Liver cancer

Disease Description (Causes and Symptoms)

• Definition summary: Hepatocellular carcinoma (HCC) is a malignant tumor originating in the liver and accounts for most primary liver cancers.
• Main causes: Chronic hepatitis B or C, cirrhosis (including alcoholic cirrhosis), and malignant transformation of hepatocytes due to chronic inflammation. Aflatoxin exposure is also a risk factor.
• Pathophysiology (brief): Accumulation of genetic mutations during ongoing liver injury and regeneration → abnormal proliferation of hepatocytes → tumor formation. The risk of developing HCC is very high in people with cirrhosis.
• Typical symptoms: It is often asymptomatic in the early stages. As it progresses, weight loss, right upper abdominal pain or tenderness, an abdominal mass, jaundice, ascites, and generalized weakness may occur.

Treatment Methods and Precautions

• Key factors in treatment decisions: Tumor size and number, presence or absence of vascular invasion, liver function (such as Child-Pugh), and the patient’s overall condition (suitability for surgery).
• Curative treatment (in early-stage disease, if liver function permits)
  • Hepatectomy (partial resection): One of the standard treatments for localized lesions.
  • Liver transplantation: A curative option when liver function is poor and the tumor is within the transplantation eligibility criteria (e.g., the Milan criteria: a single tumor ≤5 cm or up to 3 tumors, each ≤3 cm).
  • Local ablation (thermal treatment): Minimally invasive curative procedures such as radiofrequency ablation (RFA) and percutaneous ethanol injection.
• Noncurative/local treatment (for intermediate or advanced disease, or when curative treatment is not possible)
  • Transarterial chemoembolization (TACE): A standard local treatment for multiple intrahepatic tumors or patients who cannot undergo surgery.
  • Radiation therapy (including SBRT) and selective internal radiation therapy (SIRT/TARE), among others.
• Systemic treatment (advanced or metastatic HCC)
  • Combination immunotherapy: Atezolizumab + bevacizumab (atezo+bev) is often recommended as the first-line standard therapy (preservation of liver function and bleeding risk assessment are necessary).
  • Targeted therapies: Sorafenib and lenvatinib are first-line alternatives; second-line drugs include regorafenib, cabozantinib, and ramucirumab (when AFP ≥400 ng/mL). Immune checkpoint inhibitors (such as nivolumab and pembrolizumab) may be considered in some situations.
• Treatment of infectious diseases (underlying diseases): Appropriate antiviral treatment for chronic HBV and HCV can reduce the risk of cirrhosis and HCC, so active treatment is recommended.
• Lifestyle management and precautions
  • Abstain from alcohol and manage fatty liver disease and obesity.
  • Monitor for anticoagulation and bleeding risks, as well as symptoms of hepatic encephalopathy and liver failure.
  • Because of the risks of bleeding and tumor seeding (rare), biopsy is often avoided when imaging findings are typical.
• Risk of complications: Liver failure, thrombosis due to portal vein invasion, ascites or variceal bleeding, and metastasis (such as to the lungs or bones).

Checkpoints Before an Outpatient Visit (Including Preparation and Sample Questions)

• Items to bring (recommended)
  • A list of current medications (medication names and doses), including supplements and herbal medicines
  • Previous test results (ultrasound, CT/MRI, AFP, etc.) and imaging CDs or images
  • Past medical history (history of hepatitis, diagnosis of cirrhosis, records of surgeries and procedures)
  • A record of symptom changes (weight, abdominal pain, jaundice, changes in urine or stool, etc.) and when they began
• Useful tests during a visit (the doctor may request these)
  • Blood tests: Liver function (ALT/AST, bilirubin, albumin), coagulation (PT/INR), AFP, etc.
  • Imaging: Liver ultrasound and, if necessary, contrast-enhanced CT or MRI, and evaluation of portal vein blood flow
  • Hepatitis B and C tests and viral serology tests
• Sample questions to show the doctor during an outpatient visit
  • What do my recent test results (imaging and AFP) mean?
  • Is my liver function at an appropriate level for surgery or treatment?

General Sample Questions to Ask the Doctor

• “What are my disease stage and liver function status (Child-Pugh, MELD)? How do they affect treatment choices?”
• “What curative treatment options (surgery/transplantation/local treatment) do you recommend, and what are the advantages, disadvantages, and recovery times of each?”
• “Is systemic treatment (immunotherapy or targeted therapy) appropriate for me? What effects can be expected, and what are the major side effects?”
• “How often should I have regular checkups, and which tests (AFP, ultrasound, etc.) should be performed?”

Examples of Disease-Specific Questions

• “Does my tumor meet the Milan criteria (a single tumor ≤5 cm or up to 3 tumors, each ≤3 cm)? Could you explain whether I am eligible for liver transplantation?”
• “Imaging shows signs of vascular (portal vein/hepatic vein) invasion. How does this affect the treatment plan (e.g., TACE or systemic therapy) or prognosis?”

(Note: High-risk groups for whom regular checkups are recommended include patients with chronic hepatitis B or C and patients with cirrhosis. In general, liver ultrasound and AFP testing are recommended every 6 months.)