{"entity":{"id":"hcc-early","kind":"cancer","name":"Early hepatocellular carcinoma (BCLC 0 and A)","aka":["Very early HCC (BCLC 0)","Early-stage HCC (BCLC A)","Resectable hepatocellular carcinoma","HCC within Milan criteria"],"tldr":"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.\n\nResection 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.\n\nRecurrence 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.","asOf":"2026-09-17","wikipedia":"https://en.wikipedia.org/wiki/Hepatocellular_carcinoma","links":[{"label":"BCLC 2022 update (J Hepatol)","url":"https://pubmed.ncbi.nlm.nih.gov/34801630/"},{"label":"Milan criteria (NEJM 1996)","url":"https://www.nejm.org/doi/full/10.1056/NEJM199603143341104"},{"label":"IMbrave050 (Lancet 2023)","url":"https://pubmed.ncbi.nlm.nih.gov/37871608/"},{"label":"Wikipedia","url":"https://en.wikipedia.org/wiki/Hepatocellular_carcinoma"}],"tags":["subtype-page"],"related":["hcc-advanced","hcc-intermediate"],"cancers":[],"sections":[],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["li-rads","depth-of-invasion"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":["paper-mazzaferro-milan-criteria-nejm-1996","paper-bclc-2022-reig-j-hepatol-2022","paper-imbrave050-lancet-2023","paper-storm-adjuvant-sorafenib-bruix-lancet-oncol-2015"],"journals":[],"dependsOn":[],"notes":[],"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"],"standardOfCare":[{"setting":"Single tumour, preserved liver function","approach":"Hepatectomy, increasingly laparoscopic or robotic; ablation as an alternative for tumours up to 3 cm.","refs":["hepatectomy","thermal-ablation","radiofrequency-ablation","microwave-ablation","robotic-surgery","bclc-staging"]},{"setting":"Within Milan criteria with cirrhosis or portal hypertension","approach":"Liver transplantation, with bridging ablation or chemoembolisation on the waiting list and downstaging for patients just outside the criteria.","refs":["liver-transplant-oncology","bridging-therapy","tace","thermal-ablation"]},{"setting":"Not suitable for surgery or ablation","approach":"Stereotactic body radiotherapy or radioembolisation.","refs":["sbrt","radioembolisation-tare"]},{"setting":"After curative treatment","approach":"No proven adjuvant therapy (STORM and IMbrave050 negative in the end); antiviral therapy, alcohol abstinence and continued imaging surveillance.","refs":["imbrave050","atezolizumab","bevacizumab","hcc-surveillance","hbv-hcv"]},{"setting":"Detection","approach":"Six-monthly ultrasound with alpha-fetoprotein in cirrhosis and chronic hepatitis B.","refs":["hcc-surveillance","ultrasound","afp","mri"]}],"stateOfArt":["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."],"history":[{"year":1996,"title":"Mazzaferro defines the Milan criteria for liver transplantation in HCC","refs":["liver-transplant-oncology"]},{"year":1999,"title":"Barcelona Clinic Liver Cancer staging published (Llovet)","refs":["bclc-staging"]},{"year":2006,"title":"Randomised trial shows radiofrequency ablation equals resection for small tumours (Chen)","refs":["radiofrequency-ablation"]},{"year":2015,"title":"STORM: adjuvant sorafenib fails after resection or ablation","refs":["sorafenib"]},{"year":2023,"title":"IMbrave050: adjuvant atezolizumab-bevacizumab improves recurrence-free survival at interim analysis","refs":["imbrave050"]},{"year":2025,"title":"IMbrave050 update: the recurrence-free survival benefit is not sustained","refs":["imbrave050"]}],"pipeline":["imbrave050","liver-transplant-oncology","idea-hcc-io-before-transplant","idea-hcc-blood-surveillance","hcc-surveillance","hifu-histotripsy","mrd-testing"],"openProblems":["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."],"parent":"hcc"},"route":"/cancers/hcc-early/","neighbours":{"cancer":[{"id":"hcc-advanced","kind":"cancer","name":"Advanced hepatocellular carcinoma (BCLC C)","route":"/cancers/hcc-advanced/"},{"id":"hcc","kind":"cancer","name":"Hepatocellular carcinoma","route":"/cancers/hcc/"},{"id":"hcc-intermediate","kind":"cancer","name":"Intermediate hepatocellular carcinoma (BCLC B)","route":"/cancers/hcc-intermediate/"}],"term":[{"id":"afp","kind":"term","name":"Alpha-fetoprotein (AFP)","route":"/terms/afp/"},{"id":"bclc-staging","kind":"term","name":"BCLC staging","route":"/terms/bclc-staging/"},{"id":"bridging-therapy","kind":"term","name":"Bridging therapy","route":"/terms/bridging-therapy/"},{"id":"depth-of-invasion","kind":"term","name":"Depth of invasion (DOI)","route":"/terms/depth-of-invasion/"},{"id":"hepatectomy","kind":"term","name":"Hepatectomy (liver resection)","route":"/terms/hepatectomy/"},{"id":"hbv-hcv","kind":"term","name":"Hepatitis B and C as cancer causes","route":"/terms/hbv-hcv/"},{"id":"li-rads","kind":"term","name":"LI-RADS (Liver Imaging Reporting and Data System)","route":"/terms/li-rads/"},{"id":"microwave-ablation","kind":"term","name":"Microwave ablation (MWA)","route":"/terms/microwave-ablation/"},{"id":"radiofrequency-ablation","kind":"term","name":"Radiofrequency ablation (RFA)","route":"/terms/radiofrequency-ablation/"}],"paper":[{"id":"paper-bclc-2022-reig-j-hepatol-2022","kind":"paper","name":"BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update","route":"/key-papers/paper-bclc-2022-reig-j-hepatol-2022/"},{"id":"paper-imbrave050-lancet-2023","kind":"paper","name":"IMbrave050: adjuvant atezolizumab plus bevacizumab versus active surveillance after resection or ablation of high-risk hepatocellular carcinoma","route":"/key-papers/paper-imbrave050-lancet-2023/"},{"id":"paper-mazzaferro-milan-criteria-nejm-1996","kind":"paper","name":"Liver transplantation for small hepatocellular carcinomas in patients with cirrhosis (the Milan criteria)","route":"/key-papers/paper-mazzaferro-milan-criteria-nejm-1996/"},{"id":"paper-storm-adjuvant-sorafenib-bruix-lancet-oncol-2015","kind":"paper","name":"STORM: adjuvant sorafenib after resection or ablation of hepatocellular carcinoma","route":"/key-papers/paper-storm-adjuvant-sorafenib-bruix-lancet-oncol-2015/"}],"technology":[{"id":"hifu-histotripsy","kind":"technology","name":"Focused ultrasound & histotripsy","route":"/technologies/hifu-histotripsy/"},{"id":"hcc-surveillance","kind":"technology","name":"HCC surveillance in cirrhosis (ultrasound + AFP)","route":"/technologies/hcc-surveillance/"},{"id":"liver-transplant-oncology","kind":"technology","name":"Liver transplantation for cancer (Milan criteria and beyond)","route":"/technologies/liver-transplant-oncology/"},{"id":"mrd-testing","kind":"technology","name":"MRD / molecular residual disease testing","route":"/technologies/mrd-testing/"},{"id":"mri","kind":"technology","name":"MRI","route":"/technologies/mri/"},{"id":"radioembolisation-tare","kind":"technology","name":"Radioembolisation (TARE / SIRT, yttrium-90)","route":"/technologies/radioembolisation-tare/"},{"id":"robotic-surgery","kind":"technology","name":"Robotic & minimally invasive surgery","route":"/technologies/robotic-surgery/"},{"id":"sbrt","kind":"technology","name":"SBRT / SABR (stereotactic radiotherapy)","route":"/technologies/sbrt/"},{"id":"thermal-ablation","kind":"technology","name":"Thermal ablation (RFA, microwave, cryo)","route":"/technologies/thermal-ablation/"},{"id":"tace","kind":"technology","name":"Transarterial chemoembolisation (TACE)","route":"/technologies/tace/"},{"id":"ultrasound","kind":"technology","name":"Ultrasound","route":"/technologies/ultrasound/"}],"drug":[{"id":"atezolizumab","kind":"drug","name":"Atezolizumab","route":"/drugs/atezolizumab/"},{"id":"bevacizumab","kind":"drug","name":"Bevacizumab","route":"/drugs/bevacizumab/"},{"id":"sorafenib","kind":"drug","name":"Sorafenib","route":"/drugs/sorafenib/"}],"trial":[{"id":"nct05489289","kind":"trial","name":"A Phase III Study of AK104 as Adjuvant Therapy in HCC With High Risk of Recurrence After Curative Resection","route":"/trials/nct05489289/"},{"id":"nct03383458","kind":"trial","name":"A Study of Nivolumab in Participants With Hepatocellular Carcinoma Who Are at High Risk of Recurrence After Curative Hepatic Resection or Ablation","route":"/trials/nct03383458/"},{"id":"nct04639180","kind":"trial","name":"A Study to Evaluate Camrelizumab Plus Rivoceranib (Apatinib) as Adjuvant Therapy in Patients With Hepatocellular Carcinoma (HCC) at High Risk of Recur","route":"/trials/nct04639180/"},{"id":"nct05862337","kind":"trial","name":"Anlotinib Hydrochloride Capsules Combined With Penpulimab Injection for the Treatment of Hepatocellular Carcinoma at High Risk of Recurrence.","route":"/trials/nct05862337/"},{"id":"nct03847428","kind":"trial","name":"Assess Efficacy and Safety of Durvalumab Alone or Combined With Bevacizumab in High Risk of Recurrence HCC Patients After Curative Treatment","route":"/trials/nct03847428/"},{"id":"imbrave050","kind":"trial","name":"IMbrave050","route":"/trials/imbrave050/"},{"id":"nct03916627","kind":"trial","name":"Neoadjuvant Cemiplimab for the Treatment of Resectable NSCLC, HCC, and HNSCC in Adult Patients","route":"/trials/nct03916627/"},{"id":"nct07324304","kind":"trial","name":"NWRD06 DNA Plasmid for HCC After Curative Resection.","route":"/trials/nct07324304/"}],"idea":[{"id":"idea-hcc-blood-surveillance","kind":"idea","name":"Blood-based HCC surveillance to replace six-monthly ultrasound","route":"/ideas/idea-hcc-blood-surveillance/"},{"id":"idea-hcc-io-before-transplant","kind":"idea","name":"Immunotherapy downstaging to transplant with a safe washout","route":"/ideas/idea-hcc-io-before-transplant/"}],"person":[{"id":"jordi-bruix","kind":"person","name":"Jordi Bruix","route":"/people/jordi-bruix/"}]}}