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Facts about liver cancer and HCC
Hepatocellular carcinoma, HCC, is the most common form of primary liver cancer in adults and develops from liver cells, hepatocytes. The disease often occurs in a liver that is already chronically damaged, especially in cirrhosis or long-term hepatitis B or C. HCC is more common in men and occurs mainly in older people.
Liver cancer can cause few or diffuse symptoms in the early stages. Diagnosis is based primarily on imaging of the liver together with blood tests and assessment of liver function. AFP may be elevated in HCC but cannot alone diagnose or rule out the disease.
Treatment is adapted to the size and extent of the tumor, any spread, liver function and the patient's general condition. In early disease, surgery, liver transplantation or local tumor treatment may be appropriate, while more advanced HCC can be treated with, for example, local-regional or systemic drug therapy.
Hepatocellular carcinoma (HCC)
Hepatocellular carcinoma, HCC, is the most common form of primary liver cancer in adults. Primary liver cancer means that the tumor has arisen in the liver itself, unlike liver metastases where a cancer from another organ has spread to the liver. HCC develops from the main cell type of the liver, the hepatocytes.
In Sweden, just over 700 people are diagnosed with liver cancer each year. The disease is significantly more common in men than in women and occurs primarily in older people. HCC often develops in a liver that is already chronically damaged, especially in liver cirrhosis or long-term infection with hepatitis B or hepatitis C. People at higher risk can therefore be followed regularly to detect new liver changes at an earlier stage.
Hepatocellular carcinoma, HCC
Hepatocellular carcinoma is the most common primary liver cancer and occurs when hepatocytes acquire genetic changes that cause the cells to grow uncontrollably. The tumor can appear as a single lesion, as multiple tumor foci, or as a more diffuse tumor growth in the liver. HCC can grow into the blood vessels of the liver, especially the portal vein, and can also spread outside the liver. Common sites of distant spread are the lungs, lymph nodes, bones, and adrenal glands.
Symptoms of liver cancer
Liver cancer may cause few or nonspecific symptoms in the early stages. In people with already known cirrhosis, the first sign may sometimes be a deterioration in liver function without any other clear explanation.
Present symptoms and signs may include:
- pain or discomfort under the right rib cage.
- a feeling of pressure or fullness in the upper part of the stomach.
- unintentional weight loss.
- decreased appetite and early feeling of satiety.
- fatigue and worsening general condition.
- nausea.
- enlarged liver.
- swollen abdomen due to ascites.
- jaundice with yellow skin and yellow whites of the eyes.
- dark urine and light stools with pronounced cholestasis or liver damage.
The symptoms are not specific to liver cancer and can occur with several other liver and biliary tract diseases. New symptoms in a person with cirrhosis or other chronic liver disease should therefore be evaluated medically.
Causes and risk factors for liver cancer
HCC often develops after many years of chronic liver damage. Repeated inflammation and tissue damage lead to the need for liver cells to continuously regenerate. Over time, genetic changes can accumulate and contribute to the development of a malignant cell clone.
Levercirros
Levercirros är en av de viktigaste riskfaktorerna för hepatocellulär cancer. Cirros är ett sent stadium av långvarig leverskada där frisk levervävnad successivt ersätts av ärrvävnad (fibros), vilket förändrar leverns struktur och försämrar dess funktion.
Flera leversjukdomar kan med tiden leda till cirros. Det gäller bland annat långvarig hög alkoholkonsumtion, kronisk virushepatit och metabolt associerad fettlever. Vid fettlever lagras för mycket fett i levern. Hos vissa personer utvecklas även inflammation och fibros, som över tid kan bli så uttalad att cirros uppstår. Risken för HCC är särskilt förhöjd när leverskadan har utvecklats till avancerad fibros eller cirros.
Hepatitis B and hepatitis C
Chronic infection with hepatitis B or hepatitis C are established risk factors for liver cancer. Chronic hepatitis can cause inflammation, fibrosis and cirrhosis over many years, which in turn increases the risk of HCC. In chronic hepatitis B, HCC can also develop without fully developed cirrhosis. People with certain risk profiles can therefore be followed with regular liver monitoring even if cirrhosis is not established.
Alcohol-related liver disease
Long-term high alcohol consumption can cause fatty liver, inflammation and eventually liver cirrhosis. It is especially when cirrhosis has developed that the risk of HCC is clearly increased.
Fatty liver and metabolic disease
Metabolically associated steatotic liver disease can develop in people with, for example, obesity, type 2 diabetes, insulin resistance and other parts of the metabolic syndrome. In some people, the disease progresses to inflammation, fibrosis and cirrhosis, which can increase the risk of HCC.
Hereditary and other liver diseases
Some more uncommon liver diseases can also increase the risk of HCC, such as hemochromatosis and other conditions that cause long-term liver inflammation or fibrosis. Having a risk factor does not mean that liver cancer will develop. The risk is affected by, among other things, the degree of liver damage, age, other diseases and how long the liver has been affected.
Investigation of suspected liver cancer
The investigation of suspected HCC is based primarily on imaging of the liver. Unlike many other forms of cancer, HCC can in some situations be diagnosed based on a typical imaging pattern without the need to take a tissue sample. This applies especially to people at high risk, such as patients with liver cirrhosis or chronic hepatitis B, where a focal liver change shows a characteristic contrast pattern on computed tomography or MRI.
MRI liver in case of suspicion of HCC
MR liver is an established method for examining focal changes in the liver and can provide detailed information about the size, number, tissue character and relationship of the tumor to the blood vessels of the liver. MRI has high contrast resolution and can, among other things, assess fat deposition, fibrosis and iron deposition in the liver. With dynamic contrast examination, the radiologist can also analyze how a liver lesion absorbs and secretes contrast during different phases.
HCC often has a characteristic contrast pattern with increased contrast loading during the arterial phase and relative reduction of contrast in later phases, so-called washout. In people at high risk, this image pattern can be sufficient for diagnosis in the right clinical context.
RCC recommends that MRI liver is used primarily when computed tomography does not provide an unambiguous answer in the case of a focal change in a cirrhotic liver. The assessment is often made according to standardized criteria such as LI RADS.
Computed tomography and other imaging diagnostics
When primary liver cancer is suspected, multiphase computed tomography of the liver and abdomen is often used together with computed tomography of the chest. The examination is used both to characterize the tumor and to map possible spread.
AFP in liver cancer
AFP is a protein that is normally present in high levels during fetal development but only in low concentrations in adults. AFP can rise in hepatocellular cancer and is therefore used as a tumor marker in certain parts of the investigation and follow-up.
However, an elevated AFP does not mean that a person has liver cancer. AFP can also rise in other liver diseases and certain other tumor diseases. At the same time, a significant proportion of people with HCC have normal AFP levels.
AFP is therefore not recommended as a stand-alone diagnostic test for HCC. RCC states that the marker has insufficient sensitivity and specificity to make the diagnosis on its own. High AFP levels, however, may have prognostic significance and are used, among other things, in certain assessments prior to liver transplantation.
What other blood tests may be relevant?
Blood tests are primarily used to assess liver function, underlying liver disease and the patient's conditions for treatment. They can also help detect complications of cirrhosis or advanced tumor disease.
Relevant blood tests may include:
- ALAT and ASAT to assess hepatocellular involvement.
- ALP and GT in cases of biliary tract involvement.
- bilirubin which reflects the liver's ability to handle and excrete bilirubin.
If underlying chronic liver disease is suspected, targeted testing for, for example, hepatitis B, hepatitis C, iron overload or other specific causes may also be appropriate.
Can a blood test detect liver cancer?
No, there is no single blood test that can reliably diagnose or rule out HCC. AFP may be elevated, but a normal AFP level does not rule out liver cancer and an elevated value may have other causes. The diagnosis of HCC is therefore based primarily on imaging and the patient's risk profile. The blood tests serve as supplementary information and are used to assess liver function, tumor activity and treatment.
Is a biopsy needed to diagnose HCC?
A biopsy is not always needed for suspected hepatocellular cancer. In a person with liver cirrhosis or other clearly high risk, a liver lesion with typical radiological features on contrast-enhanced MRI or computed tomography can in some cases be diagnosed as HCC without a tissue sample. If the imaging does not show a typical pattern, if the patient lacks an established risk background or if there is suspicion of another tumor type, a tissue sample may be needed. The sample is then examined histopathologically to determine the type of tumor.
How is liver cancer diagnosed?
HCC can spread within the liver, grow into the liver's major blood vessels, or metastasize to other organs. In distant spread, the lungs, regional lymph nodes, bones, and adrenal glands are common sites.
Imaging of the liver, abdomen and thorax is therefore used to map the extent of the disease. The number, size, vascular ingrowth, possible spread and the remaining liver function of the tumor are weighed together before treatment decisions are made.
Treatment of hepatocellular cancer
The treatment of HCC is not only guided by the size and spread of the tumor. Since many patients also have cirrhosis, the remaining function of the liver also needs to be taken into account. Two people with tumors of similar size may therefore need completely different treatment depending on liver function and other health conditions.
In early HCC, curative treatment may be possible through surgical resection, liver transplantation or local tumor treatment with ablation. In more widespread disease, local regional treatment can be used, for example transarterial treatment where the tumor's blood supply is attacked via the arteries of the liver. In advanced or disseminated HCC, systemic drug treatment with immunotherapy and other targeted drugs may be appropriate.
Liver transplantation for HCC
Liver transplantation can be a treatment option for selected patients with early HCC and concomitant advanced chronic liver disease. The transplantation treats both the tumor and the underlying diseased liver.
The assessment prior to transplantation is based on several factors, including the number and size of the tumors, any vascular ingrowth or spread, and sometimes AFP levels. The selection is made within specialized liver and transplant care.
Prognosis for liver cancer
The prognosis for HCC varies greatly and is influenced by both the tumor stage and the underlying liver function. A small localized tumor in a liver with relatively preserved function has completely different treatment options than an advanced cancer in a person with pronounced cirrhosis. The relative five-year survival for liver cancer as a group is around 25%, but population statistics cannot be used to predict the prognosis for an individual patient.
When should you seek medical attention?
Contact your healthcare provider if you have new or persistent pain under the right rib cage, unexplained weight loss, decreased appetite, increased abdominal size, or other new symptoms that may indicate liver involvement. People with known cirrhosis, chronic hepatitis B, or other conditions that pose a high risk of HCC should follow the plan for regular liver monitoring recommended by their treating physician.
Jaundice, rapidly increasing abdominal swelling, bloody vomiting, black stools, confusion, or a marked deterioration in general condition may be signs of serious liver disease and should be evaluated urgently.
Important information about screening and health checks
MRI liver and AFP are not used as general screening for liver cancer in people without specific risk factors. Structured surveillance is particularly relevant for people with a clearly increased risk, for example with liver cirrhosis and certain forms of chronic hepatitis B. If liver cancer is suspected, it is the combination of medical history, liver function, imaging and, if necessary, further examinations that determine whether HCC is present.
