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Health condition · Clinically reviewed

Hepatocellular carcinoma, surveillance, LI-RADS diagnosis and modern treatment.

The commonest primary liver cancer, almost always arising on cirrhosis. Caught early on surveillance it is often curable; even in advanced disease modern immunotherapy has changed the outlook.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a UK-based hepatology clinician before publication.

  • 02

    Sourced from guidance

    Checked against EASL, BSG and NICE guidance and the current UK specialist commissioning framework.

  • 03

    Current for 2026

    Reflects modern first-line immunotherapy (atezolizumab plus bevacizumab, STRIDE) and LI-RADS reporting.

Key facts

HCC at a glance.

The essentials, in plain English: what HCC is, who is at risk, and how it is diagnosed and treated in the UK today.

  • What it is

    Hepatocellular carcinoma (HCC) is a primary cancer of the hepatocytes. It accounts for around 90% of primary liver malignancies.

  • Main driver

    Cirrhosis, from any cause, is the dominant risk factor. Hepatitis B can also cause HCC without cirrhosis.

  • Surveillance

    6-monthly ultrasound with alpha-fetoprotein (AFP) in patients with cirrhosis or chronic hepatitis B, per EASL and BSG.

  • Imaging

    Contrast-enhanced MRI or CT, reported using LI-RADS. Typical imaging often avoids the need for biopsy.

  • Staging

    Barcelona Clinic Liver Cancer (BCLC) staging links tumour, liver function and performance status to treatment.

  • First-line systemic

    Atezolizumab plus bevacizumab (IMbrave150) is the NICE-approved first-line option for advanced HCC.

Why this guide matters

A stage-guided plan, from surveillance to systemic therapy.

HCC is one of the few cancers where routine surveillance in an at-risk population saves lives. The three points below shape everything else on this page.

  • Surveillance changes outcomes

    6-monthly ultrasound and AFP in cirrhosis or chronic hepatitis B catches HCC when it is small and curable.

  • Staging drives everything

    Barcelona Clinic Liver Cancer (BCLC) staging matches tumour, liver function and performance status to a specific treatment ladder.

  • Immunotherapy has changed the picture

    Atezolizumab plus bevacizumab and the STRIDE regimen have transformed outcomes in advanced HCC over the last five years.

How the diagnosis is made

From surveillance ultrasound to a specialist plan.

The steps a UK hepatology and HCC team will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    Surveillance in at-risk patients

    6-monthly liver ultrasound plus AFP in cirrhosis of any cause and in selected chronic hepatitis B carriers.

  2. 02

    Assessing

    Clinical assessment

    Decompensation signs, weight loss, right upper quadrant pain, jaundice, ascites or a first variceal bleed prompt urgent imaging.

  3. 03

    Assessing

    Cross-sectional imaging

    Multiphase contrast MRI or CT of the liver, reported using LI-RADS. Extra-hepatic staging with CT chest and abdomen.

  4. 04

    Confirming

    Tumour markers

    AFP and PIVKA-II (DCP) help characterise the lesion, monitor treatment and flag AFP-driven systemic options.

  5. 05

    Confirming

    Selective biopsy

    Reserved for atypical imaging, non-cirrhotic livers or when systemic therapy needs tissue confirmation.

  6. 06

    Preparing

    BCLC staging and MDT

    BCLC stage, Child-Pugh score and performance status agreed at a specialist HCC MDT (King’s, Royal Free, Freeman, Birmingham and others).

  7. 07

    Preparing

    Viral hepatitis and cause review

    Confirming and treating hepatitis B or C, and managing alcohol, MASH or haemochromatosis, is part of every plan.

Typical timeline: from suspicious ultrasound to a specialist MDT plan within two to four weeks.

Symptoms

What HCC actually looks like.

Early HCC is usually silent, which is why surveillance matters. Later features often reflect decompensation of the underlying cirrhosis as much as the tumour itself.

  • Found on surveillance

    Many early HCCs are picked up on 6-monthly ultrasound in patients already known to have cirrhosis, before symptoms appear.

  • Right upper quadrant pain

    A dull ache or fullness below the right ribs is a classic later feature, sometimes with a palpable liver.

  • Weight loss and fatigue

    Unexplained weight loss, reduced appetite and profound tiredness are common when the tumour is more advanced.

  • Decompensated cirrhosis

    New jaundice, ascites, encephalopathy or a first variceal bleed in known cirrhosis should prompt HCC imaging.

  • Jaundice

    Yellow eyes and skin can reflect either liver dysfunction or biliary obstruction from a large tumour.

  • Ascites

    Progressive abdominal swelling in a cirrhotic patient warrants urgent liver imaging as well as diagnostic paracentesis.

  • Rising AFP

    A steadily rising AFP on surveillance is suspicious for HCC even when ultrasound looks unchanged.

  • Red flag – variceal bleed

    Haematemesis or melaena in known cirrhosis needs emergency admission and, once stable, urgent HCC screening.

Treatment

How HCC is treated in the UK.

Care follows the BCLC framework: resection, ablation or transplant for early disease; TACE or TARE for intermediate disease; and systemic therapy, led by atezolizumab plus bevacizumab, for advanced disease.

  • Liver resection

    Curative option for single tumours in patients with preserved liver function and no clinically significant portal hypertension.

  • Ablation (RFA and MWA)

    Radiofrequency or microwave ablation for small tumours where resection is not suitable. See our radiofrequency ablation of liver tumours clinic.

  • Liver transplantation

    Considered for early HCC within Milan or expanded UCSF criteria. See our liver transplant assessment clinic.

  • TACE

    Transarterial chemoembolisation for intermediate-stage disease still confined to the liver. See our TACE clinic.

  • TARE (Y-90)

    Yttrium-90 selective internal radiation therapy, an option for selected intermediate and locally advanced HCC. See our TARE (Y-90) clinic.

  • Atezolizumab plus bevacizumab

    First-line systemic therapy for advanced HCC (IMbrave150), NICE approved in 2020. See our atezolizumab plus bevacizumab HCC clinic.

  • STRIDE (durvalumab and tremelimumab)

    Single priming dose of tremelimumab followed by durvalumab, approved after the HIMALAYA trial for advanced HCC.

  • Tyrosine kinase inhibitors

    Sorafenib, lenvatinib, regorafenib and cabozantinib remain valuable options across first and later lines of therapy.

What this guide is based on

The sources behind every claim on this page.

European, UK national and NHS specialist commissioning guidance, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your hepatologist or HCC team knows your liver, your imaging and your history and can tell you which parts apply to you. If in doubt, get seen.

  • European Association for the Study of the Liver (EASL). Clinical Practice Guidelines: management of hepatocellular carcinoma.

  • British Society of Gastroenterology (BSG). Guidance on HCC surveillance in cirrhosis and chronic hepatitis B.

  • NICE. Atezolizumab with bevacizumab for treating advanced or unresectable hepatocellular carcinoma (TA666).

  • NHS England. Specialised HCC services and specialist commissioning framework.

Red flags

When HCC needs urgent attention.

Most HCC is managed on scheduled specialist pathways. These are the features that need same-day or same-week review.

  • Sudden severe abdominal pain

    Acute right upper quadrant pain with shock can indicate tumour rupture and intra-abdominal bleeding. This is a surgical emergency.

  • Rapidly worsening jaundice

    New or fast-progressing jaundice in known cirrhosis needs urgent imaging to look for HCC or biliary obstruction.

  • Refractory ascites

    Ascites that no longer responds to diuretics can reflect portal vein tumour thrombus or disease progression.

  • Variceal bleeding

    Haematemesis or melaena in cirrhosis warrants emergency endoscopy and, once stable, urgent HCC imaging.

  • Hepatic encephalopathy

    Confusion, drowsiness or personality change in cirrhosis is a serious sign and needs same-day medical review.

  • Weight loss on surveillance

    Unintentional weight loss in a patient in HCC surveillance should trigger early re-imaging rather than waiting for the next scheduled scan.

  • Rising AFP with normal ultrasound

    A steadily rising AFP with a stable ultrasound is a recognised trigger for contrast MRI or CT.

  • New portal vein thrombus

    A portal vein thrombus in cirrhosis can be tumour-related and should be characterised on contrast imaging.

  • Suspected pregnancy on systemic therapy

    Bevacizumab and TKIs are contraindicated in pregnancy. Any suspected exposure needs urgent specialist review.

Living with it

A serious diagnosis, with real options at every stage.

Four things that make the biggest difference: treating the underlying liver disease, sticking with surveillance, staying under a specialist HCC MDT, and involving palliative care early alongside active treatment.

A quiet reminder

Consistency of follow-up beats intensity of intervention.

Small, steady habits kept up for years, from antiviral therapy to alcohol support to surveillance scans, do more than any single heroic treatment.

  1. 01 Cause

    Treat the underlying liver disease

    Antiviral therapy for hepatitis B or C, alcohol support, MASH management and iron removal in haemochromatosis are all part of HCC care.

  2. 02 Surveillance

    Keep to the 6-monthly scans

    Regular ultrasound and AFP saves lives by catching HCC while curative treatments are still possible.

  3. 03 MDT

    Care through a specialist centre

    HCC is a specialist-commissioned service in the UK. Insist on discussion at a designated HCC MDT before major decisions.

  4. 04 Support

    Palliative and family support

    Specialist palliative care alongside active treatment improves symptom control, mood and quality of life throughout the journey.

Frequently asked

Everything we get asked about HCC.

Quick answers on risk, surveillance, staging, and modern systemic therapy.

  • What is hepatocellular carcinoma?

    Hepatocellular carcinoma (HCC) is a primary cancer arising from hepatocytes, the main liver cells. It accounts for around 90% of primary liver cancers and almost always develops on the background of chronic liver disease, most often cirrhosis.

  • Who is most at risk of HCC?

    The main risk factor is cirrhosis of any cause, including hepatitis B and C, alcohol-related liver disease, metabolic dysfunction-associated steatohepatitis (MASH) and haemochromatosis. Chronic hepatitis B can also cause HCC without cirrhosis. Obesity, type 2 diabetes and smoking add further risk.

  • How is HCC diagnosed?

    Most HCC in the UK is diagnosed through 6-monthly ultrasound and AFP surveillance in people with cirrhosis. Suspicious lesions are characterised on multiphase contrast MRI or CT using the LI-RADS system. Typical imaging in a cirrhotic liver usually avoids the need for biopsy.

  • What are the main treatment options?

    Treatment follows the BCLC framework. Very early and early HCC can be treated with resection, ablation (RFA or MWA) or liver transplantation within accepted criteria. Intermediate HCC is treated with TACE or TARE. Advanced HCC is treated with systemic therapy, most often atezolizumab plus bevacizumab as first line.

  • What is the role of immunotherapy in HCC?

    Atezolizumab combined with bevacizumab is the current NICE-approved first-line therapy for advanced HCC, based on the IMbrave150 trial. The STRIDE regimen (a single priming dose of tremelimumab with durvalumab) is another approved option following the HIMALAYA trial. Other checkpoint inhibitors are used in later lines.

  • Can HCC be cured?

    Yes, when it is found early. Resection, ablation and liver transplantation are all potentially curative for suitable patients. This is why 6-monthly surveillance in cirrhosis and chronic hepatitis B is so important, and why care through a specialist HCC centre matters.

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