# Early hepatocellular carcinoma (BCLC 0 and A)

Source: https://onco.cc/cancers/hcc-early/  
OnCo record `hcc-early` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

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.

## Summary

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.

## Fields

- Kind: Cancer
- Last checked: 2026-09-17
- Also known as: Very early HCC (BCLC 0); Early-stage HCC (BCLC A); Resectable hepatocellular carcinoma; HCC within Milan criteria
- Tags: subtype-page
- Group: gastrointestinal
- Burden: 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.
- Subtypes: 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
- Biomarkers: 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

## Sections of this record

The page is a hub with ten sections in reading order; large sections have their own page. The same plan as JSON: https://onco.cc/api/v1/cancers/hcc-early/sections.json

- Overview (on the hub): The TL;DR, the family this cancer belongs to, the organ, who gets it and what the state of the art is. https://onco.cc/cancers/hcc-early/#overview [3 state-of-the-art points]
- Types and stages (on the hub): Anatomy, the subtypes and how they differ, how it is staged, and where advanced disease spreads. https://onco.cc/cancers/hcc-early/#what-it-is [5 subtypes]
- Symptoms and diagnosis (on the hub): How this cancer shows itself, how the diagnosis is confirmed, and the biomarkers clinicians test for. https://onco.cc/cancers/hcc-early/#finding-it [5 biomarkers]
- Treatment (on the hub): The standard of care by setting, the medicines, surgery and radiotherapy named in it, and the regimens behind them. https://onco.cc/cancers/hcc-early/#treating-it [5 settings, 5 decisions with options]
- Trials and papers (on the hub): Trials recruiting now, the landmark trials, the trials held by this cancer's subtypes, the key papers and what they mean, the latest literature, and the milestones year by year. https://onco.cc/cancers/hcc-early/#evidence [8 trials, 4 key papers, 6 milestones]
- Biology and targets (on the hub): The molecular landscape: the targets and how often each appears, the pathways, the mechanics stages and the preclinical models. https://onco.cc/cancers/hcc-early/#science [3 targets]
- Countries and centres (own page): Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes. https://onco.cc/cancers/hcc-early/where-you-are/
- Decisions and support (on the hub): The decisions you may face, the aids that walk through them, the warnings on record, the first sixty days and the questions to ask. https://onco.cc/cancers/hcc-early/#living-with-it [16 questions, 5 red cards]
- Pipeline and open problems (own page): Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record. https://onco.cc/cancers/hcc-early/coming/ [3 medicines, 8 trials, 2 ideas, 3 open problems]
- Data (own page): Every connected record, the notes, the JSON, Markdown and RDF twins, and where the record came from and when it was checked. https://onco.cc/cancers/hcc-early/data/ [51 connected records]

## Standard of care

- Single tumour, preserved liver function: Hepatectomy, increasingly laparoscopic or robotic; ablation as an alternative for tumours up to 3 cm. ([Hepatectomy (liver resection)](https://onco.cc/terms/hepatectomy/), [Thermal ablation (RFA, microwave, cryo)](https://onco.cc/technologies/thermal-ablation/), [Radiofrequency ablation (RFA)](https://onco.cc/terms/radiofrequency-ablation/), [Microwave ablation (MWA)](https://onco.cc/terms/microwave-ablation/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [BCLC staging](https://onco.cc/terms/bclc-staging/))
- Within Milan criteria with cirrhosis or portal hypertension: Liver transplantation, with bridging ablation or chemoembolisation on the waiting list and downstaging for patients just outside the criteria. ([Liver transplantation for cancer (Milan criteria and beyond)](https://onco.cc/technologies/liver-transplant-oncology/), [Bridging therapy](https://onco.cc/terms/bridging-therapy/), [Transarterial chemoembolisation (TACE)](https://onco.cc/technologies/tace/), [Thermal ablation (RFA, microwave, cryo)](https://onco.cc/technologies/thermal-ablation/))
- Not suitable for surgery or ablation: Stereotactic body radiotherapy or radioembolisation. ([SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Radioembolisation (TARE / SIRT, yttrium-90)](https://onco.cc/technologies/radioembolisation-tare/))
- After curative treatment: No proven adjuvant therapy (STORM and IMbrave050 negative in the end); antiviral therapy, alcohol abstinence and continued imaging surveillance. ([IMbrave050](https://onco.cc/trials/imbrave050/), [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Bevacizumab](https://onco.cc/drugs/bevacizumab/), [HCC surveillance in cirrhosis (ultrasound + AFP)](https://onco.cc/technologies/hcc-surveillance/), [Hepatitis B and C as cancer causes](https://onco.cc/terms/hbv-hcv/))
- Detection: Six-monthly ultrasound with alpha-fetoprotein in cirrhosis and chronic hepatitis B. ([HCC surveillance in cirrhosis (ultrasound + AFP)](https://onco.cc/technologies/hcc-surveillance/), [Ultrasound](https://onco.cc/technologies/ultrasound/), [Alpha-fetoprotein (AFP)](https://onco.cc/terms/afp/), [MRI](https://onco.cc/technologies/mri/))

## 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.

## Open problems

- Recurrence in the remaining cirrhotic liver after resection or ablation.
- 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.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Hepatocellular_carcinoma
- BCLC 2022 update (J Hepatol): https://pubmed.ncbi.nlm.nih.gov/34801630/
- Milan criteria (NEJM 1996): https://www.nejm.org/doi/full/10.1056/NEJM199603143341104
- IMbrave050 (Lancet 2023): https://pubmed.ncbi.nlm.nih.gov/37871608/
- Wikipedia: https://en.wikipedia.org/wiki/Hepatocellular_carcinoma

## Connected records

- cancers: [Advanced hepatocellular carcinoma (BCLC C)](https://onco.cc/cancers/hcc-advanced/), [Hepatocellular carcinoma](https://onco.cc/cancers/hcc/), [Intermediate hepatocellular carcinoma (BCLC B)](https://onco.cc/cancers/hcc-intermediate/)
- terms: [Alpha-fetoprotein (AFP)](https://onco.cc/terms/afp/), [BCLC staging](https://onco.cc/terms/bclc-staging/), [Bridging therapy](https://onco.cc/terms/bridging-therapy/), [Depth of invasion (DOI)](https://onco.cc/terms/depth-of-invasion/), [Hepatectomy (liver resection)](https://onco.cc/terms/hepatectomy/), [Hepatitis B and C as cancer causes](https://onco.cc/terms/hbv-hcv/), [LI-RADS (Liver Imaging Reporting and Data System)](https://onco.cc/terms/li-rads/), [Microwave ablation (MWA)](https://onco.cc/terms/microwave-ablation/), [Radiofrequency ablation (RFA)](https://onco.cc/terms/radiofrequency-ablation/)
- key papers: [BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update](https://onco.cc/key-papers/paper-bclc-2022-reig-j-hepatol-2022/), [IMbrave050: adjuvant atezolizumab plus bevacizumab versus active surveillance after resection or ablation of high-risk hepatocellular carcinoma](https://onco.cc/key-papers/paper-imbrave050-lancet-2023/), [Liver transplantation for small hepatocellular carcinomas in patients with cirrhosis (the Milan criteria)](https://onco.cc/key-papers/paper-mazzaferro-milan-criteria-nejm-1996/), [STORM: adjuvant sorafenib after resection or ablation of hepatocellular carcinoma](https://onco.cc/key-papers/paper-storm-adjuvant-sorafenib-bruix-lancet-oncol-2015/)
- technologies: [Focused ultrasound & histotripsy](https://onco.cc/technologies/hifu-histotripsy/), [HCC surveillance in cirrhosis (ultrasound + AFP)](https://onco.cc/technologies/hcc-surveillance/), [Liver transplantation for cancer (Milan criteria and beyond)](https://onco.cc/technologies/liver-transplant-oncology/), [MRD / molecular residual disease testing](https://onco.cc/technologies/mrd-testing/), [MRI](https://onco.cc/technologies/mri/), [Radioembolisation (TARE / SIRT, yttrium-90)](https://onco.cc/technologies/radioembolisation-tare/), [Robotic & minimally invasive surgery](https://onco.cc/technologies/robotic-surgery/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Thermal ablation (RFA, microwave, cryo)](https://onco.cc/technologies/thermal-ablation/), [Transarterial chemoembolisation (TACE)](https://onco.cc/technologies/tace/), [Ultrasound](https://onco.cc/technologies/ultrasound/)
- drugs: [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Bevacizumab](https://onco.cc/drugs/bevacizumab/), [Sorafenib](https://onco.cc/drugs/sorafenib/)
- trials: [A Phase III Study of AK104 as Adjuvant Therapy in HCC With High Risk of Recurrence After Curative Resection](https://onco.cc/trials/nct05489289/), [A Study of Nivolumab in Participants With Hepatocellular Carcinoma Who Are at High Risk of Recurrence After Curative Hepatic Resection or Ablation](https://onco.cc/trials/nct03383458/), [A Study to Evaluate Camrelizumab Plus Rivoceranib (Apatinib) as Adjuvant Therapy in Patients With Hepatocellular Carcinoma (HCC) at High Risk of Recur](https://onco.cc/trials/nct04639180/), [Anlotinib Hydrochloride Capsules Combined With Penpulimab Injection for the Treatment of Hepatocellular Carcinoma at High Risk of Recurrence.](https://onco.cc/trials/nct05862337/), [Assess Efficacy and Safety of Durvalumab Alone or Combined With Bevacizumab in High Risk of Recurrence HCC Patients After Curative Treatment](https://onco.cc/trials/nct03847428/), [IMbrave050](https://onco.cc/trials/imbrave050/), [Neoadjuvant Cemiplimab for the Treatment of Resectable NSCLC, HCC, and HNSCC in Adult Patients](https://onco.cc/trials/nct03916627/), [NWRD06 DNA Plasmid for HCC After Curative Resection.](https://onco.cc/trials/nct07324304/)
- ideas: [Blood-based HCC surveillance to replace six-monthly ultrasound](https://onco.cc/ideas/idea-hcc-blood-surveillance/), [Immunotherapy downstaging to transplant with a safe washout](https://onco.cc/ideas/idea-hcc-io-before-transplant/)
- people: [Jordi Bruix](https://onco.cc/people/jordi-bruix/)

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JSON: https://onco.cc/api/v1/entities/hcc-early.json