Liver Cancer

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Liver cancer at a glance

• Hepatocellular carcinoma (HCC) starts in the main working cells of the liver, called hepatocytes. It often develops in a liver affected by long-term inflammation (chronic hepatitis), severe scarring (cirrhosis) or fatty liver disease linked to conditions such as diabetes.
• Scans can sometimes confirm HCC without a biopsy, which means taking a small tissue sample for testing. Computed tomography (CT) and magnetic resonance imaging (MRI) produce detailed pictures. A multiphasic liver scan takes pictures at different times after an injection of contrast dye to look for the pattern typical of HCC.
• Stage describes how much cancer is present and where it is. It is only part of the treatment decision. The team also checks how well your liver is working, the pressure in the vein carrying blood to the liver, your overall health, whether surgery can remove the cancer, whether a transplant is possible and your goals.
• Early HCC may be curable. Options include surgery to remove the affected part of the liver (resection), replacing the liver with a donated liver (transplant), or destroying the tumour in place (ablation). Treatment with curative intent means treatment aimed at a cure.
• Liver-directed treatment targets cancer within the liver. It includes ablation, blocking the tumour’s blood supply (embolisation), delivering radiation through the liver’s arteries (radioembolisation), and focused radiation from outside the body.
• Systemic treatment uses medicines that travel through the body. Immunotherapy helps the immune system attack cancer; targeted drugs block signals that help cancer grow. The choice depends on liver function, bleeding risk, other illnesses, any previous transplant and your preferences.
• Follow-up matters even when treatment appears to have removed or destroyed all the cancer. HCC can return, or a new cancer can develop in the remaining liver.

Understand

What your liver does

The liver sits under the right ribs. It processes nutrients and medicines, removes waste from the blood, makes proteins that help blood clot, and produces bile to help digest fat. It can keep working despite damage for a long time, so both liver disease and cancer may cause no symptoms at first.

Why this changes cancer care

• Surgery must leave enough functioning liver behind.
• Embolisation or radiation can injure healthy liver as well as the tumour. The team carefully plans the amount of treatment and the area it reaches.
• Many medicines are processed by the liver; dosing and side effects may change as liver function changes.
• Cirrhosis can raise the pressure in the portal vein, which carries blood to the liver. This is called portal hypertension. It can cause a low platelet count (fewer blood cells that help clotting), fluid in the abdomen (ascites) and enlarged veins (varices) in the lower part of the food pipe (oesophagus) that may bleed.

Which type of liver cancer is this?

A mass in the liver is not automatically HCC. The place where a cancer started determines what it is and how it is treated.

Why the distinction changes care

• Scan findings and tumour markers, substances measured in blood that may help assess cancer, mean different things in HCC and bile duct cancer.
• The value of biopsy, molecular testing, surgery, transplantation and drug treatment depends on the exact diagnosis.
• If the diagnosis is uncertain, specialists can review the scans and tissue samples together before treatment is chosen.

Symptoms and warning signs

Early HCC often causes no symptoms. New, persistent or worsening symptoms should still be assessed, especially in someone with chronic liver disease.

Possible symptoms

• Dull pain, pressure or fullness under the right ribs; a new abdominal lump.
• Reduced appetite, unexplained weight loss, nausea or feeling full quickly.
• Tiredness, weakness, fever or a general decline without a clear cause.
• Jaundice, dark urine, pale stools or troublesome itching.
• Abdominal swelling from ascites or swelling of the feet and legs.

Symptoms may come from the tumour, cirrhosis, portal hypertension, infection or another condition. A normal-feeling day does not prove that the cancer is stable, and a bad day does not always mean that it has grown.

Risk factors

Usually there is no single answer. Risk factors increase probability; they do not prove cause, and HCC is not a patient's fault.

Lowering future risk

• Hepatitis B vaccination; testing and treatment for hepatitis B or C when indicated.
• Avoid alcohol when the liver is damaged; stop tobacco; work gradually on weight, diabetes and blood pressure.
• Some moulds on poorly stored grains and nuts produce harmful substances called aflatoxins, which can increase liver cancer risk. Keep these foods in a cool, dry place and throw away any that look mouldy, are discoloured or smell unusual.
• Attend the surveillance schedule recommended by the liver team.

Surveillance before cancer is diagnosed

Surveillance means regular checks to find HCC early in people at increased risk, even when they feel well. It is not a one-off 'liver cancer test' for everyone.

Who may need it

• Most adults with cirrhosis who could benefit from HCC treatment.
• Selected people with chronic hepatitis B even without cirrhosis, based on age, origin, family history, viral activity and other risk features.
• People previously treated for HCC, using a follow-up schedule rather than general surveillance.

What happens after an abnormal result

1. The team checks how clearly the liver was seen, the size of any abnormal area and whether it has changed, and the AFP blood results over time.
2. A new abnormal area may need repeat ultrasound or a multiphasic CT or MRI scan, depending on its size and the other findings.
3. An abnormal AFP or ultrasound is not itself a cancer diagnosis.

Tests and diagnosis

Your care team

HCC care works best when liver and cancer specialists review your results together. This is called a multidisciplinary team (MDT). A hepatobiliary team specialises in the liver, bile ducts and gallbladder.

How cancer is diagnosed

You are unlikely to need every possible test. The sequence below shows the common logic.

1. 1

   A nodule is found

   A nodule is a small lump or spot, often found on ultrasound or another scan.

2. 2

   Multiphasic CT or MRI

   Shows how the abnormal area takes up contrast dye and whether nearby blood vessels are involved.

3. 3

   Diagnosis is confirmed

   Imaging may be sufficient; some people need a tissue sample.

4. 4

   Treatment planning

   Combines cancer stage, how well the liver works (liver reserve), your overall health, the options available and your goals.

Four questions the team is answering

1. Is this HCC? A typical scan pattern may confirm it in a person at high risk. Otherwise, a biopsy may be needed.
2. Where is it? The team checks the number, size and location of tumours, nearby blood vessels and bile ducts, and any spread to lymph nodes or other organs.
3. How well is the liver working? Blood results, portal hypertension, ascites, encephalopathy and the amount of healthy liver all matter.
4. Which treatment is suitable? The team first considers whether a cure is possible, then discusses other ways to control cancer and symptoms in line with your goals.

Scans and staging tests

Blood tests and liver reserve

Blood tests help assess liver and kidney function, clotting and tumour markers. They help your team plan treatment safely, but cannot show the full cancer stage on their own.

How liver reserve is described (4 useful views)

Liver reserve means how well your liver can carry out its normal jobs. It matters alongside the cancer stage because it affects which treatments your liver can safely tolerate. Your team uses the following assessments to help plan your care.

1. Child–Pugh score. Combines three blood results (bilirubin, albumin and INR, a blood-clotting measure) with assessments of fluid in the abdomen (ascites) and changes in brain function caused by liver disease (hepatic encephalopathy).Use the Child–Pugh calculator↗
2. Albumin–bilirubin (ALBI) score. Uses the albumin and bilirubin blood results to assess liver function.Use the ALBI calculator↗
3. Model for End-stage Liver Disease (MELD) score. Uses blood test results to assess how severe liver disease is and helps guide priority for a liver transplant.
4. Portal hypertension. This means high pressure in the vein carrying blood to the liver. Your team assesses it using your medical history, platelet count, spleen size, scans, endoscopy (a camera test) and sometimes direct pressure measurements.

Biopsy and your pathology report

HCC can sometimes be diagnosed confidently on scans without a biopsy. If a biopsy is recommended, ask how the result could change your care, how bleeding risk is checked and when you will receive the result.

When imaging may be enough

In a person with cirrhosis or another recognised high-risk setting, a lesion with a characteristic multiphasic CT/MRI pattern may meet imaging criteria for HCC. Avoiding biopsy can reduce delay and procedure risk.

When tissue may add value

• Scans do not give a clear answer, or the person does not have the liver conditions in which scans alone can reliably diagnose HCC.
• Cholangiocarcinoma, combined HCC-cholangiocarcinoma, metastasis or another tumour is possible.
• A clinical trial or selected molecular testing requires tissue.
• The result would change the treatment plan.

After surgery, the pathology report describes the tumour and the removed tissue. Grade describes how abnormal the cells look. Vascular invasion means cancer is in blood vessels; margins are the edges of the removed tissue.

The report may also describe a capsule around the tumour or nearby small tumours (satellite nodules). These findings help estimate the chance of cancer returning, but do not automatically mean extra drug treatment is needed.

Planning your treatment

Five factors shape the treatment plan

For HCC, a stage label alone is never enough.

1. 1

   Tumour extent

   The number, size and location of tumours, growth into blood vessels, and spread to lymph nodes or other organs.

2. 2

   Liver reserve

   Child–Pugh or ALBI results, complications of liver disease and how much healthy liver would remain after treatment.

3. 3

   Overall fitness

   Ability to manage daily activities (performance status), strength, heart and kidney health, infection risk and nutrition.

4. 4

   Treatment feasibility

   What can be delivered safely now at an experienced centre, including donor and technology access.

5. 5

   Your priorities

   Chance of cure or control, side effects, travel, caregiving, work, fertility, time and cost.

Treatment options

Your treatment options at a glance

The first question is whether treatment can aim for a cure. Other goals include lasting cancer control, preserving liver function, helping you live longer and relieving symptoms. A treatment may have several aims.

Treatment routes can change

• Bridging therapy aims to keep HCC controlled while a patient waits for transplant.
• Downstaging aims to shrink the cancer enough to make transplant or another treatment aimed at cure possible.
• Conversion treatment may make a cancer that cannot currently be removed by surgery (unresectable) removable. This is possible for some people, but is not guaranteed.
• Supportive and palliative care helps with symptoms, emotional wellbeing and practical needs at every stage, including during treatment aimed at a cure.

How your treatment plan is chosen

Good decisions combine evidence with anatomy, liver reserve, feasibility and what matters to you.

Questions the team considers

1. Could a liver resection remove all visible HCC while leaving enough healthy liver?
2. Would transplant better treat both the cancer and the underlying liver disease?
3. Could ablation provide curative local control for a small, accessible tumour?
4. If cure is not currently feasible, which liver-directed or systemic treatment best preserves future options?
5. What supportive measures are needed now to protect function and quality of life?

A very small spot (under 1 cm) or an uncertain finding may be best checked with another scan after a short interval. Other findings need prompt treatment. Your team should explain the reason for either approach and when the next step will happen.

Liver resection

Resection removes the tumour-bearing part of the liver and can cure selected patients.

Who may be suitable

• All visible HCC can be removed, with no cancer at the cut edges (clear margins).
• Enough working liver with a good blood supply will remain. This is called the future liver remnant.
• Liver function is well preserved and portal hypertension is absent or acceptable.
• The patient is fit enough for a major operation.

The operation may remove a small wedge or one or more sections of liver. It may use a larger incision (open surgery) or smaller incisions with a camera (laparoscopic or robot-assisted surgery). The priority is safe, complete removal while preserving enough healthy liver.

Preparing the liver

If too little healthy liver would remain, a procedure called portal vein embolisation may help. It redirects blood flow to encourage the part that will remain to grow before surgery. Other specialist approaches may also be considered. Nutrition, exercise, diabetes control, smoking cessation and treatment of infection or hepatitis may also reduce risk.

Liver transplant

Transplant replaces the entire liver, so it can treat both HCC and the liver disease in carefully selected patients.

Selection is more than tumour size

• A widely used benchmark is the Milan criteria: one tumour up to 5 cm, or up to three tumours each up to 3 cm, without major vessel invasion or spread outside the liver.
• The team also considers AFP, how the cancer behaves and responds to treatment, your general health and ability to manage lifelong medicines and follow-up.
• Centres may use validated criteria beyond Milan. Meeting a size rule does not guarantee transplant; being outside it does not always end the discussion.

Bridging and downstaging

Ablation, embolisation with or without chemotherapy, radioembolisation or focused radiation may control the tumour while waiting. After downstaging, the team checks whether the cancer now meets transplant criteria and stays controlled over time.

After transplant, lifelong medicines reduce the risk of your immune system attacking the donated liver (rejection). Follow-up checks for rejection, infection, medicine side effects and returning cancer. Cancer immunotherapy before or after transplant can cause serious rejection and must be discussed with the transplant team before any dose.

Tumour ablation

Ablation destroys a tumour in place without removing a large part of the liver. It can be curative for selected small HCCs.

Microwave and radiofrequency ablation are the usual methods. Other techniques may suit selected situations.

How it is done

A needle or probe is guided into the tumour using scans. It may pass through the skin or be placed during surgery. The aim is to destroy the tumour and a small surrounding margin while protecting nearby organs, bile ducts and the diaphragm, the breathing muscle above the liver.

Choosing the type of ablation

Discuss the type of ablation with your doctor. The safest and most effective choice depends on several factors:

• Tumour size and number. Ablation often works best for a small number of tumours, usually around 3 cm or smaller.
• Safe access. The team needs to reach the tumour with a needle or probe and treat a small margin around it.
• Nearby structures. Tumours close to bile ducts, bowel or major blood vessels need careful planning to reduce injury. Blood flowing through large vessels can also carry heat away, making some heat treatments less effective.
• Liver function and local expertise. Your liver health, the treatments available and the team's experience also help guide the choice.

A follow-up scan using contrast checks whether any active cancer remains in the treated area. Repeat ablation or another treatment may be needed.

TACE, TAE and arterial treatment

HCC receives much of its blood from the hepatic artery, which carries blood to the liver. Specialists can use a thin tube called a catheter to deliver treatment through this artery. Transarterial embolisation (TAE) blocks the tumour’s blood supply; transarterial chemoembolisation (TACE) also delivers chemotherapy.

What the names mean

When it may be used

• Liver-limited HCC that is not suitable for resection or ablation, often in intermediate-stage disease.
• Bridging or downstaging before transplant.
• Selected combinations or sequences with radiation or systemic therapy.

Safety depends on blood flow to the liver, liver function, ascites, the amount of cancer and the healthy liver remaining. TACE is not repeated automatically. The team checks the scans and liver health to decide whether another session or a different treatment is best.

Radioembolisation and focused radiation

Radiation can be delivered from inside the liver artery or from a machine outside the body.

TARE / SIRT / Y-90 radioembolisation

Transarterial radioembolisation (TARE) is also called selective internal radiation therapy (SIRT). Tiny beads containing the radioactive substance yttrium-90 (Y-90) are delivered through a catheter into arteries feeding the tumour.

Before TARE, you usually have a separate planning procedure to map the liver’s blood vessels, followed by a scan using a small amount of radioactive tracer. This includes a lung-shunt assessment to estimate how much of the treatment could reach the lungs, helping the team decide whether TARE is suitable and plan the radiation dose.

• May control HCC confined to the liver, help while waiting for transplant, or shrink cancer to allow another treatment. Treating one small section of liver with a high radiation dose is called radiation segmentectomy.
• May suit some people whose cancer has grown into the portal vein, when treatments that block blood flow are unsuitable.
• Fatigue, abdominal discomfort and temporary liver-test changes are common; ulcers, gallbladder injury and radiation-induced liver disease are uncommon but serious.

External-beam radiotherapy

Stereotactic body radiotherapy (SBRT), also called stereotactic ablative radiotherapy (SABR), gives highly focused radiation over a few sessions. Other techniques shape radiation around the tumour; proton therapy uses a different type of radiation particle. The team may consider these for tumours in difficult locations, cancer in blood vessels, returning cancer or symptoms such as bone pain.

When systemic treatment is needed

Even when surgery cannot remove HCC or it has spread to other organs (metastatic cancer), medicines may help control it and relieve symptoms.

Systemic therapy is usually central when HCC has invaded major vessels, spread outside the liver, progressed despite appropriate local therapy, or is too extensive for safe liver-directed treatment.

Before choosing treatment

• Confirm HCC and map the current disease burden; obtain tissue if the diagnosis is uncertain or testing will change care.
• Assess Child–Pugh and ALBI results, ascites, encephalopathy, kidney function, blood pressure and ability to manage daily activities.
• Check hepatitis B and C; plan antiviral therapy or HBV reactivation prevention where indicated.
• Review bleeding and clotting risk, varices, recent surgery, autoimmune disease, prior organ transplant and all medicines/supplements.
• Discuss treatment goals, expected benefit, visits, side effects, fertility where relevant, access and cost.

Four checks before choosing the first treatment

First-line immunotherapy options

First-line means the first systemic treatment used for this cancer. For many people, this includes immune checkpoint inhibitors, medicines that release the immune system’s brakes so it can attack cancer. Liver function, bleeding risk, autoimmune disease and a previous transplant can change the choice.

First-line targeted tablets: lenvatinib and sorafenib

Lenvatinib and sorafenib are tyrosine kinase inhibitors (TKIs), targeted tablets that block signals involved in cancer growth and blood-vessel formation. Both are established treatments for HCC that cannot be removed by surgery. They are alternatives, and the choice should be individualised.

How the choice is made

• Liver reserve and current symptoms from cirrhosis or HCC.
• Blood-pressure, urine-protein, skin/foot, bowel, nutrition, cardiac and bleeding risks.
• Other medicines, planned procedures, ability to take tablets consistently and access to monitoring.
• Previous treatment, expected side-effect pattern and informed patient preference.

When treatment changes and when further tests help

Later-line treatment means treatment used after an earlier option stops working or causes unacceptable side effects. The choice depends on what you have already received, liver function, blood markers, side effects and your goals.

Options after earlier treatment

• Oral targeted drugs: cabozantinib; regorafenib after prior sorafenib that was tolerated; or an unused lenvatinib/sorafenib strategy in selected sequences.
• Ramucirumab: blocks vascular endothelial growth factor receptor 2 (VEGFR2), which helps new blood vessels form. It may suit selected patients with AFP of at least 400 nanograms per millilitre (ng/mL). The established treatment setting is after sorafenib; the team should explain the evidence for the proposed sequence after any other prior treatment.
• Checkpoint immunotherapy: an unused immunotherapy approach may be considered, but evidence for every sequence after modern combinations is incomplete.
• Local treatment: radiation, ablation or arterial therapy can still help a limited progressing site or a symptom while systemic disease is otherwise controlled.
• Clinical trials: especially valuable because the best sequence after first-line immunotherapy remains an evolving area.

Molecular testing

Molecular testing looks for changes in cancer genes or proteins that might guide treatment. Broad genetic testing is not needed for every typical HCC. It may help when the diagnosis is unusual, usual treatments have been tried, or a clinical trial is being considered.

Rare findings include gene fusions, where parts of two genes join together, involving genes called NTRK or RET. Tests may also find high microsatellite instability (MSI-high) or deficient mismatch repair, signs that cancer cells cannot repair certain genetic errors normally. Your team should explain whether a result opens a suitable treatment option. A negative result does not remove the usual HCC treatments.

Managing side effects

Managing treatment side effects

Cirrhosis, cancer and treatment can cause similar symptoms. Tell your team about changes from how you usually feel; do not wait for them to become severe.

Live well

Protecting the liver during cancer treatment

The remaining liver is part of the treatment plan every day.

• Avoid alcohol. There is no safe 'detox' drink for a damaged liver, and alcohol can worsen cirrhosis, dehydration and drug toxicity.
• Review every medicine. Include prescriptions, painkillers, over-the-counter tablets, vitamins, gym products, Ayurvedic/herbal remedies and supplements. 'Natural' does not mean liver-safe.
• Treat hepatitis. Hepatitis B medicines may be needed to treat infection or prevent it becoming active again during cancer care. The liver and cancer teams should also agree when to treat hepatitis C.
• Use painkillers safely. Ask the liver team which medicine and dose are safe for you. Paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can cause harm in the wrong situation.
• Prevent infection. Ask about hepatitis A/B, influenza, COVID-19 and pneumococcal vaccination according to your history and treatment. Avoid raw or undercooked shellfish and follow food hygiene.
• Protect kidneys and circulation. Report vomiting, diarrhoea, low urine, dizziness or sudden weight change. Medicines that remove extra fluid (diuretics) and blood-pressure medicines may need adjustment by your team.

When to seek urgent help

Use the 24-hour number provided by your treating centre. If you cannot reach the team and the problem is severe, go to the nearest emergency department or call local emergency services.

Supportive and palliative care

Supportive care treats the person, not just the tumour. It can run alongside surgery, transplant planning, liver-directed therapy or systemic treatment at any stage.

Nutrition, muscle and activity

Cirrhosis and HCC can cause loss of muscle even when body weight looks stable because fluid hides weight loss.

Practical nutrition

• Aim for small, frequent meals with enough energy and protein; a late-evening snack may help some people with cirrhosis avoid a long overnight fast.
• Do not restrict protein routinely. Encephalopathy needs medical treatment and individual nutrition advice; severe protein restriction can worsen muscle loss.
• If ascites is present, the team may advise limiting sodium, the main component of salt. Do not restrict fluid unless specifically told to, usually because blood sodium is low.
• Choose safe, familiar foods that you can tolerate. Avoid raw shellfish, unpasteurised products and poorly stored/mouldy grains or nuts.
• Ask before using high-dose vitamins, protein powders or herbal products; some interact with treatment or damage the liver.

Movement

• Short walks, sit-to-stand practice and light resistance work help preserve muscle and independence when safe.
• Build activity gradually. Stop if you feel unwell. Chest pain, new breathlessness, fainting or bleeding needs urgent assessment.
• After surgery, ablation or arterial treatment, follow restrictions on lifting, bathing, driving and wound care.

Follow-up, response and recurrence

Follow-up is planned to detect recurrence, protect liver function, manage late effects and decide whether treatment needs to change.

After curative-intent resection or ablation

Follow-up commonly includes imaging and AFP blood tests every 3–6 months after treatment. Some centres also measure PIVKA-II if it was useful before treatment. Your team will explain the scan type, timing and longer-term schedule based on recurrence risk, kidney and liver health, and any transplant plans. Ongoing follow-up remains important even when scans show no cancer.

During systemic or liver-directed treatment

Scans and blood tests are repeated at intervals suited to your treatment. The team checks tumour size and how it takes up contrast dye, which can help show whether cancer remains active. Effective treatment may reduce contrast uptake before the tumour shrinks. AFP or PIVKA-II trends help only if that marker was useful before treatment.

If cancer returns

• A recurrence may be a new HCC in the at-risk liver or spread from the original tumour; in practice the distinction is not always possible.
• Resection, transplant, ablation, arterial therapy, radiation or systemic treatment may again be considered using the same five decision factors.
• A limited recurrence may still be treated with curative intent. Wider recurrence is treated to control disease and symptoms.

Emotions, family, work and access

There is no correct way to feel. Shock, fear, anger, sadness, relief and uncertainty can sit together or change from day to day.

Related care

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Meet our doctors

Dr (Prof) Vijay Agarwal

Professor and Lead Consultant – Medical Oncology

Dr Prathyush V

Senior Consultant – Medical Oncology & Haemato-Oncology

Dr Darshan R S

Consultant – Medical Oncology & Haemato-Oncology

Where to get care

Bannerghatta Road

Apollo Hospitals
Bengaluru

Seshadripuram

Apollo Hospitals
Bengaluru

Sarjapur

Apollo Hospitals
Bengaluru

Jayanagar

Apollo Speciality Hospital
Bengaluru