Hepatocellular Carcinoma (Primary Liver Cancer)

In this article

Identify the liver What does the liver do? What are the types of primary liver cancer? What are the risk factors and causes? What are the symptoms? How primary liver cancer is diagnosed? Staging How is the liver cancer treated? How treatment is planned? What are the benefits and disadvantages of treatment? Liver transplant / resection surgery Radiofrequency ablation (RFA) Microwave ablation (MWA) Percutaneous ethanol injection (PEI) Embolisation treatments (TACE/SIRT) Targeted therapy drugs Chemotherapy Radiotherapy Palliative care Controlling symptoms After treatment – follow-up

Primary liver cancer is cancer that starts in the liver cells. Cancer that starts in another part of the body and then spreads to the liver is called secondary or metastatic cancer - that is not discussed here. 

Identify the liver

The liver is the largest organ in the body which resides on the upper most part of your belly on to the right side. Its upper part is under your right side lower ribs.

What does the liver do?

The liver has multiple functions. They can be categorised in to three broad areas:

  • stores sugars and fats, so they can be used for energy
  • makes proteins, which help the blood to clot, prevent bleeding and maintain fluid balance in the body and many more
  • breaks down and sometimes excrete some waste products such as old haemoglobin and harmful substances such as alcohol and drugs. When old haemoglobin is broken down, it makes bile, which breaks down fats so they can be absorbed by the body.
  • The liver is good at repairing itself. It can work well even when only a small part of it is working normally.

What are the types of primary liver cancer?

There are few types of primary liver cancer. Most common types are as follows:

  1. Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. It is also called hepatoma. It starts in the main cells of the liver, called hepatocytes.
  2. Fibrolamellar Hepatocellular carcinoma is a rare type of primary liver cancer that usually affects younger people. 
  3. Bile duct cancer (cholangiocarcinoma) is another type of primary liver cancer. It starts in the cells lining the bile system.
  4. Angiosarcoma is a very rare type of liver cancer, which starts in the blood vessels of the liver.

In this article, only the hepatocellular carcinoma is discussed. For cholangiocarcinoma, please read the article in this link.

What are the risk factors and causes?

Primary liver cancer is not very common, but the number of people developing the condition is increasing probably due to increasing fatty liver related liver damage. There are many other risk factors for developing HCC. Here are some:

  1. Age: HCC is more common as people get older. Most people diagnosed are over 65.
  2. Gender: HCC is more common in men than in women.
  3. Smoking: People who smoke tobacco have a much higher risk of HCC than non-smokers.
  4. Hepatitis infection: Long-term infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) can cause HCC.
  5. Cirrhosis: People who have cirrhosis have a higher risk of getting HCC. Learn about cirrhosis here.
  6. Diabetes: People with Type 2 diabetes have a higher risk of developing HCC.
  7. Metabolic syndrome: Metabolic syndrome is a group of conditions that occur together including high blood pressure, diabetes and high blood lipids and cholesterol along with obesity. People with metabolic syndrome have a higher risk of developing HCC.
  8. Family history: Having a close family member (father, mother, sister or brother) with primary liver cancer increases a person’s risk. 
  9. Anabolic steroids taken over a long time slightly increase the risk of HCC. These are mainly used by bodybuilders.
  10. A poison called aflatoxin, found in mouldy peanuts and grains, is a major risk for HCC.

What are the symptoms?

In the early stages of HCC, there are often no symptoms. Therefore, people with long-term (chronic) liver disease such as cirrhosis may have regular tests to check their liver. If they develop HCC, these tests may finnd it before symptoms develop.

Possible symptoms of HCC include:

  • losing your appetite
  • feeling full soon after beginning to eat
  • losing weight for no obvious reason
  • feeling vomitish (nausea) and vomiting
  • feeling extremely tired, generally weak or unwell
  • aching or pain on the right side of the tummy area (abdomen) under the ribs
  • fever and flu-like symptoms
  • swollen tummy, caused by fluid build-up (called ascites)
  • yellow colour in the skin and whites of the eyes (called jaundice)
  • dark urine and pale, chalky stools
  • bruising or bleeding easily.

It is important to see your doctor if you have any of these symptoms, even though they can be caused by other conditions. It is especially important to get them checked if you have risk factors for liver cancer.

How primary liver cancer is diagnosed?

It is best done by a gastroenterological specialist. It can be started at the doctor’s consultation. Your doctor will ask about your symptoms and examine you. Your doctor will usually take blood samples to check your general health. They may arrange other tests, such as an ultrasound. 

If you have long-term liver disease, you may have regular blood tests and ultrasound scans to check your liver. If HCC develops, these tests may find the cancer at an earlier stage.e blood tests and they will explain which other tests you need.

Blood tests

Liver function tests (LFTs) to check how well your liver is working

alpha-fetoprotein (AFP) - a tumour marker for HCC because it is sometimes higher in people with liver cancer

Liver ultrasound scan

To check architectural changes in the liver cell arrangements which can happen in liver cancer.

CT (computerised tomography) scan

To assess liver structure and details of suspected liver cancer. In some cases, CT scan itself will be enough to accurately diagnose the cancer. 

To assess the progression of the cancer i.e. stage in order to plan treatment

MRI (magnetic resonance imaging) scan

This test is sometimes useful if there are any doubts about the diagnosis or if detail information on the billiard tree is necessary.


This operation allows the surgeon to look at the liver and other organs close by. It helps them to decide if it is possible to remove the tumour with surgery. The surgeon may also take a small sample of tissue (biopsy) for examination under a microscope.

Liver biopsy

During a biopsy, a small piece of tissue or a sample of cells is removed so that it can be examined under a microscope. Not everyone needs a biopsy. Doctors may be able to diagnose HCC with scans. Or they may diagnose it after surgery to remove the tumour. This necessary to clear up any residual doubts about the diagnosis especially if you are being considered for non operative treatment. 


The stage of a cancer describes its size and whether it has spread from where it first started. Knowing the stage is important. It helps you and your doctors to decide on the best treatment for you.

Doctors may use a number system to stage HCC:

  1. Stage 1 – There is one tumour in the liver and the cancer has not spread into any blood vessels in the liver.
  2. Stage 2 – There is one tumour that has spread into a blood vessel. Or there are several tumours but none are bigger than 5cm.
  3. Stage 3 is divided into:
  • 3A – There is more than one tumour and at least one is bigger than 5cm.
  • 3B – The cancer has grown into a major blood vessel in the liver.
  • 3C – The cancer has spread outside the liver into organs nearby (except the gall bladder).
  1. Stage 4 is divided into:
  • 4A – The cancer has spread outside the liver into lymph nodes in that area. Lymph nodes help fight infection. They are sometimes called lymph glands.
  • 4B – The cancer has spread to another part of the body, such as the lungs or bones.

Child-Pugh classification

Doctors will assess how well your liver is working using the Child-Pugh classification system. It gives a score from A to C:

A means the liver is working well.

C means it is very damaged and is not working well.

The results help doctors decide which treatments are best for your situation. Having certain treatments will depend on how well the liver is able to cope.

Child-Pugh looks at:

  • the level of bilirubin (a waste product of old red blood cells) in the blood
  • the level of albumin (blood protein) in the blood
  • how quickly your blood clots (prothrombin time)
  • whether there is any build-up of fluid in the abdomen (ascites)
  • whether liver damage is affecting how the brain is working (encephalopathy).

How is the liver cancer treated?

The treatment you have will usually depend on:

  • where the cancer is in the liver – there may be several areas of cancer in different parts of the liver
  • the size of the tumour or tumours
  • how many tumours there are
  • whether the cancer has spread outside the liver
  • whether any important blood vessels in the liver are affected
  • how well your liver is working
  • your general health.

How treatment is planned?

A team of specialists will meet to discuss the best treatment for you. Multidisciplinary team (MDT) uses current accepted treatment guidelines to decide the most suitable treatment for you. This multidisciplinary team (MDT) will include:

  1. gastroenterological surgeon 
  2. hepatologist – a liver disease specialist
  3. medical oncologist – a doctor who specialises in giving chemotherapy
  4. clinical oncologist – a radiotherapy and chemotherapy specialist
  5. interventional radiologist – a doctor who uses imaging to help them give treatments such as ablation or embolisation 
  6. radiologists – who help to analyse x-rays and scans
  7. pathologists – who advise on the type and spread of the cancer.
  8. palliative care doctor who specialises in symptom control
  9. dietitian
  10. physiotherapist
  11. psychologist or a counsellor

What are the benefits and disadvantages of treatment?

  • Treatment can be given for different reasons and the potential benefits will vary depending on your individual situation.
  • Treatment has side effects. However, side effects can usually be controlled with medicines.
  • In people with early-stage liver cancer, surgery may be done with the aim of curing the cancer. Or treatments may be used to control the cancer and prolong your life.
  • If the cancer is advanced or has spread to other parts of the body, treatment may only be able to control it. It may or may not prolong your life, improve your symptoms and give you a better quality of life.
  • For some people, the treatment will have no effect on the cancer and they will get the side effects without any of the benefit.
  • You are also free to choose not to have the treatment. The doctor can explain what may happen if you don’t have it. 

Liver transplant / resection surgery

If eligible for surgery, that is the most effective treatment for HCC. The type of surgery depends on the stage and liver cirrhosis grade. Only a small number of people with HCC can have surgery. There are two types of operation:

liver transplant –if a single tumour < 5cm or 5cm to 7cm which does not grow over six months or <5 tumours that are <3cm.

liver resection – if single tumour or a limited number of tumours limited to one side of the liver, without or early cirrhosis.

Radiofrequency ablation (RFA)

Suitable for small <3cm tumours. This treatment destroys cancer cells by heating them to a high temperature. Some people have RFA more than once.

The doctor passes a fine needle (called an electrode) through your skin, into the liver tumour. An electrical current is passed through the needle. This heats the cancer cells and destroys them.

Microwave ablation (MWA)

Suitable for small <3cm tumours. This is a type of treatment where the tumour is exposed to high temperatures created by microwaves. It is done in the same way as RFA

Percutaneous ethanol injection (PEI)

Suitable for small <3cm tumours. This involves a doctor injecting pure alcohol (ethanol) through the skin and into the tumour. The alcohol destroys the cancer cells.

Embolisation treatments (TACE/SIRT)

Suitable for small <3cm tumours. Embolisation is a way of blocking blood vessels. Using x-rays to guide a long plastic tube into the artery that carries blood to the liver cancer, the doctor injects a substance into this artery to block the blood flow. This reduces the supply of oxygen and food to the cancer, which can shrink it or stop it growing. In HCC, embolisation is usually given with chemotherapy. This is called chemoembolisation. Less commonly, embolisation is given with radiation. This is called radioembolisation or SIRT (selective internal radiation therapy).

Targeted therapy drugs

Targeted therapy drugs target the differences between cancer cells and normal cells. These treatments are also sometimes called biological therapies.

The most commonly used targeted therapy drug for HCC is a tablet called sorafenib. It can be used to treat HCC that is advanced or has spread to other parts of the body. 


Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy is not used very often for HCC. This is because doctors are concerned that it does not work very well for this type of cancer. However, it may be used to try to control the tumour and reduce symptoms. It is not suitable for everyone because the liver may not be working well enough to cope with the drugs.


Radiotherapy uses high-energy rays to destroy cancer cells. New advances in technology mean that radiation can be given more precisely. This is to avoid damaging normal tissues as much as possible.

Palliative care

If you decide not to have treatment, there is a still a lot that can be done to control symptoms and support you. Your doctor can refer you to a team of doctors and nurses who specialise in controlling symptoms. This is called a palliative care team.

Controlling symptoms

Treating the cancer in the liver will often ease the symptoms. Other treatments can also be used to control symptoms. This is sometimes called palliative treatment or supportive care. Your doctor may refer you to a palliative care team who are experts in controlling symptoms. They will support you and your family. The team often includes a doctor and nurses. They often work closely with a local hospice and can visit you and your family at home.


If the cancer stretches the capsule surrounding the liver, it may cause pain. Some people get pain in the right shoulder, which doctors sometimes call referred pain. It can happen if the liver stimulates the nerves beneath the diaphragm. These nerves connect to nerves in the right shoulder.

There are different types of painkillers your doctor can prescribe. If your pain is not controlled, let them know as soon as possible. They can adjust the dose of the drug or give you a different one that works better for you. 

Sometimes drugs called steroids can relieve pain by reducing swelling around the liver. You usually have them as a short course of treatment over a few weeks or months. They can also make you feel more energetic and improve your appetite.


Ascites is a build-up of  fluid in the tummy area (abdomen). It can make you feel bloated and uncomfortable. It may make you feel breathless as it can prevent your lungs from fully expanding as you breathe. Doctors sometimes prescribe drugs that help the body get rid of extra  fluid as urine. These drugs are called water tablets or diuretics. Your doctor may put a small,  fine tube through the skin of your tummy to drain off the  fluid. This is usually done in the hospital but some people may be able to have it done at home. It can be done more than once if needed. 


Sometimes the bile duct becomes blocked by the cancer. The bile duct is a tube that drains bile out of the liver and into the small bowel . If it is blocked, bile builds up in the liver and flows back into the blood. It makes the whites of the eyes and skin turn yellow, and you feel itchy. Doctors call these symptoms jaundice. Your doctor can prescribe drugs to help relieve the itching. Your doctor may put a narrow tube (stent) into the bile duct to keep it open. This allows the bile to  ow into the small bowel and relieves the jaundice.

After treatment – follow-up

After your treatment finishes, you will have regular check-ups. Your specialist will do a physical examination. You will usually also have blood tests. Depending on the treatment you had, you may have regular CT scans to check that the tumour has not come back. After a liver transplant, you also have checks to make sure your body is not rejecting the new liver. Your doctor will talk to you about what to look out for.