Liver Cancer (Hepatocellular Carcinoma)
Liver cancer is, for the most part, a complication of long-standing liver disease. That makes it different from most other cancers: we are treating the tumour and the underlying liver at the same time. The good news — many of the people most at risk are already known, and surveillance picks up early, treatable tumours.
What hepatocellular carcinoma is — in plain words
Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver — meaning cancer that starts in the liver, not cancer that has spread to it from somewhere else. Almost all HCC develops in a liver damaged by long-standing inflammation. In Pakistan, the leading causes are chronic hepatitis C, chronic hepatitis B and, increasingly, fatty liver disease related to diabetes and obesity. Alcohol and aflatoxin exposure contribute too.
Signs and symptoms to take seriously
Early HCC usually causes no symptoms at all — which is exactly why surveillance of high-risk patients matters so much. When symptoms appear, they may include:
Right-sided abdominal pain
A dull ache or fullness in the upper-right abdomen.
Weight loss and fatigue
Unintentional weight loss, loss of appetite, and a tiredness that doesn't lift.
Jaundice
Yellowing of the eyes or skin, dark urine, pale stools.
Worsening cirrhosis
Increasing abdominal swelling, leg swelling, confusion, or new bleeding — any of these in someone with known liver disease warrants prompt imaging.
"If you have chronic hepatitis or cirrhosis, the most important six-monthly appointment of your year is your liver ultrasound. Most early HCCs we cure today were found on a routine surveillance scan."
How liver cancer is diagnosed
- Ultrasound — the screening tool for high-risk patients. A new nodule prompts further imaging.
- Multi-phase CT or MRI of the liver — HCC has a characteristic blood-flow pattern (arterial enhancement with washout) that often allows diagnosis without biopsy.
- Alpha-fetoprotein (AFP) — a blood marker that is elevated in many but not all HCCs.
- Biopsy — used when imaging is uncertain. Often unnecessary if the imaging features are typical.
- Assessment of liver function — Child-Pugh score and MELD score tell us how well the underlying liver is working, which determines what treatment is safe.
How we stage HCC
HCC staging considers three things together: the tumour (size, number, vascular invasion), the liver's reserve (Child-Pugh A, B or C), and the patient's performance status. The most widely used system is the Barcelona Clinic Liver Cancer (BCLC) staging.
Very early / early (BCLC 0–A)
A single small tumour, well-preserved liver. Potentially curable with ablation, resection or transplant.
Intermediate (BCLC B)
Multiple tumours confined to the liver, still good liver function. Treated with locoregional therapy such as TACE.
Advanced (BCLC C)
Vascular invasion or spread outside the liver. Systemic therapy with immunotherapy and targeted drugs.
Terminal (BCLC D)
Severe liver failure or very poor performance status. Focus is on comfort and quality of life.
How we treat liver cancer
Surgical resection
For a single tumour in a patient with preserved liver function (no significant portal hypertension), surgical removal can be curative. The surgeon leaves enough healthy liver behind for normal function.
Liver transplantation
The most definitive treatment — it removes both the cancer and the diseased liver. Selection uses the Milan criteria (one tumour up to 5 cm, or up to three tumours each up to 3 cm). Access to transplant in our region is limited, so timing and listing matter.
Ablation
Radiofrequency or microwave ablation destroys small tumours with heat delivered through a needle placed under imaging guidance. For tumours under 3 cm, results can rival surgery.
Trans-arterial chemoembolisation (TACE)
A catheter is threaded into the artery feeding the tumour, and chemotherapy is injected directly along with particles that block the blood supply. Effective for intermediate-stage disease and often repeatable.
Trans-arterial radioembolisation (TARE / Y-90)
A related technique that delivers radioactive yttrium-90 spheres directly to the tumour through the hepatic artery. Used in selected centres for specific patterns of disease.
Systemic therapy
- Atezolizumab plus bevacizumab — the current first-line standard for advanced HCC. Combines immunotherapy with an anti-angiogenic antibody and has improved outcomes substantially.
- Durvalumab plus tremelimumab — a dual immunotherapy alternative.
- Tyrosine kinase inhibitors — sorafenib, lenvatinib (first-line) and regorafenib, cabozantinib (second-line) remain important options, especially where immunotherapy is contraindicated.
Read more about immunotherapy →
What the outlook honestly looks like
For very early and early HCC, five-year survival after curative treatment (resection, ablation or transplant) can exceed 70%. For intermediate stages treated with TACE, median survival is in the 2–3 year range, with selected patients doing much better. For advanced disease on modern systemic therapy, median survival is approaching 20 months and rising — a real change from a decade ago.
Surveillance and prevention
- Surveillance ultrasound every six months for everyone with cirrhosis, and for selected hepatitis B carriers — this is the single most important practice.
- Treat hepatitis C with modern direct-acting antivirals — cure is the norm.
- Suppress hepatitis B with lifelong antiviral tablets where indicated.
- Vaccinate against hepatitis B — children at birth, adults who are not yet immune.
- Manage diabetes, weight and alcohol — fatty liver disease is the fastest-growing cause of HCC.
Life during treatment
Treatment for HCC has to respect the underlying liver. Side effects of systemic therapy — fatigue, hand-foot reaction, blood-pressure changes, immune-related effects — are managed alongside attention to liver function. We work closely with hepatologists to keep the liver as stable as possible throughout.
After treatment — survivorship
Cure is achievable, especially in early disease, but the underlying liver disease remains. Lifelong surveillance for recurrence and for new tumours is essential. Read about survivorship care →
A liver scan has shown a suspicious lesion?
Bring all the scans and liver-function tests. The right treatment depends on both the tumour and the underlying liver — we'll go through both together.
Medically reviewed by
Dr. Rehan Abdullah
Dr. Rehan Abdullah is a dual-trained clinical and radiation oncologist with over a decade of experience treating both solid tumours and hematologic malignancies. He serves as Consultant Oncologist at INMOL Hospital and sees patients at Farooq Hospital and Healthnox Medical Center, Lahore. Read full profile →
This page is patient education, not a substitute for an in-person consultation. Cancer care must be individualised. Read our medical disclaimer →