When you’ve been told you need surgery for primary liver cancer (HCC) – preparing as a patient
For patients, families, and primary care teams. From the team behind prehabforsurgery.com
Hepatocellular carcinoma – HCC, the most common form of primary liver cancer – is genuinely different from most other cancers. It almost always arises in a liver that is already damaged: from chronic hepatitis B or C, alcohol-related liver disease, metabolic-associated steatohepatitis (MASH, formerly NASH), or haemochromatosis. That underlying liver disease shapes everything about treatment – which operation is possible, who is suitable for transplant rather than resection, how aggressive prehab needs to be, and what the long-term outlook looks like.
If you have been told you need surgery for HCC, the chances are you have been carrying chronic liver disease for a long time – perhaps without knowing it until the scan that found the cancer. The good news is that modern HCC care is genuinely transformed compared to even ten years ago: hepatitis C is now curable; transplantation criteria have expanded; ablation, TACE, and Y90 radioembolisation give bridging or alternative options; immunotherapy has reshaped advanced disease management. Many patients diagnosed with HCC at an early stage and treated at specialist centres are alive and well at five years.
This article walks through what HCC is, what the surgical and non-surgical options look like, how the multidisciplinary team decides between them, and what you can do in the weeks before surgery to improve your odds. It is not a substitute for advice from your own hepatology and HPB team – it is a starting point for the conversations that follow. For the general overview of liver resection that covers all indications, see [Liver surgery – an overview for patients and families →]
New to prehab? Start with our complete guide to what prehab is.
What is HCC, and why does the underlying liver matter so much?
HCC is cancer that arises from hepatocytes – the main functioning cells of the liver (and different from the bile duct cells, growth of which may lead to a different type of primary liver tumour, called Cholangiocarcinoma). It is the most common primary liver cancer worldwide and the third-leading cause of cancer death globally. Around 80–90% of HCC cases worldwide arise in a liver that is already diseased – most commonly cirrhotic. The combination of HCC plus underlying cirrhosis is what makes treatment genuinely complex: you are managing two diseases at once.
Common causes of the underlying liver disease:
• Chronic hepatitis B (HBV) infection – globally the largest single cause; vaccination has reduced new cases dramatically in younger generations
• Chronic hepatitis C (HCV) infection – now CURABLE with direct-acting antivirals (DAAs); cure reduces but does not eliminate future HCC risk
• Alcohol-related liver disease – risk increases significantly with sustained intake above 2-3 units/day for women and 3-4 units/day for men over years
• Metabolic dysfunction-associated steatohepatitis (MASH, formerly NASH) – rising cause linked to obesity, type 2 diabetes, and metabolic syndrome
• Hereditary haemochromatosis – iron overload disorder, particularly common in Irish populations
• Rare causes: Wilson’s disease, alpha-1-antitrypsin deficiency, autoimmune hepatitis, primary biliary cholangitis
A small but growing proportion of HCC – perhaps 10–20% in some recent series – arises in patients without significant underlying liver disease, particularly with MASH-related HCC. These patients have more treatment options because their liver function is preserved.
What modern outcomes look like
Outcomes for HCC vary enormously by stage at diagnosis, by liver function, and by the treatment modality possible. Realistic figures from large international series:
• Early-stage HCC (single small tumour, well-compensated liver) treated by surgical resection or transplant: 5-year survival 50–70%
• Intermediate-stage HCC treated by transarterial chemoembolisation (TACE) or Y90: median survival 20–40 months
• Advanced HCC treated by modern systemic therapy (atezolizumab + bevacizumab; tremelimumab + durvalumab): median survival 19-23 months in the IMbrave150 and HIMALAYA trials respectively
• Liver transplantation for HCC within Milan criteria: 5-year survival 70-80%, with significantly lower recurrence rates than resection in cirrhotic livers
Stage at diagnosis is the single biggest determinant. HCC screening in patients with known cirrhosis – abdominal ultrasound and AFP every 6 months – is what catches it early enough for curative treatment. If you have known cirrhosis and have not been on a screening programme, raise this with your hepatology team.
Who is suitable for surgery – and what are the alternatives?
HCC treatment is decided by the multidisciplinary team using a staging framework called BCLC (Barcelona Clinic Liver Cancer staging). Without getting into the details, the framework asks three questions:
1. How extensive is the cancer?
Single tumour or multiple? How large? Has it invaded blood vessels in the liver (portal vein, hepatic vein)? Has it spread outside the liver? These determine whether curative treatment is even possible.
2. How well is the underlying liver functioning?
This is measured by the Child-Pugh score (A, B, C) and MELD score. Child-Pugh A means liver function is well-preserved and major surgery is possible. Child-Pugh B is the grey zone – some resections possible but transplantation often preferred. Child-Pugh C means surgery carries unacceptable risk and transplantation is usually the only curative option.
3. How well is the patient overall?
Performance status, comorbidities, age (biological not chronological), nutritional state. A fit 75-year-old may tolerate major hepatectomy better than a deconditioned 55-year-old.
From the answers, the team chooses from a hierarchy of treatments:
• Surgical resection – for single tumours in a non-cirrhotic or Child-Pugh A liver where enough functional liver remains after resection
• Liver transplantation – for patients within Milan criteria (one tumour ≤5cm OR up to three tumours each ≤3cm) and increasingly under expanded criteria (UCSF, up-to-7, AFP-modified) – particularly attractive if underlying liver function is poor
• Ablation (radiofrequency, microwave) – for small tumours (≤3cm) where surgery is not feasible due to liver function or comorbidity; outcomes for very small tumours approach those of resection
• Transarterial chemoembolisation (TACE) – for intermediate-stage disease confined to the liver; can also be used as a ‘bridge’ to transplant
• Yttrium-90 (Y90) radioembolisation – selective internal radiation; sometimes used for tumours difficult to address with TACE, or for downstaging before transplant
• Systemic therapy – atezolizumab + bevacizumab; tremelimumab + durvalumab; lenvatinib; sorafenib — for advanced disease, sometimes for downstaging
• Best supportive care – for end-stage disease where curative or life-prolonging treatment is no longer beneficial
Your MDT decision depends on which combination of these you are suitable for. Many HCC patients receive more than one treatment over time – for example, TACE first to downstage, then transplantation. This is normal.
The pre-operative assessment journey
If surgery (resection or transplantation) is on the table, expect:
• Triphasic CT and MRI with liver-specific contrast (Primovist) – for detailed lesion characterisation and FLR planning
• AFP (alpha-fetoprotein) tumour marker – used for trend monitoring; very high levels can sometimes contraindicate transplantation
• Detailed liver function assessment – bilirubin, INR, albumin, platelets, plus ICG (indocyanine green) clearance or hepatobiliary scintigraphy in selected cases
• Hepatology review – essential. Underlying liver disease must be characterised and optimised before surgery
• Variceal screening – upper GI endoscopy if not done recently. Significant varices may need banding pre-op to reduce intra-operative bleeding risk
• Ascites assessment – and treatment with diuretics or paracentesis if significant; uncontrolled ascites is a relative contraindication to major surgery
• Cardiopulmonary exercise testing (CPET) – standard pre major hepatectomy, especially in the UK.
• If transplantation is being considered: full transplant workup (cardiology, pulmonary, dental, psychosocial, transplant committee review)
• Discussion of consent – risks of post-hepatectomy liver failure are higher in cirrhotic patients and must be discussed honestly
This work-up takes 2-8 weeks depending on whether transplantation is in scope. Use this time actively for prehab.
Prehab for HCC – what’s specific to your situation
HCC prehab has two dimensions: optimising the underlying liver disease, and optimising general fitness for surgery. Both matter; the liver-disease piece is what makes HCC prehab distinct from prehab for CRLM or other liver indications.
1. Optimise the underlying liver disease – every cause has its own priority
If your HCC is on a background of:
• Chronic HCV – get cured. Direct-acting antivirals (DAAs) achieve >95% sustained virological response in 8–12 weeks of oral therapy. SVR before surgery improves post-op liver regeneration and reduces future HCC risk. Talk to your hepatology team immediately if you are not already on treatment.
• Chronic HBV – get suppressed. Tenofovir or entecavir reduces HBV DNA to undetectable levels and reduces HCC recurrence risk post-resection. Continue indefinitely.
• Alcohol-related – STOP completely. For at least 12 weeks pre-op, ideally permanently. Alcohol affects liver regeneration, immune function, and post-op outcomes. Your team will not lecture you but will absolutely assess whether you have stopped.
• MASH/NASH – weight loss, glycaemic control if diabetic, lipid management. Even 5-10% weight loss measurably improves liver histology. Not always achievable in 4-6 weeks pre-op but worth pursuing.
• Haemochromatosis – phlebotomy programme to reduce iron stores if not already on one.
2. Cardiopulmonary fitness
Same as for any major liver surgery – even 3-4 weeks of structured exercise (brisk walking 30-45 minutes most days) measurably improves outcomes. If you have significant cirrhosis with ascites or hepatic hydrothorax, exercise tolerance may be limited – work within what your team thinks is safe, but do something every day.
3. Nutrition – protein, micronutrients, and the salt question
Cirrhotic patients are very commonly sarcopenic and malnourished even when they look well – the liver’s reduced protein-synthesising capacity drives this. Aim for 1.2-1.5 g protein per kg body weight per day in the 4-6 weeks pre-op. A bedtime snack (e.g., glass of milk, peanut butter on toast) helps overnight protein balance in cirrhotic patients specifically – this is specific to cirrhosis and is recommended by EASL/ESPEN guidelines.
• Salt restriction if you have ascites (typically <2 g sodium/day) – your dietitian will guide
• Fat-soluble vitamins (A, D, E, K) – often low in cirrhotic patients; supplemented as needed
• Zinc supplementation in selected cases (some cirrhotic patients have functional zinc deficiency)
• Oral nutritional supplements (Ensure, Fortisip, Fresubin) – commonly prescribed; specifically formulated low-sodium variants exist if ascites is an issue
4. Smoking cessation
Same evidence as for any major surgery – stop ≥4 weeks pre-op ideally, 8 weeks better. Smoking is particularly harmful to liver regeneration in cirrhotic patients.
5. Variceal management
If pre-op endoscopy identifies oesophageal or gastric varices, your team may band them before surgery to reduce risk of catastrophic bleeding during or after the operation. This is outpatient endoscopy, well-tolerated, materially reduces post-op bleeding risk.
6. Ascites and renal function
Uncontrolled ascites significantly increases post-op risk. Indeed, ascites is often deemed a contraindication to liver resection. Diuretic optimisation (spironolactone ± furosemide), salt restriction, and occasionally large-volume paracentesis with albumin replacement may be needed pre-op. Renal function is monitored closely – hepatorenal syndrome is a feared complication and is more likely in patients with poorly-controlled ascites.
7. Diabetes optimisation
If you have MASH-related HCC, you likely have type 2 diabetes. Aim for HbA1c <64 mmol/mol (8%) ideally, lower if achievable, before surgery. Diabetes is associated with worse post-op outcomes after liver surgery.
8. Practical preparation at home
• Help at home for 4-6 weeks post-discharge – recovery is slower in cirrhotic patients than in healthy-liver patients
• Stock the freezer with low-sodium, high-protein, easy-prepare meals
• Sort financial / work matters early
• Plan transport for follow-up appointments (often more frequent in HCC than in CRLM)
• If transplant is in scope: arrange for someone to drive you to a hospital at short notice when a donor organ becomes available — usually within 24 hours of call
Surgical strategies – resection vs transplant
The fundamental choice for many HCC patients is between liver resection (remove the part of the liver containing the cancer) and liver transplantation (replace the whole liver with a donor liver). Each has trade-offs:
Resection
Pros: faster (no waiting for donor organ), preserves your own liver, no immunosuppression needed post-op. Cons: leaves the underlying diseased liver behind, which can develop new HCC elsewhere; not safe if liver function is poor; risk of post-hepatectomy liver failure in cirrhotic patients. Best for patients with Child-Pugh A liver and a single, peripherally-located tumour where enough functional liver remains.
Transplantation
Pros: removes both the cancer AND the diseased liver, addressing both problems at once; lower recurrence rates than resection in cirrhotic livers. Cons: requires waiting for a donor (months to years depending on country and MELD score); lifelong immunosuppression post-op; strict eligibility criteria (Milan; UCSF; up-to-7; AFP-modified). Best for patients with poor liver function or multifocal disease within criteria.
Other techniques sometimes used
• Portal vein embolisation (PVE) – less commonly used in HCC than in CRLM because cirrhotic livers regenerate poorly; useful in selected non-cirrhotic patients
• ALPPS – generally avoided in cirrhotic patients (high risk of post-hepatectomy liver failure)
• Anatomic vs non-anatomic resection – anatomic resections (taking a full segment) may have oncological advantages in HCC because of how the cancer can spread along portal vein branches
• Laparoscopic / robotic resection – increasingly common for peripherally-located HCC, particularly in cirrhotic patients where it reduces ascites and wound morbidity
Recovery expectations
ERAS principles apply, but recovery is generally slower than in non-cirrhotic patients:
• Hospital stay: typically 7-10 days for open major hepatectomy in cirrhotic patients; 4-6 days for laparoscopic resections; significantly longer for transplant (2-4 weeks)
• First 2-3 weeks home: low energy, swelling/ascites possible, careful monitoring
• Weeks 4-8: progressive recovery; return to office-type work usually 6-8 weeks
• Months 2-6: full physical recovery in most resection patients; transplant patients have ongoing immunosuppression management for life
• Long-term: regular hepatology / oncology / transplant follow-up indefinitely
Long-term outlook and ongoing surveillance
Even after successful resection of HCC, the underlying liver remains at risk of developing new HCC. Surveillance after resection typically involves:
• Triphasic CT or MRI every 3-6 months for the first 2 years, then 6-12 monthly thereafter
• AFP at each visit
• Ongoing hepatology management of the underlying liver disease (DAAs for HCV cure if not already done; HBV antivirals continued; alcohol abstinence maintained; MASH management ongoing)
• Variceal surveillance endoscopy as advised
• Annual screening for the consequences of cirrhosis if relevant: osteoporosis, malnutrition, hepatorenal function
After transplantation, surveillance is for both HCC recurrence and for transplant-specific issues (rejection, immunosuppression side effects, opportunistic infection, secondary cancers from long-term immunosuppression).
Resources
• British Liver Trust – britishlivertrust.org.uk – comprehensive patient information, support line, financial advice
• Irish Liver Foundation – liver.ie – Irish patient charity
• Irish Cancer Society – irishcancer.ie – patient support, information line, financial advice
• EASL (European Association for the Study of the Liver) – easl.eu – patient leaflets and information
• Hep B/C support: Hepatitis Ireland (hepatitis.ie), British Liver Trust hepatitis sections
• Patient transplant communities: Transplant Sport, Irish Kidney Association (also supports liver transplant patients)
• Your local hepatobiliary unit’s patient information leaflets – ask for one
Evidence base
Key sources informing this article:
• EASL Clinical Practice Guidelines: management of hepatocellular carcinoma. J Hepatol 2018;69(1):182–236 (with subsequent updates — verify most recent version).
• Reig M, Forner A, Rimola J et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update. J Hepatol 2022;76(3):681–693.
• Mazzaferro V, Regalia E, Doci R et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334(11):693–699 (Milan criteria, foundational).
• Yao FY, Mehta N, Flemming J et al. Downstaging of hepatocellular cancer before liver transplant: long-term outcome compared to tumors within Milan criteria. Hepatology 2015;61(6):1968–1977.
• Finn RS, Qin S, Ikeda M et al. Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma (IMbrave150). N Engl J Med 2020;382(20):1894–1905.
• Abou-Alfa GK, Lau G, Kudo M et al. Tremelimumab Plus Durvalumab in Unresectable Hepatocellular Carcinoma (HIMALAYA). NEJM Evid 2022;1(8).
• Plauth M, Bernal W, Dasarathy S et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019;38(2):485–521.
• Melloul E, Hübner M, Scott M et al. Guidelines for perioperative care for liver surgery: ERAS Society recommendations. World J Surg 2016;40(10):2425–2440 (with updates).
• NICE — Hepatocellular carcinoma management pathway and updates including DAA-era guidance.
A final word
Primary liver cancer (HCC) is a more complex diagnosis than most other liver cancers because it usually sits on top of underlying liver disease. The good news is that modern HCC care is transformed compared to even a decade ago: hepatitis C is curable; transplantation criteria have expanded; the toolkit of treatments now includes ablation, TACE, Y90, transplantation, and increasingly effective immunotherapy. Many patients diagnosed at an early stage and treated at specialist centres are alive and well at five years.
The weeks before surgery are time you can spend actively improving the odds — optimising the underlying liver disease, building fitness, eating well, stopping alcohol completely if relevant, getting variceal and ascites issues addressed. Patients who arrive at surgery having done this work recover faster, have fewer complications, and are better positioned to complete any treatment that follows.
If anything in this article does not match what your own team is telling you, follow your team’s advice for your particular situation. This is a general guide; your care is specific.
Reviewed by Mr Tom Gallagher, Consultant HPB Surgeon, St Vincent’s Healthcare Group, Dublin. Last updated 1 June 2026.