Hepatocellular carcinoma (HCC) is the most common primary liver cancer in adults. Its treatment is different from that of other liver cancers because doctors have to manage two problems at the same time: the cancer itself and the condition of the liver in which it has developed.
Depending on the stage of HCC, the number and location of tumors, blood-vessel involvement, liver function and overall health, treatment may include surgery, liver transplantation, tumor ablation, transarterial procedures, radiation therapy, immunotherapy or targeted medicines. Understanding liver cancer treatment for HCC therefore requires looking at the whole clinical picture rather than choosing a treatment based on tumor size alone.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
Why Is HCC Treatment Different From Other Cancers?
HCC frequently develops in a liver that has already been affected by chronic disease, such as cirrhosis or long-standing hepatitis. This means that removing or treating the tumor is only part of the treatment decision.
A person may have a relatively small tumor but limited liver reserve, making major surgery unsafe. Another person may have a larger tumor but enough healthy liver tissue to make resection possible. Doctors therefore consider three broad areas:
- The cancer: Its size, number, location, growth pattern and whether it has invaded blood vessels or spread beyond the liver.
- The liver: The amount of functioning liver tissue, presence and severity of cirrhosis, portal hypertension and overall hepatic reserve.
- The person: General health, physical condition, other medical problems, previous treatments and ability to tolerate treatment.
How Is HCC Staged Before Treatment?
HCC treatment is guided by staging systems that consider more than the tumor itself. The Barcelona Clinic Liver Cancer (BCLC) system, for example, incorporates tumor characteristics, liver function, physical condition and cancer-related symptoms.
Doctors may use contrast-enhanced CT or MRI to determine the number and size of tumors, their relationship with major blood vessels and whether there are signs of spread. Blood tests and clinical assessment help determine how well the liver is functioning.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
These findings help establish whether the disease is potentially curable with a local treatment, treatable with a liver-directed procedure, or more appropriately managed with systemic therapy.
Early HCC: When Treatment Can Aim to Eliminate the Cancer
When HCC is detected at an early stage, treatment may be directed at completely removing or destroying the tumor. Depending on the patient's liver function and tumor characteristics, the main approaches include surgical resection, liver transplantation and ablation.
Surgical Resection
A liver resection, or partial hepatectomy, removes the portion of the liver containing the tumor while preserving enough healthy liver tissue to maintain adequate function.
Resection may be considered when the cancer can be completely removed and the remaining liver has sufficient functional reserve. It is particularly relevant in selected patients with localized HCC and well-preserved liver function.
The location of the tumor also matters. Before surgery, imaging is used to assess its relationship with blood vessels, bile ducts and other important structures and to estimate whether enough healthy liver will remain after the operation.
*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.
Liver Transplantation
Liver transplantation has a unique role in HCC because it can treat both the tumor and the underlying diseased liver. It may be considered for carefully selected patients whose HCC remains within accepted transplant criteria and who have significant underlying liver dysfunction that makes resection unsuitable.
Traditional transplant selection often refers to the Milan criteria, which include a single tumor smaller than 5 cm or up to three tumors, each smaller than 3 cm, without certain forms of spread. Modern transplant assessment can be more individualized, and some patients outside traditional criteria may be considered after successful downstaging within an appropriate transplant programme.
Tumor Ablation
Ablation destroys the tumor in place rather than removing it surgically. It can be particularly useful for selected small HCCs when surgery is not the preferred approach. Common techniques include:
- Radiofrequency ablation (RFA)
- Microwave ablation
- Cryoablation
The choice depends on tumor size, location and its relationship with blood vessels, bile ducts and nearby organs. Ablation is generally most effective for smaller tumors, while its ability to completely control larger tumors may decrease.
What If HCC Is Intermediate Stage?
Some patients have several tumors confined to the liver but are not suitable candidates for resection, transplantation or ablation. In selected patients with liver-limited disease and adequate liver function, treatment directed through the tumor's blood supply may be considered.
Transarterial Chemoembolization
Transarterial chemoembolization, commonly called TACE, delivers treatment through the arteries supplying the tumor and simultaneously reduces its blood supply.
A catheter is guided through the blood vessels to the arteries feeding the tumor. Embolizing material is then used to restrict blood flow, while an anticancer drug may be delivered locally as part of the procedure.
TACE can be repeated in selected patients, but it is not appropriate for everyone. Significant liver dysfunction, certain patterns of vascular involvement and other clinical factors may increase the risk of complications.
Transarterial Radioembolization
Another liver-directed approach is transarterial radioembolization, or TARE. Tiny radioactive particles are delivered through the hepatic artery toward the tumor, where they provide localized radiation.
TARE may be considered in selected patients when a liver-directed treatment is appropriate. The choice between TACE, TARE and other local treatments depends on tumor distribution, vascular anatomy, liver function and the treatment strategy being used.
Is Chemotherapy Used for HCC?
Traditional cytotoxic chemotherapy does not have the same role in HCC that it has in many other cancers. Current treatment strategies for advanced HCC rely much more heavily on immunotherapy-based regimens and targeted therapies.
This is an important distinction because the term “liver cancer” includes several different cancers. Treatment approaches used for cholangiocarcinoma, for example, should not automatically be applied to HCC.
What If the Tumor Can Be Reduced Before Definitive Treatment?
Not every tumor that initially appears unsuitable for surgery or transplantation remains unsuitable after treatment. In selected patients, treatment may be used to control or reduce the extent of HCC before another potentially definitive treatment is considered. This approach is known as downstaging.
For example, a liver-directed treatment may reduce tumor burden sufficiently for a patient to become eligible for transplantation under the criteria used by a particular transplant programme. Downstaging is highly individualized and depends on tumor biology, response to treatment, liver function and transplant criteria.
The Bottom Line
Treatment for hepatocellular carcinoma depends on two things that have to be considered together: the extent of the cancer and the condition of the liver. Early HCC may be treated with surgery, ablation or liver transplantation, with the choice depending on tumor characteristics and hepatic reserve.
When HCC is not suitable for these approaches, liver-directed treatments such as TACE or TARE may be considered in selected patients. More advanced disease may require systemic treatment, including immunotherapy-based combinations or targeted medicines. Radiation therapy also has a role in carefully selected situations.
Because HCC treatment can change as the disease responds or progresses, management is often a continuing process rather than a single procedure. A multidisciplinary evaluation helps determine whether the goal should be cure, long-term disease control, downstaging toward another treatment, or symptom and quality-of-life management.
