Snapshot A 65-year-old man presents to his primary care physician for right upper quadrant abdominal pain. He was diagnosed with hepatitis C infection, complicated by hepatic cirrhosis. Abdominal ultrasound demonstrates a focal hepatic lesion. He underwent a multi-phase contrasted abdominal CT scan, which demonstrated an enhancing focal hepatic mass during the arterial phase with rapid washout during the portal venous phase. Introduction Overview primary malignancy affecting hepatocytes may result in a paraneoplastic syndrome hypoglycemia erythrocytosis hypercalcemia severe diarrhea EPO, insulin-like growth factor, and PTHrP Epidemiology risk factors cirrhosis (80-90% of cases) chronic hepatitis B infection chronic hepatitis C infection aflatoxin, produced by Aspergillus species alcohol use hereditary hemochromatosis α1-antitrypsin deficiency obesity diabetes mellitus non-alcoholic fatty liver disease Pathophysiology β-catenin activation and inhibition of p53 play a role in the development of hepatocellular carcinoma Presentation Symptoms/physical exam right upper quadrant pain weight loss ascites obstructive jaundice however, patients can be asymptomatic and be incidentally found to have HCC due to routine screening in patients with cirrhosis Imaging Abdominal ultrasound indication monitoring lesions < 1 cm every 3-6 months for up to 2 years can be used as a screening imaging study in patients with cirrhosis if there are findings concerning for HCC, then confirmatory imaging (or possibly biopsy) is needed findings masses with poorly defined margins irregular echoes Multi-phase contrasted CT abdomen indication a confirmatory imaging study findings typically a focal nodule with early enhancement (in the arterial phase) and rapid contrast washout (in the portal venous phase) Multi-phase contrasted MRI abdomen indication a confirmatory imaging study findings enhancement in the arterial phase with rapid contrast washout Studies Serum labs α-fetoprotein (AFP) if elevated > 400-500 ng/mL may be suggestive of HCC may be seen in patients with active liver disease (e.g., HCV or HBV infection) a normal value does not exclude HCC Differential Hepatic adenoma differentiating factor benign liver tumor seen in patients with prolonged contraception use, anabolic steroid use, glycogen storage disorders, and pregnancy Treatment Surgical resection indication recommended if the lesion is resectable and the patient has good performance status liver transplantation indication recommended based on the patient's performance status and that the tumor is unresectable liver-directed therapies indication in patients with local disease who are not candidates for resection or liver transplantation may potentially down-stage the tumor, enabling the possibility of transplantation or resection modalities radioablation delivers local radiofrequency thermal energy transarterial chemoembolization (TACE) delivers high-dose chemotherapy (e.g., cisplatin and doxorubicin) to local areas in the liver therefore, this decreases the risk of developing systemic toxicities Complications Hepatic failure Hemoperitoneum Portal, hepatic, or renal vein thrombosis