Hepatocellular Carcinoma Initial Assessment

Clinical Presentation

Signs and Symptoms  

Localized hepatocellular carcinoma is usually asymptomatic for much of its natural history. Non-specific symptoms with more advanced hepatocellular carcinoma include jaundice, anorexia, weight loss, malaise and upper abdominal pain. Physical signs are hepatomegaly and ascites.

Diagnosis or Diagnostic Criteria

Diagnostic Criteria  

The diagnosis of hepatocellular carcinoma is established by fulfilling the criteria of the 2018 American Association for the Study of Liver Diseases (AASLD) guidelines based on the Liver Imaging Reporting and Data System (LI-RADS).  

The criteria for LI-RADS 5, which confirm the diagnosis of hepatocellular carcinoma, include the following:

• ≥20 mm lesions: Arterial phase hyperenhancement (APHE) and ≥1 of the following:
  • Non-peripheral "washout"
  • Enhancing capsule
  • Threshold growth (increase in lesion's size by ≥50% in ≤6 months)
• 10-19 mm lesions: APHE and non-peripheral "washout" enhancing capsule and threshold growth, or APHE and "washout" or APHE and threshold growth
• Lesions must be nodules >1 cm in diameter with imaging studies findings typical of hepatocellular carcinoma (ie hypervascular in the arterial phase with hypodensity in the portal venous or delayed phase) on a 4-phase (unenhanced, arterial, portal venous and delayed phases) MDCT scan, or a 4-phase dynamic contrast-enhanced magnetic resonance imaging in a liver that has cirrhosis

Biological imaging with gadoxetic acid may be utilized for the diagnosis of hepatocellular carcinoma for suspicious lesions that do not fulfill the AASLD requirements for diagnosis by imaging. There is a high likelihood of having high-grade dysplastic nodules or well-differentiated hepatocellular carcinoma in lesions without arterial phase hyperenhancement, but with both venous phase hypoenhancement and hepatobiliary phase hypointensity by gadoxetic acid-enhanced magnetic resonance imaging. These lesions should be considered as "high-risk" lesions. In patients with risk factors for hepatocellular carcinoma such as chronic viral hepatitis, liver cirrhosis, etc, an alternative diagnostic criterion can be met if space-occupying lesions of the liver demonstrated by computed tomography scan (non-dynamic) or magnetic resonance imaging (non-dynamic) are present, together with either: Serum alpha fetoprotein level of ≥400 mcg/L or dense homogenous lipiodol retention shown after hepatic lipiodol angiography with follow-up post-lipiodol computed tomography scan. 

Screening

Screening Methods  

Ultrasonography and alpha fetoprotein (AFP) testing are used for screening patients at risk for hepatocellular carcinoma. Patients with positive alpha fetoprotein or nodules ≥10 mm in ultrasound should undergo additional tests/imaging to confirm the diagnosis of hepatocellular carcinoma.  

Serum Alpha Fetoprotein (AFP)

Hepatocellular Carcinoma_Initial Assesment