A 58-year-old man from rural India presents with a 3-month history of right upper quadrant pain and progressive abdominal distension. He has a 20-year history of hepatitis B (HBsAg positive) and drinks alcohol socially. On examination, he is icteric, has hepatomegaly with a hard, nodular surface, and ascites. Serum AFP is 1200 ng/mL (normal

Question

A 58-year-old man from rural India presents with a 3-month history of right upper quadrant pain and progressive abdominal distension. He has a 20-year history of hepatitis B (HBsAg positive) and drinks alcohol socially. On examination, he is icteric, has hepatomegaly with a hard, nodular surface, and ascites. Serum AFP is 1200 ng/mL (normal <20 ng/mL). Abdominal ultrasound shows a 4 cm heterogeneous mass in the right lobe with features suggestive of arterial hyperenhancement. What is the most likely diagnosis?

Accepted Answer

D. Hepatocellular carcinoma. ## Clinical Diagnosis: Hepatocellular Carcinoma

### Key Clinical Features

**Key Point:** The combination of cirrhotic liver disease (chronic HBV), markedly elevated AFP (>400 ng/mL is highly suggestive), and imaging findings of arterial hyperenhancement in a nodule >1 cm establishes HCC diagnosis without need for biopsy.

### Diagnostic Criteria (AASLD/EASL)

For nodules in cirrhotic livers:

| Nodule Size | Imaging Criteria for HCC Diagnosis |
|---|---|
| >2 cm | One imaging modality (CT/MRI/US) with arterial phase hyperenhancement (APHE) + washout |
| 1–2 cm | Two imaging modalities showing APHE + washout, OR one imaging modality + AFP >400 ng/mL |
| <1 cm | Surveillance; biopsy if high suspicion |

**Clinical Pearl:** In this patient, the 4 cm mass with APHE on ultrasound + AFP 1200 ng/mL + cirrhotic liver (HBsAg+) meets diagnostic criteria for HCC without biopsy.

### Risk Factors Present

1. **Chronic hepatitis B** — most common cause of HCC in Asia-Pacific region
2. **Cirrhosis** — evident from clinical signs (jaundice, ascites, hard nodular hepatomegaly)
3. **Age >50** — typical presentation age

### Pathophysiology

Chronic HBV infection → chronic inflammation → cirrhosis → dysplastic nodules → HCC. HBV integration into hepatocyte genome and HBx protein expression drive malignant transformation.

**High-Yield:** AFP >400 ng/mL in a cirrhotic patient with a nodule is diagnostic for HCC; biopsy is unnecessary and may seed tumor.

### Imaging Hallmark

**Arterial phase hyperenhancement (APHE)** followed by **venous/delayed phase washout** is the pathognomonic imaging signature of HCC — reflects tumor's arterial blood supply (from hepatic artery) rather than portal venous supply of normal liver parenchyma.

![Hepatocellular Carcinoma diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/3079.webp)

Answer

A. Focal nodular hyperplasia

Answer

B. Cholangiocarcinoma

Answer

C. Hepatic adenoma

Explanation

Clinical Diagnosis: Hepatocellular Carcinoma

Key Clinical Features

Diagnostic Criteria (AASLD/EASL)

Risk Factors Present

Pathophysiology

Imaging Hallmark

Practice similar questions

Join our NEET PG community

Nodule Size	Imaging Criteria for HCC Diagnosis
>2 cm	One imaging modality (CT/MRI/US) with arterial phase hyperenhancement (APHE) + washout
1–2 cm	Two imaging modalities showing APHE + washout, OR one imaging modality + AFP >400 ng/mL
<1 cm	Surveillance; biopsy if high suspicion