Hepatocellular carcinoma

Last revised by Henry Knipe on 25 Feb 2024

Hepatocellular carcinoma (HCC), also called hepatoma, is the most common primary malignancy of the liver. It is strongly associated with cirrhosis, from both alcohol and viral etiologies. Hepatocellular carcinomas constitute approximately 5% of all cancers partly due to the high endemic rates of hepatitis B infection 1.

Hepatocellular carcinoma is the fifth most common cancer in the world and is the third most common cause of cancer-related death (after lung and stomach cancer). The incidence of hepatocellular carcinoma is rising, largely attributable to a rise in hepatitis C infection 2.

The highest prevalence occurs in Asia, in regions where chronic hepatitis B infection is endemic, and this accounts for >80% of hepatocellular carcinoma cases worldwide. In Western countries, the rate of hepatitis B infection is lower and alcohol accounts for the majority of cases.

Hepatocellular carcinoma is typically diagnosed in late middle-aged or elderly adults (average 65 years) and is more common in males (75% of cases) 7. In regions where chronic hepatitis B infection is endemic, young adults aged 20 to 40 (who had contracted the virus via maternal-fetal transmission) have the highest risk of developing hepatocellular carcinoma 30.

Hepatocellular carcinoma also occurs in the pediatric population, and is the second most common pediatric primary liver tumor after hepatoblastoma.

Fibrolamellar hepatocellular carcinoma is a distinct variant of hepatocellular carcinoma not associated with cirrhosis and has different demographics and risk factors.

Risk factors include 1:

The presentation is variable and, in affluent nations, is often found in the setting of screening programs for patients with known risk factors 8. Otherwise, presentation may include:

The origin of hepatocellular carcinomas is believed to be related to repeated cycles of necrosis and regeneration, irrespective of the cause. Additionally, the genomes of HBV and HCV contain genetic material that may predispose cells to accumulate mutations or disrupts growth control, thus allowing for a second mechanism by which infection with these agents predisposes to hepatocellular carcinoma 1.

On gross pathology, hepatocellular carcinomas typically appear as pale masses within the liver and may be unifocal, multifocal or diffusely infiltrative at the time of presentation.

The macroscopic growth of hepatocellular carcinoma is usually categorized into three subtypes: nodular, massive and infiltrative. Each has different radiological features, which are detailed below 9. The infiltrative subtype is characterized by a growth of multiple tiny nodules throughout the entire liver or an entire liver segment.

Microscopically they range from well-differentiated to undifferentiated.

Hepatocellular carcinomas can have a variety of appearances:

  • massive (focal)

    • large mass

    • may have necrosis, fat and /or calcification

  • nodular (multifocal)

    • multiple masses of variable attenuation

    • may also have central necrosis

  • infiltrative (diffuse) 10

    • may be difficult to distinguish from associated cirrhosis: also called cirrhotomimetic-type hepatocellular carcinoma or cirrhosis-like hepatocellular carcinoma

Hepatocellular carcinoma receives most of its blood supply from branches of the hepatic artery, accounting for its characteristic enhancement pattern: early arterial enhancement with early "washout." Hence, small foci of hepatocellular carcinoma may be seen within a regenerative liver nodule as foci of arterial enhancement (nodule-in-nodule appearance) 11.

Hepatocellular carcinoma uncommonly demonstrates a central scar similar to focal nodular hyperplasia but may be differentiated by the absence of delayed contrast enhancement of the scar (as seen in focal nodular hyperplasia).

Rim enhancement on delayed post-contrast images causing a capsule-appearance is considered relatively specific for hepatocellular carcinoma (see case 4). 

Additionally, these tumors have the propensity to invade vascular structures, most commonly the portal vein, but also the hepatic veins, IVC, and right atrium. One should remember that a large number of patients will have concomitant cirrhosis, and thus also be at risk for bland portal vein thrombosis from synthetic dysfunction of clotting factors.

Variable appearance depending on the individual lesion, size, and echogenicity of background liver. Typically:

  • small focal hepatocellular carcinoma appears hypoechoic compared with normal liver

  • larger lesions are heterogeneous due to fibrosis, fatty change, necrosis and calcification 12

  • a peripheral halo of hypoechogenicity may be seen with focal fatty sparing (see the discussion below on the CT session)

  • diffuse hepatocellular carcinoma may be difficult to identify or distinguish from background cirrhosis

  • contrast-enhanced ultrasound 13

    • arterial phase

      • arterial enhancement from neovascularity

    • portal venous phase

      • decreased echogenicity relative to background liver ("washout")

      • tumor thrombus may be visible

    • variants have been described with arterial phase hypovascularity with no enhancement or arterial enhancement with no "washout"

Several patterns can be seen, depending on the subtype of hepatocellular carcinoma. Enhancement pattern is the key to the correct assessment of hepatocellular carcinomas.

Usually, the mass enhances vividly during late arterial (~35 seconds) and then washes out rapidly, becoming indistinct or hypoattenuating in the portal venous phase, compared to the rest of the liver.

Additionally, they may be associated with a wedge-shaped perfusion abnormality due to arterioportal shunts (APS), and this, in turn, can result in a focal fatty change in the normal liver or focal fatty sparing in the diffusely fatty liver 14. A halo of focal fatty sparing may also be seen around a hepatocellular carcinoma in an otherwise fatty liver 15.

Portal vein tumor thrombus can be distinguished from bland thrombus by demonstrating enhancement.

When seen in the setting of cirrhosis, small hepatocellular carcinomas need to be distinguished from regenerative and dysplastic nodules 16.

In general, MRI signal is:

  • T1

    • variable

    • iso- or hypointense cf. surrounding liver 17

    • hyperintensity may be due to

      • intratumoral fat 3

      • decreased intensity in the surrounding liver

  • T1 C+ (Gd)

    • enhancement is usually arterial ("hypervascularity")

    • rapid "washout", becoming hypointense to the remainder of the liver (96% specific) 3

      • this is because the supply to hepatocellular carcinoma is predominantly from the hepatic artery rather than the portal vein

    • rim enhancement may persist ("capsule")

    • an imaging classification system (LI-RADS) has been developed to stratify lesions

  • T1 C+ (Eovist/Primovist)

    • similar to assessment with extracellular gadolinium, but evaluation of the hepatobiliary phase requires care

      • most commonly arterial phase hyperenhancement (APHE) with portal venous washout 31

      • washout on transitional phase (3 minutes delayed) is less reliable (see: Eovist and LI-RADS)

      • well-differentiated HCC can have absent APHE and appaer hypointense on hepatobiliary phase 31

      • 10-15% HCCs will be hyperintense on hepatobiliary phase 31

  • T2: variable, typically moderately hyperintense

  • C+ post-SPIO (iron oxide): increases sensitivity in diagnosing small hepatocellular carcinomas

  • DWI: intratumoral high signal; increases sensitivity and specificity 31

  • hypervascular tumor

  • threads and streaks pattern: sign of tumor thrombus in the portal vein

The typical TNM staging system seen in most other epithelial cancers is not as prognostically useful for stratification of patients with hepatic cancers.

There are several substitute staging systems used in guiding therapy for hepatocellular carcinoma (see hepatocellular carcinoma staging)18. The LI-RADS imaging classification system is also used to stratify lesions in an at-risk liver.

If the lesion is small then resection is possible (partial hepatectomy) and may result in remission. The remarkable ability of the liver to regenerate means that up to two-thirds of the liver can be resected 19.

Liver transplantation is also a curative option. To be suitable for liver transplantation it is agreed that certain criteria should be met (see Milan criteria).

If neither of these options are possible, then a variety of options exist including chemotherapy, transarterial chemoembolisation (TACE), transarterial radioembolization (TARE) / selective internal radiation therapy (SIRT), thermal ablation (RFA, cryoablation, or microwave ablation), and chemical ablation 20-22.

If a tumor is resectable, then 5-year survival is ~45% (range 37-56%) 23.

Metastasis occurs in the final stages of disease (IVa) and carries a poor prognosis 24,25. The most frequently involved sites are the lung, adrenal glands, lymph nodes, and bone.

General imaging differential considerations include:

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Cases and figures

  • Figure 1: gross pathology: hepatocellular carcinoma
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  • Case 1: arterial phase
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  • Case 2: massive HCC
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  • Case 3: diffuse HCC
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  • Case 4: showing scar and rim enhancement
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  • Case 5
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  • Case 6: with peritoneal metastasis
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  • Case 7: with multiple peritoneal implants
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  • Case 8: arterial phase
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  • Case 8: portovenous phase
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  • Case 9
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  • Case 10
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  • Case 11: with atypical imaging features
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  • Case 12: recurrent HCC - washout
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  • Case 13: with bony metastasis
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  • Case 14: multifocal
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  • Case 15
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  • Case 16
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  • Case 18: with AV fistula
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  • Case 19: with right atrial invasion
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  • Case 20
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  • Case 21
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  • Case 22
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  • Case 23
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  • Case 24
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  • Case 25: with background hemochromatosis
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  • Case 26: in segment II
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  • Case 27
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  • Case 28: diffuse HCC
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  • Case 29
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  • Case 30
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  • Case 31: multifocal
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  • Case 32: diffuse HCC
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  • Case 33: with IVC and left portal vein branch thrombosis
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  • Case 34
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  • Case 35: multifocal
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  • Case 36: multifocal
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  • Case 37: multifocal
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  • Case 38
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  • Case 39: with spontaneous rupture
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  • Case 40
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  • Case 41: multifocal
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  • Case 42: multifocal
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  • Case 43
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