Dr Sanjay Kumar Yadav

Health TV Online : The liver, the body’s largest internal organ, makes up about 2% of body weight (1-1.5 kg in adults) and performs over 500 functions, earning it the nickname “Factory of the Human Body.” It can regenerate in healthy people within 6 to 8 weeks, but damaged livers often cannot. October is Liver Cancer Awareness Month, focusing on hepatocellular carcinoma (HCC), promoting early detection, prevention, and education.

October is Liver Cancer Awareness Month: Key Awareness Message

-Know your risk factors for liver cancer

-Early detection can make liver cancer curable.

-Get screened if you have hepatitis, cirrhosis, diabetes, or fatty liver.

-Get vaccinated for hepatitis B and treatment for hepatitis B and C

-Regular check-ups and healthy living protect your liver and your life.

Hepatocellular Carcinoma (HCC) is the most common liver cancer. It is a significant global health concern, with projections indicating an incidence exceeding one million cases by 2025. HCC is the predominant form of primary liver cancer and accounts for approximately 800,000 deaths annually worldwide. It ranks as the fifth most frequently diagnosed cancer and the fourth leading cause of cancer-related mortality. Incidence rates of HCC demonstrate considerable regional variation, with the highest prevalence observed in Asia and Africa. More than 80% of new cases are concentrated in developing countries, particularly Sub-Saharan Africa and East Asia, largely attributable to the elevated HBV infection. Notably, the incidence of HCC is also rising in Western countries, where non-alcoholic fatty liver disease (NAFLD) represents the principal risk factor. Epidemiological data further indicate that HCC occurs two to three times more frequently in males compared to females.

Risk Factors for Hepatocellular Carcinoma (HCC)

HCC usually develops in the setting of chronic liver disease and cirrhosis. Around 80–90% of HCC cases occur in the setting of cirrhosis, regardless of cause. One third of cirrhosis patients (33% of all cirrhosis patients) will develop HCC during their lifetime, with an annual risk of 1% to 8% depending on the etiology of liver cirrhosis. Sometimes HCC can develop in chronic hepatitis B infection without liver cirrhosis. In addition to cirrhosis, the risk of developing HCC in chronic hepatitis B infection is related to high viral load, active viral replication, genotype C, and the presence of liver dysfunction. HCC can develop in chronic hepatitis B viral infection in the absence of cirrhosis in 20-30% cases. The major risk factors for HCC are as follows:

-Chronic hepatitis B and C infection

-Chronic alcohol consumption

-Fatty Liver Disease

-Non-Alcoholic Steatohepatitis

-Obesity and Diabetes Mellitus

-Aflatoxin Exposure- contaminated grains and nuts by Aspergillus flavus

-Cigarette smoking

Prevention of HCC

HCC is mostly preventable since it usually results from liver diseases that can be identified and managed. Prevention aims to lower liver injury and cirrhosis rates, while screening allows for early detection and treatment. Some evidence suggests coffee consumption may reduce HCC risk.

1.Preventing Liver Injury and Cirrhosis

a. Prevent and Treat Viral Hepatitis

–Hepatitis B vaccination:

-Highly effective  up to 95% protection.

-Universal vaccination at birth dramatically reduces HCC incidence.

HBV and HCV screening and treatment:

-Antiviral therapy (e.g., tenofovir or entecavir for HBV; direct-acting antivirals for HCV)

-Reduces risk of cirrhosis and HCC by 70–80%.

Safe practices:

-Avoid unsterile injections, unsafe blood transfusions, and unprotected sex.

b. It is recommended to abstain from alcohol consumption. Alcohol is classified as a carcinogen and has been linked to liver cancer, as well as other cancers such as colorectal, oral, and esophageal cancers. There is no established safe threshold for alcohol intake; even small amounts may increase cancer risk.

c. Manage Metabolic Risk Factors

-Control obesity, diabetes, and dyslipidemia.

-A healthy diet and regular exercise reduce fatty liver progression.

-In NASH patients, weight loss ≥10% can reduce fibrosis and HCC risk.

d. Preventing exposure to Aflatoxins can be achieved through proper food storage and drying of grains and nuts.

f. Avoid Other Toxins

-Limit anabolic steroid or arsenic exposure.

-Stop smoking.

2.Early Detection and Monitoring:

The purpose of screening for cancer is to reduce mortality through detection at an early stage, which can be treated with curative modalities. All patients with Liver Cirrhosis or chronic hepatitis B & C infection must undergo regular screening with USG abdomen and AFP every 6 months, which helps in early detection and treatment of HCC.  USG is the screening modality of choice because of cost effective and easy availability, and safe imaging modality. Similarly, there are highly effective medical treatments for chronic hepatitis B and C infection.

Signs and Symptoms of Liver Cancer

HCC presents clinically across a spectrum, from an asymptomatic stage—often detected through screening—to more pronounced manifestations. Early liver cancer is frequently without obvious signs or symptoms, highlighting the necessity of regular HCC surveillance for individuals at increased risk, such as those with cirrhosis. In advanced disease, patients may experience symptoms related to underlying cirrhosis (ascites, jaundice, upper gastrointestinal bleeding, hepatic encephalopathy) or those directly caused by tumor growth, including abdominal pain, unintentional weight loss, reduced appetite, and palpable abdominal masses.

Diagnosis-

USG and AFP, PIVKA II are standard initial tests for HCC. If a liver mass is detected on USG, further evaluation is done with CT Triphasic Abdomen or MRI Dynamic Liver. Nuclear scans such as PET assess extrahepatic spread and staging. Unlike many cancers, a liver biopsy is usually unnecessary for HCC.

Management of HCC:

The management of HCC is complex and typically involves a multidisciplinary team approach. The management of HCC depends on the stage of Liver cirrhosis and the stage of HCC. The management includes resection, transplantation, ablation, TACE, and TARE, and targeted chemotherapy and immunotherapy.

(Dr Yadav is Consultant HPB & Liver Transplant Surgeon at Narayana Superspeciality Hospital)