Treatment for hepatocellular carcinoma (HCC), the most common primary liver cancer, depends on both where the cancer is and how well the liver is working. Early HCC may be treated with surgery, ablation, or liver transplantation. When tumours are confined to the liver but these options are unsuitable, treatment delivered through the liver’s arteries may help. If the cancer has invaded major blood vessels, spread beyond the liver, or is unsuitable for liver-directed treatment, immunotherapy or targeted medicines may be considered. [1–3]
By Dr Raman Narang, Consultant Medical & Hemato-Oncologist, New Delhi
Two people can have a liver tumour of the same size and receive different treatment recommendations. If the surrounding liver is healthy, removing part of it may be feasible. If the liver is scarred and functioning poorly, ablation or transplant assessment may be more appropriate. If you are seeking liver cancer treatment in Delhi, ask your team to explain the cancer stage and the condition of the liver separately. Both can change the first treatment.
1. What are the symptoms, risk factors, and types of liver cancer?
Early HCC often causes few symptoms and may be found during surveillance for chronic liver disease. Possible symptoms include persistent pain or fullness under the right ribs, loss of appetite, unexplained weight loss, jaundice, or increasing abdominal swelling. In someone with cirrhosis, new or worsening swelling, jaundice, or confusion can also reflect a decline in liver function. Vomiting blood, passing black tarry stools, or developing new confusion requires emergency assessment. [1, 2]
| Finding | What it means |
|---|---|
| Hepatocellular carcinoma (HCC) | Cancer that starts in the main cells of the liver. This page focuses on HCC. |
| Intrahepatic cholangiocarcinoma | Cancer that starts in the bile ducts inside the liver. Its biopsy, surgery, and drug treatment follow a different pathway. |
| Liver metastases | Cancer that started in another organ, such as the colon or breast, and spread to the liver. Treatment is guided by the original cancer type. |
| Benign liver lesion | A finding such as a cyst or haemangioma. Its imaging features help determine whether it needs further investigation. |
Cirrhosis is a major risk factor for HCC. Causes include chronic hepatitis B or C, alcohol-related liver disease, and metabolic dysfunction-associated steatotic liver disease, often called fatty liver disease. Some people with chronic hepatitis B are at increased risk even without cirrhosis. Eligible patients with cirrhosis or higher-risk hepatitis B are generally offered surveillance about every six months, usually with ultrasound, with or without an AFP blood test depending on the guideline and individual circumstances. [1, 2]
2. How is liver cancer diagnosed, and when is a biopsy needed?
A multiphasic contrast CT or MRI using a liver protocol shows how the lesion takes up and releases contrast at different times. In people at defined high risk, such as many patients with cirrhosis, a characteristic pattern can establish an HCC diagnosis without a biopsy. If the scan is atypical, the person falls outside the group in which imaging can establish the diagnosis, or another cancer is suspected, a biopsy may be needed. [1, 2]
Alpha-fetoprotein (AFP) is a blood marker that can support assessment and help track response in some patients. AFP can be normal in HCC and elevated for other reasons. The team interprets it alongside imaging and, when needed, pathology. [1, 2]
Staging looks at the number, size, and location of tumours, whether they have grown into major blood vessels, and whether cancer has spread outside the liver. The team also checks bilirubin, albumin, clotting tests, and signs of portal hypertension, meaning raised pressure in the vessels that carry blood to the liver. A history of abdominal fluid build-up or episodes of confusion can also affect treatment safety. The Barcelona Clinic Liver Cancer (BCLC) system brings together tumour extent, liver function, and the patient’s ability to manage daily activities. [1–3]
3. How is early-stage liver cancer treated?
For early HCC, the main options with the aim of cure are liver resection, thermal ablation, and liver transplantation. Which option fits depends on the size and position of the tumour, the amount of healthy liver that would remain, and whether the person is eligible for a transplant. [1–3]
| Treatment | When it may be considered |
|---|---|
| Liver resection | Surgery removes the part of the liver containing the tumour. It may be suitable when the cancer can be removed completely and enough functioning liver will remain. In someone with cirrhosis, the degree of portal hypertension also matters. |
| Thermal ablation | A needle delivers heat to destroy the tumour. Radiofrequency or microwave ablation can be used with the aim of cure for selected small tumours, often up to about 3 cm. The location must allow treatment without undue risk to nearby structures. |
| Liver transplantation | Removes the cancer and replaces the diseased liver. It may be an option for selected patients who meet transplant criteria, particularly when cirrhosis or portal hypertension makes resection less suitable. |
If transplant is being considered, the team may recommend a bridging treatment to control the tumour while the patient waits. In selected cases, liver-directed treatment can also help downstage tumours so the patient can be reassessed against transplant criteria. Ask early whether transplant assessment is relevant, as it can affect the treatment sequence. [1–3]
4. What if the cancer is confined to the liver but surgery is unsuitable?
Some people have several tumours within the liver without major blood vessel invasion or distant spread. If liver function is adequate, transarterial chemoembolisation (TACE) may be an option. A specialist delivers chemotherapy through a catheter into arteries supplying the tumour and reduces blood flow to it. Transarterial radioembolisation (TARE), often called Y-90 treatment, uses tiny radioactive particles delivered through the same arterial route. Focused external radiation may also be considered in selected cases. [1–3]
The decision depends on how much of the liver is involved, where the tumours sit, how blood is flowing through the liver, and whether there is enough liver reserve to tolerate treatment. After a procedure, the team reviews both the scan response and liver function before deciding whether another procedure is worthwhile. If liver-directed treatment is unlikely to help or the cancer progresses despite it, systemic treatment may be more appropriate. [1–3]
5. How is advanced or metastatic liver cancer treated?
Advanced HCC can involve major blood vessels even when scans show no spread outside the liver. When systemic treatment is appropriate and liver function is sufficiently preserved, first-line options can include atezolizumab plus bevacizumab or durvalumab plus tremelimumab. If immunotherapy is unsuitable, targeted tablets such as lenvatinibor sorafenib may be considered in selected patients. The choice depends on liver function, bleeding risk, other medical conditions, prior treatment, and the applicable Indian prescribing indication and access. [1–3]
Bleeding risk is particularly important before bevacizumab. Cirrhosis can cause enlarged veins in the oesophagus or stomach, called varices. The team may arrange an upper GI endoscopy and treat high-risk varices before starting a bevacizumab-containing regimen. A history of an organ transplant or certain autoimmune conditions can also affect whether immunotherapy is suitable. [1, 2]
Care for the liver continues alongside cancer treatment. It can include treatment for hepatitis B, management of fluid build-up or pain, and nutrition support. When liver function is severely impaired, the team assesses whether transplant is feasible and whether cancer-directed treatment is likely to help. [1–3]
What I look for clinically before recommending treatment
I review the original CT or MRI alongside the liver tests. I want to know whether the scan establishes HCC, whether major blood vessels are involved, and how much functioning liver can be preserved. I also ask about previous bleeding, abdominal fluid build-up, or confusion, as these may change which treatment is safe. If several options are reasonable, I discuss the case with the liver surgeon, hepatologist, interventional radiologist, and transplant team as appropriate.
How the next step is decided
| If the reports show… | The next discussion is about… |
|---|---|
| An indeterminate liver lesion | Whether a dedicated liver MRI, follow-up imaging, or a biopsy would clarify the diagnosis |
| A small HCC with preserved liver function | Whether resection or ablation offers the better chance of complete treatment |
| Early HCC with cirrhosis or significant portal hypertension | Transplant eligibility, ablation, and whether bridging treatment is needed |
| Several tumours confined to the liver | Whether TACE, Y-90, or systemic treatment fits the distribution of disease and liver reserve |
| Major blood vessel invasion or spread outside the liver | Systemic treatment, liver function, and bleeding risk |
What to bring to a liver cancer consultation in Delhi
- Ultrasound, liver-protocol CT or MRI, and staging scan reports with the original images.
- Biopsy and pathology reports, if a biopsy was performed.
- Recent bilirubin, albumin, INR, creatinine, blood count, and dated AFP results.
- Hepatitis B and C test results and details of any antiviral treatment.
- Endoscopy reports and records of varices, bleeding, abdominal fluid drainage, or hospital admissions for liver disease.
- Details of previous surgery, ablation, TACE, Y-90, radiation, or systemic treatment.
Frequently asked questions
Does a high AFP confirm liver cancer?
AFP alone cannot confirm HCC. The team looks at dedicated liver imaging, your underlying liver condition, and sometimes a biopsy. [1, 2]
Can liver cancer be treated without an operation?
Yes. Ablation can treat selected small tumours with the aim of cure. TACE, Y-90, focused radiation, or systemic treatment may be appropriate in other settings. [1–3]
Does everyone with cirrhosis and liver cancer need a transplant?
Transplant is one option for eligible patients. Tumour size and number, liver function, other medical conditions, and transplant criteria guide the decision. Some patients can be treated with resection or ablation. [1–3]
Is cancer that has spread to the liver treated like HCC?
A liver metastasis is treated according to the cancer it came from. For example, a colon cancer metastasis in the liver follows the colorectal cancer treatment pathway, with liver surgery or ablation considered in selected cases. [1, 2]
Before treatment, ask your team to write down the exact diagnosis, your liver function assessment, and the aim of the proposed treatment. If more than one option is feasible, ask how each could affect your liver function and when the team will review the response.
This page is for general education. Individual treatment decisions require review of your imaging, liver function, pathology when available, and overall health by your treating team.
Clinical references
- European Society for Medical Oncology. Hepatocellular Carcinoma: ESMO Clinical Practice Guideline for Diagnosis, Treatment and Follow-up. 2025.
- European Society for Medical Oncology. Pan-Asian Adapted ESMO Clinical Practice Guidelines for the Diagnosis, Treatment, and Follow-up of Patients With Hepatocellular Carcinoma.
- Barcelona Clinic Liver Cancer Group. BCLC Strategy for Prognosis Prediction and Treatment Recommendations: The 2026 Update. Journal of Hepatology.