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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- HCC usually arises in cirrhosis, but chronic HBV can cause HCC without cirrhosis
- Surveillance: ultrasound with or without AFP every 6 months
- Diagnosis can be noninvasive in high-risk patients using multiphasic CT/MRI arterial enhancement and washout
- Curative options: resection, ablation, or liver transplant depending on tumor burden and liver function
- Decompensated cirrhosis with early HCC often favors transplant evaluation
Overview
HCC is the most common primary liver cancer and a major complication of cirrhosis. Tumor stage, liver function, portal hypertension, and performance status determine therapy.
Epidemiology
Major US risk factors are cirrhosis from HCV, HBV, alcohol, and MASLD/MASH. HBV-related HCC can occur without cirrhosis. Surveillance improves early detection and eligibility for curative therapy.
Clinical Features
Symptoms
Often asymptomatic on surveillance
RUQ pain, weight loss, early satiety
Decompensation: ascites, jaundice, variceal bleeding
Acute severe pain/hypotension from tumor rupture
Signs
Hepatomegaly or RUQ mass
Jaundice, ascites, cachexia
Signs of cirrhosis
Fever or bruit over liver rarely
Investigations
First-line
Surveillance ultrasound +/- AFPEvery 6 months in at-risk cirrhosis and selected HBV
Multiphasic CT or MRIArterial phase hyperenhancement with portal/delayed washout
Liver labs and MELDAssess hepatic reserve
Second-line
AFPMay support diagnosis/prognosis but normal AFP does not exclude HCC
Chest/abdomen imagingStaging for metastasis and vascular invasion
Specialist
HCC surveillanceUltrasound with or without AFP every 6 months when indicated
Transplant/hepatology evaluationAdvanced fibrosis, decompensation, or early HCC
Management
AASLD Practice Guidance on HCC 20231
Curative intent
- Resection for solitary tumors with preserved liver function and no significant portal hypertension
- Ablation for small tumors not suitable for resection
- Liver transplant for early-stage HCC within accepted criteria and decompensated cirrhosis
2
Locoregional/systemic
- TACE or radioembolization for selected intermediate-stage disease
- Systemic immunotherapy/targeted therapy for advanced disease
- Palliative care integrated for advanced unresectable disease
3
Prevention
- Treat HBV/HCV and manage cirrhosis
- Alcohol cessation and metabolic risk reduction
- Continue surveillance after HCV cure if cirrhosis remains
Complications
- Portal vein invasion: Advanced disease and poor prognosis.
- Rupture/hemoperitoneum: Sudden pain and shock.
- Decompensated cirrhosis: Limits treatment options.
- Metastasis: Lung, bone, lymph nodes.
USMLE Step 2 CK Exam Tips
- 1Cirrhosis + liver mass with arterial enhancement and venous washout = HCC
- 2AFP can be normal
- 3HBV can cause HCC without cirrhosis
- 4Surveillance is every 6 months
- 5Biopsy is not always needed with classic imaging in high-risk patients
- 6Transplant can treat tumor and cirrhosis
- 7New decompensation in cirrhosis should prompt HCC evaluation
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