Early hepatocellular carcinoma (BCLC 0 and A)
Early hepatocellular carcinoma means a single tumour, or up to three small ones, in a liver that still works, without spread or vein invasion. It is treated to cure: cutting out the tumour, destroying it with heat through a needle, or replacing the liver by transplant, chosen by tumour size, liver function and portal pressure.
Overview
The Barcelona Clinic Liver Cancer system, first published in 1999 and updated in 2022, defines very early disease (BCLC 0) as a single tumour under 2 cm and early disease (BCLC A) as a single tumour of any size or up to three tumours each under 3 cm, with preserved liver function and performance status and no vascular invasion or spread. Most such tumours are found by six-monthly ultrasound surveillance of people with cirrhosis or chronic hepatitis B, and diagnosis rests on contrast imaging with the LI-RADS criteria rather than biopsy in a cirrhotic liver.
Resection is the first choice for a single tumour when liver function is preserved and portal hypertension absent, and is increasingly done laparoscopically or by robot; thermal ablation with radiofrequency or microwave is the alternative for tumours up to 3 cm, with survival equivalent to resection in randomised trials of small tumours and fewer complications, and stereotactic radiotherapy where ablation is impossible. Liver transplantation, for patients within the Milan criteria of a single tumour up to 5 cm or up to three tumours each up to 3 cm, treats both the cancer and the cirrhosis and gives the best long-term results, with bridging ablation or chemoembolisation while waiting and downstaging protocols for those just beyond the criteria.
Recurrence after resection or ablation is the main problem, reaching about 70 percent at five years because the cirrhotic liver keeps producing new tumours. No adjuvant therapy has been established: sorafenib failed in STORM, and IMbrave050, in which atezolizumab and bevacizumab improved recurrence-free survival at the first analysis, lost that benefit with longer follow-up. Antiviral therapy for hepatitis B or C, alcohol abstinence and continued surveillance are the measures that do reduce recurrence and second tumours.
State of the art
- Resection, ablation and transplantation each cure a large share of early tumours, and the choice between them is guided by liver function and portal pressure as much as by the tumour.
- Surveillance in cirrhosis is what moves patients into this curable stage.
- Adjuvant immunotherapy has not yet delivered a durable benefit, leaving recurrence the unsolved problem.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBowel perforation
Sudden severe abdominal pain, a hard or very tender abdomen, or abdominal pain with vomiting and fever. Boxed warning for gastrointestinal perforation on bevacizumab.
- Emergency services nowHypophysitis or adrenal crisis
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
- Good to knowAnti-VEGF class toxicities (hypertension, proteinuria, bleeding, perforation)
The shared side effects of drugs that block blood vessel growth (bevacizumab, ramucirumab and VEGFR kinase inhibitors): high blood pressure, protein leaking into the urine, nosebleeds and more serious bleeding, slow wound healing, and rarely holes in the bowel.
- Good to knowRadiation necrosis (brain)
Death of brain tissue months to years after radiosurgery or high-dose brain radiotherapy, which can look exactly like tumour growing back on a scan.
- Good to knowVenous thromboembolism (VTE)
Blood clots in the leg veins or lungs. Cancer makes blood clot more easily and some treatments (IMiDs, anti-VEGF drugs, hormone therapy, central lines, surgery) add risk; clots are the second commonest cause of death in cancer patients after the cancer itself.
See all on the product pages:AtezolizumabBevacizumab·Printable cards in the navigator
Anatomy and lymph node drainage
- Right lobe (segments V-VIII)
- Left lobe (segments II-IV)
- Portal vein (macrovascular invasion)
- Capsule and diaphragm surface
- Nodes: hepatic hilar
- Nodes: coeliac
- Nodes: paracaval
Hepatocellular carcinoma grows in a cirrhotic liver and spreads first inside it and into the portal vein, so staging depends on liver function and vascular invasion as much as on size.
- Right lobe (segments V-VIII)Very early HCC (BCLC 0): single tumour under 2 cm in a cirrhotic liver · HCC in a non-cirrhotic liver (resectable at larger sizes)
- Left lobe (segments II-IV)
- Portal vein (macrovascular invasion)
- Capsule and diaphragm surface
- hepatic hilar
- coeliac
- paracaval
Same organ: Hepatocellular carcinoma, Intermediate hepatocellular carcinoma (BCLC B), Advanced hepatocellular carcinoma (BCLC C), Hepatoblastoma
The stage at which liver cancer can be cured, reached by a minority of patients worldwide but by most of those found by surveillance in cirrhosis; the BCLC system expects five-year survival above 70 percent with resection, ablation or transplantation.
- HCC surveillance in cirrhosis (ultrasound + AFP)Standard of care
- MRIStandard of care
Nothing recorded yet.
Background: Alpha-fetoprotein (AFP). Also on OnCo: Symptoms and red flags · Early detection roadmap.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Hepatectomy, increasingly laparoscopic or robotic; ablation as an alternative for tumours up to 3 cm.
Liver transplantation, with bridging ablation or chemoembolisation on the waiting list and downstaging for patients just outside the criteria.
Stereotactic body radiotherapy or radioembolisation.
No proven adjuvant therapy (STORM and IMbrave050 negative in the end); antiviral therapy, alcohol abstinence and continued imaging surveillance.
Six-monthly ultrasound with alpha-fetoprotein in cirrhosis and chronic hepatitis B.
Subtypes & biomarkers
top- Very early HCC (BCLC 0): single tumour under 2 cm in a cirrhotic liver
- Early HCC (BCLC A): single tumour or up to three under 3 cm
- HCC within Milan criteria (transplant candidates)
- HCC in a non-cirrhotic liver (resectable at larger sizes)
- Recurrent HCC after resection or ablation
- BCLC stage, Child-Pugh and ALBI liver function
- Portal hypertension (platelets, varices, hepatic venous pressure gradient) before resection
- Alpha-fetoprotein (prognosis and transplant selection)
- LI-RADS imaging category on contrast CT or MRI
- Microvascular invasion and satellite nodules on the resected specimen
How often this target appears
- 1996Mazzaferro defines the Milan criteria for liver transplantation in HCC
- 1999Barcelona Clinic Liver Cancer staging published (Llovet)
- 2006Randomised trial shows radiofrequency ablation equals resection for small tumours (Chen)
- 2015STORM: adjuvant sorafenib fails after resection or ablation
- 2023IMbrave050: adjuvant atezolizumab-bevacizumab improves recurrence-free survival at interim analysis
- 2025IMbrave050 update: the recurrence-free survival benefit is not sustained
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 8 changes by month →- 2026-09-17This recordEarly hepatocellular carcinoma (BCLC 0 and A)Facts on this page last checked
When this page itself was last checked or edited.
- 2025MilestoneIMbrave050IMbrave050 update: the recurrence-free survival benefit is not sustained
A milestone in how this cancer is treated.
- 2023Trial resultIMbrave050IMbrave050 reported
Interim RFS HR 0.
- 2023MilestoneIMbrave050IMbrave050: adjuvant atezolizumab-bevacizumab improves recurrence-free survival at interim analysis
A milestone in how this cancer is treated.
- 2015MilestoneSorafenibSTORM: adjuvant sorafenib fails after resection or ablation
A milestone in how this cancer is treated.
- 2006MilestoneRadiofrequency ablation (RFA)Randomised trial shows radiofrequency ablation equals resection for small tumours (Chen)
A milestone in how this cancer is treated.
What is in development for Early hepatocellular carcinoma (BCLC 0 and A), drawn from the whole corpus: 4 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Technologies being tested · 1
Trials reported · 1
- IMbrave050 · phase 3 · 2023 · negative
Ideas not yet in a trial · 2
Open problems and what is being done
Recurrence in the remaining cirrhotic liver after resection or ablation.
and how the field plans to fix it →What is being done about thisRecurrence and residual diseaseAvailable now- MRD / molecular residual disease testingEstablished
In trialsNothing recorded yet.
Ideas and roadmapsNothing recorded yet.
Also on OnCo: Treatment journeys · Survivorship planner.
No adjuvant therapy has held up in a phase 3 trial.
Donor shortage limits transplantation, and access to surveillance is poor in the highest-incidence countries.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
Seoul · hospital | South Korea | none recorded | 0 | 1,177 | 18,820 | none recorded | #4 |
Rochester, MN · hospital | United States | 0 | 4,511 | 44,748 | #5 | ||
Seoul · hospital | South Korea | none recorded | 0 | 464 | 3,248 | #22 | |
Stanford · university | United States | 0 | 3,000 | 50,162 | #30 | ||
Shanghai · hospital | China | none recorded | 0 | 2,872 | 31,534 | - | |
London · hospital | United Kingdom | none recorded | 0 | 2,376 | 28,940 | - | |
Sydney · cancer center | Australia | none recorded | 0 | 2,222 | 33,278 | - | |
Beijing · hospital | China | none recorded | 0 | 1,784 | 18,230 | - | |
Dallas, TX · cancer center | United States | 0 | 1,744 | 19,757 | - | ||
Miami, FL · cancer center | United States | 0 | 1,607 | 15,145 | - | ||
Utrecht · cancer center | Netherlands | none recorded | 0 | 1,422 | 20,323 | - | |
Guangzhou · hospital | China | none recorded | 0 | 1,245 | 12,931 | - | |
Tianjin · cancer center | China | none recorded | 0 | 1,219 | 11,455 | - | |
Beijing · hospital | China | none recorded | 0 | 1,154 | 11,808 | - | |
Rozzano (Milan) · hospital | Italy | none recorded | 0 | 1,031 | 10,720 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Early hepatocellular carcinoma but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Early hepatocellular carcinoma
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example BCLC stage, Child-Pugh and ALBI liver function, Portal hypertensionbefore resection, Alpha-fetoprotein, LI-RADS imaging category on contrast CT or MRI, Microvascular invasion and satellite nodules on the resected specimen), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Very early HCC: single tumour under 2 cm in a cirrhotic liver, Early HCC: single tumour or up to three under 3 cm, HCC within Milan criteria.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Single tumour, preserved liver function
- For my situation (single tumour, preserved liver function), which of the standard options do you recommend and why?Why: Guideline options include: Hepatectomy, increasingly laparoscopic or robotic; ablation as an alternative for tumours up to 3 cm.
Within Milan criteria with cirrhosis or portal hypertension
- For my situation (within milan criteria with cirrhosis or portal hypertension), which of the standard options do you recommend and why?Why: Guideline options include: Liver transplantation, with bridging ablation or chemoembolisation on the waiting list and downstaging for patients just outside the criteria.
Not suitable for surgery or ablation
- For my situation (not suitable for surgery or ablation), which of the standard options do you recommend and why?Why: Guideline options include: Stereotactic body radiotherapy or radioembolisation.
After curative treatment
- For my situation (after curative treatment), which of the standard options do you recommend and why?Why: Guideline options include: No proven adjuvant therapy (STORM and IMbrave050 negative in the end); antiviral therapy, alcohol abstinence and continued imaging surveillance.
- Am I a candidate for Atezolizumab, Bevacizumab, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of IMbrave050 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Detection
- For my situation (detection), which of the standard options do you recommend and why?Why: Guideline options include: Six-monthly ultrasound with alpha-fetoprotein in cirrhosis and chronic hepatitis B.
Any stage
- Are there clinical trials I could join, for example of IMbrave050, Liver transplantation for cancer (Milan criteria and beyond), Immunotherapy downstaging to transplant with a safe washout, Blood-based HCC surveillance to replace six-monthly ultrasound?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Recurrence in the remaining cirrhotic liver after resection or ablation”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “No adjuvant therapy has held up in a phase 3 trial”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Early hepatocellular carcinoma, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
16targets
3drugs
3companies
5terms
7trials
1ideas
2Latest papers
topQuery for this cancer: (TITLE:"Early hepatocellular carcinoma" OR ABSTRACT:"Early hepatocellular carcinoma" OR TITLE:"BCLC 0 and A" OR ABSTRACT:"BCLC 0 and A" OR TITLE:"Very early HCC BCLC 0" OR ABSTRACT:"Very early HCC BCLC 0" OR TITLE:"Early-stage HCC BCLC A" OR ABSTRACT:"Early-stage HCC BCLC A" OR TITLE:"Resectable hepatocellular carcinoma" OR ABSTRACT:"Resectable hepatocellular carcinoma" OR TITLE:"HCC within Milan criteria" OR ABSTRACT:"HCC within Milan criteria") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Early hepatocellular carcinoma (BCLC 0 and A), not a curated reading list.
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