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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Hepatocellular carcinoma

Oncology and palliative care · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Rupture or liver decompensation

Sudden abdominal pain, hypotension and falling haemoglobin may indicate tumour rupture, while encephalopathy, bleeding or sepsis can precipitate acute decompensation.

Action: Resuscitate, activate major-haemorrhage and hepatology pathways as indicated, obtain urgent multiphase imaging and involve interventional radiology and hepatobiliary surgery for haemostasis while treating precipitating liver failure.

Synopsis

Diagnose hepatocellular carcinoma through risk-based imaging or tissue when required, stage tumour and liver reserve together and select resection, transplantation, ablation, transarterial, radiotherapy or systemic treatment safely.

  • Surveillance-detected lesion is a pivotal clue in Hepatocellular carcinoma: Many potentially curable tumours are asymptomatic and found on six-monthly ultrasound in eligible people with cirrhosis.
  • Immediate priority in unstable Hepatocellular carcinoma: Resuscitate, activate major-haemorrhage and hepatology pathways as indicated, obtain urgent multiphase imaging and involve interventional radiology and hepatobiliary surgery for haemostasis while treating precipitating liver failure.
  • Surveillance ultrasound is used early to detect early HCC in people with cirrhosis who could benefit from treatment. Perform every 6 months in the eligible surveillance population; a new lesion at least 1 cm needs dedicated contrast imaging rather than serial routine ultrasound.
  • Multiphase contrast CT or MRI refines the next decision because in an appropriately high-risk liver, a classic pattern can establish HCC non-invasively; atypical lesions need alternative imaging, interval review or biopsy.
  • Move from surveillance to diagnosis: Obtain specialist multiphase CT or contrast MRI and review the lesion through a hepatobiliary radiology and cancer MDT.
  • Select resection, transplant or ablation: Refer eligible cirrhotic patients early for transplantation, using locoregional bridging or downstaging only through the transplant pathway.
  • A major avoidable harm is portal-vein invasion; Tumour thrombus worsens portal hypertension and prognosis and changes suitability for transplant, resection and embolic treatment.
  • A common diagnostic trap is intrahepatic cholangiocarcinoma: A mass-forming biliary cancer may lack classic HCC enhancement and requires tissue because systemic and surgical pathways differ.

Key red flags

A patient with cirrhosis develops unexplained decompensation, weight loss, right-upper-quadrant pain or a new liver lesion.

Sudden abdominal pain, shock and haemoperitoneum suggests rupture of a vascular tumour.

New portal-vein thrombus may represent tumour invasion rather than bland thrombosis.

Rapid jaundice, ascites, encephalopathy or variceal bleeding reduces treatment reserve and needs urgent hepatology care.

A surveillance ultrasound shows a focal lesion at least 1 cm in a high-risk liver.

Ruptured HCC

Abrupt severe abdominal pain, shock and haemoglobin fall with haemoperitoneum is a life-threatening presentation.

Investigation priorities

01
Surveillance ultrasoundFirst step

Detect early HCC in people with cirrhosis who could benefit from treatment.

Management branches

DetectMove from surveillance to diagnosis

Surveillance or symptom-directed imaging identifies a new liver lesion in a person at risk of HCC.

  1. Obtain specialist multiphase CT or contrast MRI and review the lesion through a hepatobiliary radiology and cancer MDT.
  2. Accept a non-invasive diagnosis only when risk context and enhancement pattern meet current criteria; biopsy atypical or non-cirrhotic disease when it changes care.
  3. Stage tumour burden, vascular invasion and extrahepatic disease while measuring liver reserve, portal hypertension, performance and comorbidity.

Key medicines

Atezolizumab with bevacizumabA licensed adult schedule is atezolizumab 1,200 mg intravenously followed by bevacizumab 15 mg/kg intravenously on day 1 every 3 weeks, continued while benefit and tolerability persist under the commissioned HCC pathway.Assess and treat oesophageal varices before bevacizumab, and review bleeding, hypertension, proteinuria, thrombosis, wound healing and immune toxicities; avoid in uncontrolled autoimmune disease or high untreated bleeding risk.
LenvatinibFor eligible adults weighing under 60 kg, use 8 mg orally once daily; for 60 kg or above, use 12 mg once daily, with dose interruption and reduction for toxicity.Control blood pressure, check urine protein, ECG risk, renal, liver and thyroid function and monitor diarrhoea, appetite, weight and hand–foot toxicity.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE QS152 hepatocellular carcinoma surveillanceUK quality standard for six-monthly ultrasound surveillance in eligible adults with cirrhosis.
  • NICE NG50 cirrhosis assessment and managementCurrent NICE recommendations for cirrhosis assessment and management assessment and treatment.
  • NHS England quality HCC ultrasound surveillance guidanceCurrent NHS imaging quality and recall standards for HCC surveillance.
  • Royal College of Pathologists cancer datasetsUK pathology sampling, staging, margin and molecular reporting standards.
  • BNF atezolizumab, bevacizumab, lenvatinib and lactuloseUK prescribing, contraindication and monitoring information for atezolizumab, bevacizumab, lenvatinib and lactulose.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewUnited Kingdom
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