Liver cancer
PRIMARY AND SECONDARY MALIGNANCY
Primary liver cancers include hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma and rare tumours. HCC is the commonest primary hepatic malignancy. Secondary (metastatic) deposits are more common overall than primary liver cancers and commonly arise from colorectal, pancreatic, gastric, breast and lung primaries.
RISK FACTORS AND PATHOGENESIS
HCC usually develops in chronic liver disease and cirrhosis due to HBV, HCV, alcohol-related liver disease, metabolic dysfunction-associated steatotic liver disease, haemochromatosis or other chronic injury. HBV can cause HCC without established cirrhosis. Repeated injury, inflammation, fibrosis and regenerative proliferation promote dysplasia and malignant transformation. Cholangiocarcinoma is associated with primary sclerosing cholangitis, choledochal cysts, hepatolithiasis and liver flukes in endemic regions.
CLINICAL FEATURES
Early HCC may be asymptomatic and detected during surveillance. Later features include right-upper-quadrant pain, weight loss, anorexia, hepatomegaly, abdominal mass, jaundice, ascites or deterioration in previously stable cirrhosis. Sudden pain and shock may indicate tumour rupture and intraperitoneal bleeding. Paraneoplastic features can include hypoglycaemia, erythrocytosis or hypercalcaemia. Cholangiocarcinoma may present with jaundice, pruritus, weight loss and cholestatic liver tests.
DIAGNOSIS AND STAGING
In at-risk patients, surveillance is generally ultrasound every six months, with or without AFP according to local guidance. A suspicious nodule is evaluated with multiphasic CT or MRI. In cirrhosis, arterial phase hyperenhancement with portal/delayed washout and other LI-RADS features may establish HCC non-invasively; biopsy is used when imaging is not diagnostic or the patient is outside a validated at-risk group. Assess liver reserve (Child–Pugh, MELD), portal hypertension, performance status and tumour burden. Stage with systems such as BCLC, integrating tumour extent, liver function and performance status. CT chest/abdomen/pelvis or other imaging assesses spread.
TREATMENT
Curative options for selected early HCC are surgical resection, liver transplantation or thermal ablation. Resection is most suitable with adequate liver reserve, limited tumour and no clinically significant portal hypertension. Transplantation treats both tumour and cirrhotic liver in carefully selected patients (e.g. within accepted transplant criteria). Ablation is useful for small lesions when surgery is unsuitable. Locoregional therapies include transarterial chemoembolisation (TACE) for selected intermediate-stage disease and radioembolisation in selected cases. Advanced disease may be treated with systemic immunotherapy-based combinations or tyrosine kinase inhibitors according to current oncology guidance, liver function and contraindications. Cholangiocarcinoma may be resected when localised; systemic therapy is used for unresectable/metastatic disease. Metastases are treated according to primary tumour biology; colorectal liver metastases may be resected or ablated in selected patients.