Reviewed by Dr. Chetan Kalal, Hepatologist and Liver Transplant Physician, Mumbai. Last updated: August 2026.
The short answer
Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. In the large majority of patients it does not appear in a healthy liver — it grows inside a liver already damaged by cirrhosis, hepatitis B, hepatitis C, or fatty liver disease. That single fact governs everything that follows: treatment has to deal with two diseases at once, the tumour and the failing liver underneath it.
Whether HCC is curable depends almost entirely on when it is found, not on how aggressive it looks. Found early, on a routine six-monthly scan in a patient known to have cirrhosis, it is often curable — by surgery, by ablation, or by liver transplant. Found late, when the patient first develops symptoms, the goal usually shifts from cure to control.
If you or a family member has just been told there is a mass in the liver, the most useful thing you can do in the next week is get the case in front of a hepatologist or a liver multidisciplinary team before any treatment is started. Sequence matters enormously in this disease, and the first decision often closes or opens the door to a cure.
Why liver cancer behaves differently from other cancers
In most cancers, the organ around the tumour is healthy. Surgeons can remove a generous margin and the organ recovers. The liver is different.
In HCC, the surrounding liver is usually cirrhotic — scarred, stiff, and working at reduced capacity. That creates two problems that shape every treatment decision:
- You cannot always remove the tumour safely. A cirrhotic liver may not have enough healthy reserve left to survive a large resection. A patient may have a technically removable tumour and still be inoperable, because the liver that remains would fail.
- The rest of the liver is also at risk. Cirrhosis is a field defect. Even after a tumour is perfectly removed, the remaining liver continues to generate new tumours. This is why recurrence rates after resection are high, and why transplant — which removes the whole diseased organ — occupies a unique place in liver cancer that it does not occupy in most other cancers.
This is also the reason a liver cancer diagnosis should be managed by a team that includes a hepatologist, not by tumour-directed treatment alone. Assessing how much liver function is left is as important as measuring the tumour.
Who is at risk, and who should be screened
HCC is not a random event. It has a well-defined at-risk population, which is what makes screening possible.
You are in the at-risk group if you have:
- Cirrhosis of any cause — alcohol-related, hepatitis B, hepatitis C, fatty liver disease (MASLD/MASH), autoimmune, or others
- Chronic hepatitis B infection, in whom liver cancer can develop even without cirrhosis — a pattern particularly relevant in India and much of Asia
- Advanced fibrosis from fatty liver disease, increasingly the fastest-growing risk group in Indian practice
- Prior hepatitis C that has been cured but had already caused cirrhosis — the risk falls after cure but does not fall to zero, and surveillance continues
What screening actually is: an ultrasound of the abdomen every six months, usually with a blood test for alpha-fetoprotein (AFP). It is not expensive, it is not invasive, and it is the single intervention that most reliably converts an incurable liver cancer into a curable one.
The uncomfortable reality in India is that most patients with HCC arrive at a specialist having never had a surveillance scan — often because nobody told them their fatty liver or their hepatitis B carried a cancer risk at all. If you have been told you have cirrhosis or chronic hepatitis B and you are not on a six-monthly scan, that is a gap worth closing this month.
How liver cancer is diagnosed
Liver cancer is one of the few solid tumours that can be confidently diagnosed without a biopsy. In a patient known to have cirrhosis, a lesion showing the characteristic blood-flow pattern on a multiphase CT or MRI — enhancing brightly in the arterial phase, then washing out in the later phases — is diagnostic of HCC in its own right.
This matters practically. It means the diagnostic pathway is:
- Ultrasound picks up a suspicious lesion
- Triple-phase CT or MRI of the liver characterises it — this is the decisive test, and a plain CT scan is not adequate
- Blood tests — liver function, clotting, AFP, viral markers
- Endoscopy to look for varices, because portal hypertension changes what treatment is safe
- Staging scans to check for spread outside the liver
Biopsy is reserved for cases where imaging is not conclusive, or where the liver is not cirrhotic and the diagnosis is genuinely in doubt. If you have been advised a biopsy before a proper multiphase scan has been done, ask why.
Staging: what the stage actually determines
Liver cancer is not staged the way most cancers are. The system used internationally — the Barcelona Clinic Liver Cancer (BCLC) system — combines three things: the tumour, the function of the liver, and how well the patient is functioning day to day. All three drive the treatment decision.
| Stage | What it means | Treatment usually considered |
|---|---|---|
| Very early (0) | A single small tumour, well-preserved liver function | Ablation or surgical resection — potentially curative |
| Early (A) | Single tumour, or up to three small tumours; good liver function; patient fully active | Resection, ablation, or liver transplant — potentially curative |
| Intermediate (B) | Multiple tumours confined to the liver, no vascular invasion or spread | TACE or TARE (treatment delivered through the artery feeding the tumour); some patients can be downstaged toward transplant |
| Advanced (C) | Tumour invading blood vessels, or spread outside the liver | Systemic therapy — modern immunotherapy-based combinations |
| Terminal (D) | Severely impaired liver function or very poor performance status | Best supportive care; transplant assessment in highly selected cases |
Two people with identical-looking scans can end up in different stages and receive completely different treatment, because one has a well-compensated liver and the other does not. This is why “what stage is it” cannot be answered by the radiology report alone.
Treatment options, explained plainly
Surgical resection
Removing the part of the liver containing the tumour. Excellent when the tumour is confined and the liver has enough reserve — but as above, cirrhosis and portal hypertension limit who is a safe candidate.
Ablation
Destroying a small tumour with heat delivered through a needle placed under imaging guidance (radiofrequency or microwave ablation). For small tumours this can be as effective as surgery, with far less physiological stress on a fragile liver.
TACE and TARE
Treatment delivered directly into the artery feeding the tumour — either chemotherapy with an embolic agent (TACE) or radioactive microspheres (TARE/radioembolisation). Mainstay for intermediate-stage disease, and frequently used to hold or shrink disease while a patient is being worked up for transplant.
Radiotherapy
Modern focused techniques such as SBRT have a defined role in selected patients, particularly where ablation is not technically possible.
Systemic therapy
For advanced disease, first-line treatment is now immunotherapy-based combination therapy rather than the older single-agent tablets. This has been a genuine advance in a disease where systemic options were poor for many years. Selection matters: some regimens require an endoscopy to check for varices before starting, because of bleeding risk in patients with portal hypertension — another reason hepatology input belongs in the room.
Liver transplant
Discussed in full below, because it is the option most often missed.
When is transplant the answer?
Transplant is the answer when the cancer is confined to the liver and within accepted size limits, and the liver itself is too diseased to survive any other treatment. It is the only treatment that addresses both problems at once: it removes the tumour, and it removes the cirrhotic liver that would otherwise keep producing new tumours.
That dual effect is why, in the right patient, transplant produces the best long-term outcomes of any HCC treatment — better than resection in cirrhotic patients with small tumours.
The size limits: Milan criteria
The internationally accepted starting point is the Milan criteria. A patient is generally considered within criteria if there is:
- A single tumour up to 5 cm, or
- Up to three tumours, each no larger than 3 cm, and
- No invasion of major blood vessels, and
- No spread outside the liver
Some centres also use modestly expanded criteria (such as the UCSF criteria) in selected patients, and tumour biology — including AFP level and how the tumour behaves over time — is increasingly weighted alongside raw size. A tumour that stays stable over months behaves differently from one that doubles, even at the same diameter.
Downstaging: being outside the criteria is not always the end
This is the point most patients are never told. A tumour burden that is currently too large for transplant can sometimes be brought back within criteria using TACE or TARE first, and the patient then transplanted. This is called downstaging, and in patients who respond and stay responding, outcomes can approach those of patients who were within criteria from the start.
If you have been told “the tumour is too big for transplant,” the correct follow-up question is: has downstaging been considered, and by whom?
Why the Indian situation is different — and why timing works differently here
In much of the West, transplant for HCC means joining a deceased-donor waiting list, where the wait itself can allow the tumour to progress beyond criteria. In India, the majority of liver transplants are performed using living donors — usually a family member donating part of their liver.
The practical consequence is significant: if a suitable and willing living donor is available and medically cleared, the timeline is driven by the workup rather than by a queue. For a cancer that grows on its own schedule, that is a real advantage — but only for patients who are referred while still within criteria.
When transplant is not the answer
Being honest about this matters as much as offering hope:
- Tumour invading the portal vein or hepatic veins
- Spread outside the liver — lymph nodes, lung, bone
- Tumour burden well beyond criteria that does not respond to downstaging
- Active uncontrolled infection, or cardiac and pulmonary disease making surgery unsafe
- Ongoing alcohol or substance use without a period of documented abstinence and support
Some of these are absolute; others are reversible with time and treatment. The distinction is critical, and it is covered in detail in the article on what disqualifies you from a liver transplant — absolute versus reversible contraindications.
For the broader question of transplant timing outside the cancer setting, see when a liver transplant becomes necessary and whether you are a good candidate for a liver transplant.
What to do in the first seven days after a liver cancer diagnosis
The period immediately after diagnosis is where avoidable mistakes happen — usually mistakes of sequence rather than mistakes of judgement.
- Do not start any treatment before the case has been reviewed by a liver multidisciplinary team. A treatment chosen in isolation can make a curative option impossible later.
- Get a proper triple-phase CT or MRI of the liver if one has not already been done. A plain scan is not sufficient to plan treatment.
- Get liver function fully assessed — not just an LFT, but bilirubin, INR, albumin, platelet count, and an assessment of portal hypertension.
- Ask explicitly whether transplant is on the table. If the answer is no, ask whether that is because of tumour extent, liver function, or fitness — and whether it could change with downstaging.
- Identify potential living donors early if transplant may be relevant. Donor workup takes time that a growing tumour does not always allow.
- Bring every scan, on disc, to the consultation. Reports are not enough; the images themselves need to be reviewed.
- Get a second opinion if the plan is unclear — this is a disease where the first plan determines the ceiling of what is achievable.
Prognosis: an honest answer
Outcomes in HCC vary more widely than in almost any other cancer, because they depend on tumour stage, liver function, and treatment access simultaneously. Patients treated at a very early stage with curative intent — resection, ablation, or transplant — can have excellent long-term survival. Patients presenting with advanced disease and decompensated cirrhosis have a substantially worse outlook.
I have deliberately not quoted survival percentages here. Published figures vary by population and treatment era, and a number lifted from a foreign cohort can be misleading when applied to an individual patient in India. The meaningful conversation is about your stage, your liver function, and your treatment options — not a population average.
Frequently asked questions
Is hepatocellular carcinoma curable?
Yes, when it is found early. Early-stage HCC treated with resection, ablation, or liver transplant can be cured. The main determinant is stage at diagnosis, which is why six-monthly surveillance in patients with cirrhosis or chronic hepatitis B is so important.
Can you get liver cancer without cirrhosis?
Yes. Chronic hepatitis B can cause hepatocellular carcinoma without cirrhosis, and this pattern is well recognised in India and across Asia. HCC arising in fatty liver disease without established cirrhosis is also increasingly reported. This is why hepatitis B carriers need surveillance regardless of whether they have cirrhosis.
Is a liver transplant possible if I already have liver cancer?
Yes, and in many patients with cirrhosis plus a small tumour it is the best available treatment. Eligibility depends on the number and size of tumours, absence of vascular invasion, absence of spread outside the liver, and overall fitness. The Milan criteria — one tumour up to 5 cm, or up to three tumours each up to 3 cm — are the usual starting point.
What if my tumour is too big for transplant?
It may still be possible after downstaging. Treatments such as TACE or TARE can reduce tumour burden back within transplant criteria, after which transplant becomes an option again. This requires assessment at a centre that performs both interventional treatment and transplantation.
Do I need a biopsy to confirm liver cancer?
Often not. In a patient with cirrhosis, a lesion with the typical arterial enhancement and washout pattern on triple-phase CT or MRI is diagnostic without biopsy. Biopsy is reserved for cases where imaging is inconclusive or the liver is not cirrhotic.
How often should someone with cirrhosis be screened for liver cancer?
An abdominal ultrasound every six months, usually together with an AFP blood test. Annual screening is not sufficient, because tumours can grow beyond curable size within a year.
Does a normal AFP level mean I do not have liver cancer?
No. A significant proportion of hepatocellular carcinomas do not raise AFP at all. AFP is useful as an additional marker and for tracking response, but it cannot be used alone to rule liver cancer in or out. Imaging is decisive.
Should I see an oncologist or a hepatologist for liver cancer?
Ideally both, in a multidisciplinary setting. Liver cancer treatment is limited as much by liver function as by tumour extent, and decisions about resection, ablation, arterial therapy, systemic therapy, and transplant need to be made together rather than sequentially by separate specialists.
Speak to a liver specialist
If you or a family member has been diagnosed with a liver mass, or has cirrhosis or hepatitis B and has never had a surveillance scan, a focused hepatology consultation is worth arranging early rather than late.
Dr. Chetan Kalal is a Hepatologist and Liver Transplant Physician in Mumbai, with clinical and academic focus on cirrhosis, acute-on-chronic liver failure, and liver transplantation. See how a liver cancer consultation works or request an appointment or read more about liver transplantation in India.
This article is for general information and does not replace individual medical advice. Treatment decisions in hepatocellular carcinoma must be made on an individual basis by a qualified liver specialist after reviewing your own imaging and liver function.