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Page 10 of 16 Teschke. Hepatoma Res 2019;5:40 I http://dx.doi.org/10.20517/2394-5079.2019.0017

Figure 6. Macroscopic picture of alcoholic hepatocellular carcinoma

CLINICAL CHALLENGES OF AHHC
Characteristic clinical features
AHCC develops mostly in patients with existing AC that may be compensated or not, and the
degree of decompensation of AC will determine clinical symptoms superimposing those of AHCC.
Clinical symptoms of patients with AHCC have not systematically been investigated and published
recently [5-8,15,58,59] , but based on own clinical experience, patients with AHCC may have a silent clinical
course until decompensation of AC develops. Until that point, patients are either without symptoms or
report unspecific signs like fatigue, weakness, loss of appetite and weight, nausea and vomiting, and upper
abdominal pain.

Pathology
Histology
[2]
The histologic findings of all stages in ALD have comprehensively been outlined , with some specificities
regarding HCC and its variants [60-62] : the steatohepatic HCC variant is characterized by a steatotic
appearance of > 5% of the tumor, presence of Mallory bodies, fibrosis, inflammation and ballooning of
[60]
the hepatocytes as in steatohepatitis . The inflammatory infiltrate usually consists of neutrophils, plasma
cells, and lymphocytes. Microscopically, cells of classical HCC resemble normal liver cells, the similarity to
normal liver is most evident in well to moderately differentiated tumors, but liver cell plates change from 1
[62]
to 2 cell nuclei to 3 or more . In particular, AHCCs with a diameter of 1.5 to 2 cm are usually moderately
or well differentiated with a distinct nodular structure, a rate of microinvasion of between 10% and 22%,
[6]
with satellitosis in around 10% .

Gross pathology
Macroscopically, AHCC is commonly seen in a cirrhotic liver but around 10% of AHCC are found in
[59]
alcoholic patients without AC or liver fibrosis . AHCC nodules may present singular, or multiple as
illustrated by the liver of a patient with a long history of alcohol consumption [Figure 6]. The multiple
larger nodes of AHCC stretched multifocal over the liver that otherwise presents as typical AC with focal,
small regenerative cirrhotic nodules, mostly of the micronodular type, better seen in another picture
[15]
presenting only AC that shows light splitting in the areas of micronodular regenerating nodules [Figure 7] .
Risk factors
Smoking
[43]
Sufficient evidence supports the view that smoking strikingly increases the risk of AHCC , an important
[5]
issue stressed also in a recent review article .