OncologyTier 2Disease (DEADMAN)

Malignancies - liver malignancy

Description

Hepatocellular carcinoma (HCC) - the primary liver malignancy of clinical importance, arising almost exclusively in a cirrhotic or chronically diseased liver; the liver is also a very common site of metastatic disease given its dual blood supply and filtering role

HCC is one of the most common cancers worldwide (driven by chronic viral hepatitis prevalence globally); liver metastases are far more common than primary liver cancer overall, most frequently from colorectal, pancreatic, gastric, breast, and lung primaries

Chronic liver injury -> cirrhosis -> regenerative nodules -> dysplastic nodules -> HCC - a multistep carcinogenic sequence driven by chronic inflammation and hepatocyte turnover
Major risk factors: chronic hepatitis B (can cause HCC even without cirrhosis, via direct viral oncogenic integration), chronic hepatitis C, alcohol-related cirrhosis, non-alcoholic fatty liver disease/MASLD (an increasingly dominant driver), aflatoxin exposure (in endemic regions, synergistic with hepatitis B)

Surveillance in known cirrhosis: 6-monthly liver ultrasound +/- AFP - the standard approach for early detection in at-risk patients
Diagnosis in cirrhosis often does not require biopsy - characteristic multiphase CT/MRI imaging findings (arterial enhancement with venous/delayed washout) are diagnostic on their own in a cirrhotic liver, given the bleeding/seeding risk of biopsy
AFP supports diagnosis when elevated but is neither sensitive nor specific enough to use alone
Liver metastases - biopsy for tissue diagnosis/origin when the primary is not already known; imaging characteristically shows multiple lesions (vs HCC's typical single or few lesions in a cirrhotic background)

HCC: curative options (resection, liver transplantation, ablation) for early-stage disease in appropriately selected patients (transplantation additionally treats the underlying cirrhosis); transarterial chemoembolisation (TACE) for intermediate-stage unresectable disease; systemic therapy (tyrosine kinase inhibitors, immunotherapy combinations) for advanced disease
Liver metastases: management follows the primary cancer; selected patients (e.g. oligometastatic colorectal liver metastases) may be candidates for surgical resection or ablation with curative intent
Hepatitis B/C treatment and cirrhosis management remain important regardless of cancer stage, given ongoing liver-related morbidity

Cirrhosis (any cause), chronic hepatitis B/C, MASLD, alcohol-related liver disease, colorectal cancer (most common source of liver metastases)

Prognosis in HCC is determined as much by the degree of underlying liver dysfunction (Child-Pugh class) as by tumour stage - a patient with early-stage HCC but decompensated cirrhosis may have worse prognosis than one with more advanced tumour and preserved liver function
Liver metastases from colorectal cancer carry a much better prognosis with resection than liver metastases from most other primaries, given the biology of colorectal disease and the availability of effective systemic therapy

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