Hepatocellular Carcinoma: Diagnosing Liver Cancer in Chronic Liver Disease

A 60-year-old man had a history of jaundice two years earlier and previous episodes of liver decompensation, including ascites and portal hypertension, for which he was already on beta-blockers. He returned with worsening jaundice. He was a known case of chronic hepatitis B, hepatitis B surface antigen positive, and was already on treatment for it.

The imaging finding that raised suspicion

An ultrasound showed multiple hypoechoic lesions in the liver, on a background of a cirrhotic liver from chronic liver disease. In a patient with known chronic hepatitis B and cirrhosis, new hypoechoic liver lesions are treated as a red flag for hepatocellular carcinoma, HCC, until proven otherwise.

The triple-phase CT, and how HCC behaves differently at each phase

The next step was a triple-phase CT of the abdomen and pelvis, which Dr. Raizada noted is technically a four-phase study: a pre-contrast phase, an arterial phase, a washout phase, and a delayed venous phase. In hepatocellular carcinoma, the tumour characteristically shows hyperenhancement during the arterial phase. During the washout phase, the lesion becomes relatively hypodense compared to the surrounding liver. In the delayed venous phase, a mosaic pattern can appear. Together, these features feed into the LI-RADS classification, the Liver Imaging Reporting and Data System, and a LI-RADS 5 score is considered highly suspicious for HCC.

Why this patient needed no biopsy at all

Dr. Raizada was specific about the diagnostic threshold: characteristic findings on a triple-phase CT, combined with an alpha-fetoprotein, AFP, level above 400 ng/mL, are sufficient to diagnose HCC without a biopsy, particularly in a patient with underlying chronic hepatitis B and cirrhosis. This patient's CT showed a hyperenhancing lesion consistent with LI-RADS 5, and his AFP came back at 540 ng/mL, comfortably above the threshold. No biopsy was required.

His hepatitis B viral DNA and viral load were also checked and found to be high, prompting the start of antiviral therapy alongside cancer treatment. His liver function tests were deranged, with an elevated prothrombin time and INR reflecting impaired synthetic liver function, which placed him in Child-Pugh Class B. Staging showed no spread to the chest or bones.

The three-part red flag, and why six-monthly surveillance matters

Dr. Raizada distilled the diagnostic pattern into three elements that together amount to a spot diagnosis: a background of chronic liver disease, whether from hepatitis B, hepatitis C, alcoholic liver disease, or non-alcoholic steatohepatitis; a space-occupying lesion in the liver; and a significantly elevated AFP. Any patient with chronic liver disease, regardless of whether HCC has yet developed, should receive six-monthly surveillance with ultrasound and AFP, because interval cancers can develop in the gap between scans. She drew a direct parallel to HPV vaccination here: hepatitis B vaccination has meaningfully reduced the incidence of hepatocellular carcinoma in the same way HPV vaccination has changed the incidence of HPV-related cancers.

Staging drives the treatment choice

Diagnosis by AFP and imaging is only the first step. Staging still requires assessing tumour size, the number of lesions, the presence of vascular invasion, and the underlying Child-Pugh liver function score, since all four determine what treatment is possible. Options include local ablative therapy, surgical resection, or, in selected patients with liver-limited disease, liver transplantation. If there is vascular involvement, local therapy is generally not an option and systemic therapy is indicated instead. The skill of the ultrasound operator matters too, since ultrasound is an operator-dependent test; if there is any doubt on a surveillance ultrasound, a triple-phase CT or multiphasic MRI should follow rather than waiting for the next scheduled scan.