Hepatocellular Carcinoma: Diagnosis and Surveillance

*Aditya Kale*

#### **Abstract**

Hepatocellular carcinoma arises commonly on the background of liver cirrhosis. Patients presenting with clinical symptoms have advanced stage and often are unsuitable for curative therapies. Diagnosis of hepatocellular carcinoma is commonly performed by multiphase computed tomography (CT) and / or magnetic resonance imaging scans (MRI). Contrast enhanced ultrasound and MRI with hepatobiliary contrast agents are better in characterizing small lesions. Tumor markers play an adjunct role in diagnosis. For HCC in cirrhotic liver biopsy is seldom required and diagnosis is based on typical imaging features of non-rim arterial phase hyperenhancement and washout on delayed phase and pseudocapsule appearance. This is due to differential blood supply of liver parenchyma, regenerative nodules and tumor. Biopsy is only required in noncirrhotic liver, vascular liver diseases, atypical imaging features. Surveillance programs involving high risk groups can help in early detection of lesions which are amenable for curative therapies. Biannual ultrasound with or without alfa fetoprotein are commonly used surveillance tests. Multidisciplinary teams provide platform for care coordination, reassessments of clinical course, and fine changes in treatment plans required for management of this complex group of patients.

**Keywords:** hepatocellular carcinoma, surveillance, tumor markers, multiphase computed tomography, multiphase magnetic resonance imaging, LI-RADS, multidisciplinary team

### **1. Introduction**

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of liver. It is sixth most commonly diagnosed cancer and fourth leading cause of cancer related mortality worldwide [1]. Most cases are diagnosed late in course of disease so that curative treatments could not be offered to such patients and hence incidence to mortality ratio for HCC approaches 1 [2]. Incidence of HCC is likely to increase due to increase in population and aging, as well as changing distribution of risk factors like obesity, hepatitis B and C virus infection and alcohol consumption [3]. Diagnosis at early stages and implementing surveillance programs in high risk population may reduce mortality [3]. This chapter focuses on diagnosis and surveillance for HCC.

#### **2. Diagnosis of hepatocellular carcinoma**

Diagnosis of hepatocellular carcinoma is primarily based on imaging with multiphase computed tomography (CT) scan and/or multiphase magnetic resonance

imaging (MRI) scan. Like in other cancers, biopsy is required in selective cases where there is diagnostic dilemma. HCC usually becomes symptomatic only in advanced stages of the disease hence clinical features are seldom useful for the diagnosis of disease. Tumor markers are useful blood test in supporting diagnosis and prognostication of most of HCC however, they have their own limitations in early diagnosis of HCC. This section throws light on clinical features, imaging investigations and tumor markers and there role in diagnosis of hepatocellular carcinoma.
