The first 60 days: 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. Below, week by week, is what OnCo's record of Early hepatocellular carcinoma (BCLC 0 and A) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: After curative treatment.
- RadiologistNamed in the standard of care for: After curative treatment, Detection.
- SurgeonNamed in the standard of care for: Single tumour, preserved liver function, Within Milan criteria with cirrhosis or portal hypertension.
- Medical oncologistNamed in the standard of care for: Within Milan criteria with cirrhosis or portal hypertension, Not suitable for surgery or ablation, After curative treatment.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Not suitable for surgery or ablation.
- Transplant and cell therapy teamNamed in the standard of care for: Within Milan criteria with cirrhosis or portal hypertension.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Stereotactic body radiotherapy or radioembolisation.
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.
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.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?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?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?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?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?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?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?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?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?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of IMbrave050 apply to someone like me?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?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?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?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?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?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?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Early hepatocellular carcinoma (BCLC 0 and A): the full pageEarly 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.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Bridging therapy: Treatment given to keep a fast-growing cancer in check during the weeks between deciding on CAR-T (or transplant) and actually receiving it, while the cells are being manufactured or a donor found.
- BCLC staging: The liver-cancer staging system that combines tumour size, liver function and fitness to recommend treatment: ablation or surgery, transplant, TACE, or drugs.
- Hepatitis B and C as cancer causes: Two viruses cause most liver cancer worldwide.
- Microwave ablation (MWA): Like radiofrequency ablation but using microwaves, which heat faster and larger volumes and are less affected by nearby blood vessels.
- Radiofrequency ablation (RFA): Killing a tumour by heating it with an electrical current through a needle placed under image guidance, without removing it.
- Alpha-fetoprotein (AFP): Alpha-fetoprotein is a protein made by the fetal liver that a substantial share of hepatocellular carcinomas switch back on.
- Hepatectomy (liver resection): Cutting out the part of the liver containing tumour.
Every term links to the glossary.