Hepatocellular carcinoma (HCC) is cancer that develops in the liver. It's the most common type of primary liver cancer (cancer that starts in the liver, not spreads there from elsewhere). Most cases develop in people with cirrhosis or chronic liver disease from hepatitis B, hepatitis C, or alcohol use.

What Is Liver Cancer?

The liver is your body's largest internal organ. It filters blood, makes proteins, stores energy, and helps fight infection. When cancer starts in liver cells (hepatocytes), it's hepatocellular carcinoma.

Key fact: Most liver cancer develops on top of existing liver disease. If you have cirrhosis (scarring from chronic liver disease) or hepatitis, regular screening with ultrasound and blood tests (alpha-fetoprotein/AFP) is critical.

Risk Factors

Major risk factors for liver cancer:

  • Hepatitis B (HBV): One of the leading causes of liver cancer worldwide. Vaccination is available and prevents HBV.
  • Hepatitis C (HCV): Transmitted through blood exposure. Now curable with antiviral medications (sofosbuvir, etc.).
  • Cirrhosis: Scarring of the liver from any cause—alcohol, hepatitis, fatty liver disease, autoimmune disease.
  • Alcohol-related liver disease: Long-term heavy drinking damages the liver.
  • Non-alcoholic fatty liver disease (NAFLD): More common with obesity and diabetes.
  • Aflatoxin exposure: Toxin found in moldy grains (mainly in developing regions).

Symptoms & Screening

Early liver cancer often has no symptoms. This is why people with risk factors need screening.

Symptoms when present:

  • Right upper abdominal pain or swelling
  • Jaundice (yellowing of skin and eyes)
  • Unexplained weight loss
  • Loss of appetite
  • Fatigue
  • Abdominal fluid buildup (ascites)

Who should be screened: People with cirrhosis, hepatitis B (especially if Asian, African, or Pacific Islander), hepatitis C, alcohol-related liver disease, or NAFLD with advanced fibrosis.

Diagnosis

Diagnosis tools:

  • Ultrasound: Usually the first screening test.
  • CT or MRI: Creates detailed images to look for tumors.
  • Biopsy: Needle sample of liver tissue to confirm cancer.
  • AFP blood test: Elevated AFP is a tumor marker (though not always present in early HCC).

Staging

Liver cancer uses the Barcelona Clinic Liver Cancer (BCLC) system, which considers tumor size, liver function, and overall health:

  • Very early (0): Nodule <1cm, normal liver function.
  • Early (A): Single tumor <5cm OR up to 3 tumors <3cm, good liver function.
  • Intermediate (B): Larger or multiple tumors, good liver function.
  • Advanced (C): Tumor invasion or metastasis (spread).
  • Terminal (D): Poor liver function, multiple complications.

Treatment Options

Treatment depends on tumor size, location, liver function, and overall health.

Surgery (Hepatic Resection)

Removing the tumor and surrounding liver tissue. Only possible if you have enough healthy liver remaining. Often used for early-stage HCC.

Liver Transplantation

Removing the diseased liver and replacing it with a donor liver. Best for small tumors in cirrhotic livers (within Milan Criteria: single tumor <5cm OR up to 3 tumors <3cm). Offers potential cure and new liver.

Radiofrequency Ablation (RFA)

Using heat to destroy tumors. Good for small HCC in patients who can't have surgery. Minimally invasive.

Transarterial Chemoembolization (TACE)

Injecting chemotherapy directly into the blood vessels feeding the tumor, then blocking blood flow. Used for intermediate-stage HCC.

Targeted Therapy

  • Sorafenib (Nexavar): Blocks tumor growth. For advanced HCC.
  • Lenvatinib (Lenvima): Another targeted drug option for advanced HCC.
  • Regorafenib: Used if sorafenib stops working.

Immunotherapy & Combination Therapy

  • Atezolizumab + Bevacizumab: Combines an immune checkpoint inhibitor with an anti-angiogenesis drug. FDA-approved for advanced HCC.
  • Nivolumab: Another immunotherapy option.

Radiation Therapy

Targeted radiation for tumors. Can be used alone or with other treatments.

Side Effects & Management

Depends on treatment type. Most common:

  • From surgery: Pain, fatigue, risk of liver failure if too much liver removed.
  • From TACE: Nausea, abdominal pain, temporary liver enzyme elevation.
  • From targeted therapy: Hand-foot skin reaction (sorafenib/lenvatinib), diarrhea, fatigue, high blood pressure.
  • From immunotherapy: Immune-related side effects (see immunotherapy guides), but generally tolerable.

Prognosis & Follow-Up

Outcomes depend heavily on stage at diagnosis and liver function.

  • Early-stage HCC: After surgery or transplant, 5-year survival can be 50-70%.
  • Advanced HCC: With immunotherapy, median survival has improved to 15+ months.

Follow-up includes: Regular imaging (CT/MRI every 3-4 months), AFP monitoring, liver function tests, and screening for liver disease complications (bleeding, ascites).

Living with Liver Cancer

  • Treat underlying liver disease: If hepatitis C, get curative antivirals. If alcohol-related, abstain.
  • Liver health: Avoid alcohol, manage weight, control diabetes.
  • Nutrition: Liver disease and cancer treatment can affect appetite. Work with a dietitian.
  • Clinical trials: Ask about trials for newer immunotherapy combinations.

Seek Emergency Care If You Experience:

  • Sudden severe abdominal pain
  • Vomiting blood or black, tarry stools (signs of bleeding)
  • Severe confusion (hepatic encephalopathy)
  • Inability to urinate or dark urine (sign of acute kidney injury)

Key Questions for Your Doctor

  • What stage is my liver cancer?
  • How is my liver function (Child-Pugh score)?
  • Am I a candidate for transplant, resection, or ablation?
  • What is my expected survival with treatment X vs. Y?
  • Are there clinical trials available for my stage?
  • If immunotherapy is recommended, what side effects should I watch for?