liver cancer?

HCC is the fifth most common cancer in the world. Recent data shows that HCC is becoming more common in the US. This rise is thought to be because of chronic hepatitis C, an infection that can cause HCC.

Who gets HCC?

It is well established that individuals with the hepatitis B and/or hepatitis C virus infection are at increased risk of developing HCC. Alcohol related liver disease is also a risk factor for the development of HCC.

There are certain chemicals that are associated with liver cancer-aflatoxin B1, vinyl chloride and thorotrast. Aflatoxin is the product of a mold called Aspergillus flavus and is found in foods such as peanuts, rice, soybeans, corn and wheat. Also thorotrast is no longer used for radiologic tests, and vinyl chloride, is a compound found in plastics.

Hemochromatosis, a condition in which there is abnormal iron metabolism, is strongly associated with liver cancer.

Individuals with cirrhosis from any cause such as the hepatitis virus, hemochromatosis and alpha-1-antitrypsin deficiency are at increased risk of developing HCC.

What are the symptoms of HCC?

Abdominal pain is the most common symptom of HCC and usually is present when the tumor is very large or has spread. Unexplained weight loss or unexplained fevers are warning signs in patients with cirrhosis. Sudden appearance of abdominal swelling (ascites), yellow discoloration of the eyes and skin (jaundice), or muscle wasting suggests the possibility of HCC.

How is HCC diagnosed?

The diagnosis of HCC cannot be made by routine blood tests. Screening by a blood test for the tumor marker, alpha- fetoprotein (AFP), and radiological imaging must be performed. Some doctors advocate measurement of AFP and imaging every 6- 12 months in patients with cirrhosis in an effort to detect small HCC. Sixty percent of patients with HCC will have an elevated AFP level and the remainder may have normal AFP. Therefore, a normal AFP level does not exclude HCC.

Radiological imaging studies are very important and may include one or more of the following-ultrasound, CT scan (MRI magnetic resonance imaging) and angiography.

Ultrasound examination of the liver is frequently the initial study if HCC is suspected.

CT scan is a very common study used in the USA for the workup of liver tumors. The ideal study is multi-phase CT scan with the use of oral and IV contrast.

MRI can provide sectional views of the body in different planes. MRI can actually reconstruct images of the biliary tree and the arteries and veins of the liver.

Angiography is a study where contrast material is injected into a large artery in the groin. X-ray pictures are then taken to evaluate the arterial blood supply to the liver. If the patient has HCC, a characteristic pattern is seen because of the newly formed abnormal small blood vessels that feed the tumor.

Biopsy may not be needed in patients with a risk factor for HCC and elevated AFP. Biopsy can be performed if there is some question as to the diagnosis of HCC or if the doctor feels the management may be changed by the biopsy results.

What is the prognosis of people with HCC?

The prognosis depends on the stage of the tumor and the severity of the associated liver disease. There are some factors that predict poor outcome. These include:

  • Demographics: male gender, older age, alcohol consumption
  • Symptoms: weight loss, decreased appetite
  • Signs of impaired liver function: jaundice, ascites or mental confusion related to liver disease (encephalopathy)
  • Blood tests: elevated liver tests, low albumin, high AFP, low sodium, high blood urea nitrogen
  • Staging of tumor: tumor over 3 cm, multiple tumors, tumor invasion of local blood vessels, tumor spread outside of liver.

What are the treatment options for HCC?


This may include injection of anti-cancer chemicals into the body through a vein or through chemoembolization.

The technique of chemoembolization is a procedure where chemotherapeutic drugs are given directly into the blood vessels that supply the tumor and small blood vessels are blocked so that the drug stays within the area of the tumor. Chemotherapy can provide some relief of symptoms and possibly decrease tumor size (in 50% of patients) but it is not curative.


Ablation (tissue destruction) therapy in the form of using radiofrequency waves, alcohol injection into the tumor or proton beam radiation to the tumor site are other options for treatment. There is no data to indicate that any one of these treatment is better than another.


Surgery is only available to patients with excellent liver function who have tumors less than 3-5 cm that are confined to the liver. If the patient is able to undergo surgery successfully, the five year survival is 30-40%. Many patients may have recurrence of HCC in another part of the liver.

Liver transplantation is a treatment option for patients with end-stage liver disease and small HCC. There is however a severe shortage of donors in the USA.

Is liver cancer always HCC?

Actually, in the United States most cancers that are found in the liver are ones that spread or metastasize from other organs. These cancers are not HCC, as HCC cancers begin in the cells of the liver. Cancers that commonly metastasize to the liver include colon, pancreatic, lung and breast cancer.



Radha Tamerisa, MD, and Manoop S. Bhutani, MD, FACG, FACP, University of Texas Medical Branch, Galveston, TX