Liver cancer & tumours — expert surgery, explained honestly

The liver is the body’s largest internal organ, involved in hundreds of metabolic functions. Tumours within it fall into two broad groups:

This is cancer that starts in the liver itself. The most common type is hepatocellular carcinoma (HCC), which typically arises on a background of liver cirrhosis or chronic hepatitis B or C infection. HCC can grow slowly enough that, if caught on surveillance, surgery offers a genuine chance of cure. Less common primary tumours include cholangiocarcinoma (arising from bile ducts within the liver) and hepatic angiosarcoma.

These are tumours that have spread to the liver from a cancer elsewhere in the body — most commonly colorectal (bowel) cancer. Colorectal liver metastases are, in the right patient, surgically curable. Other sources include breast, neuroendocrine tumours, and stomach cancer. The liver is a common site for spread, but “spread to the liver” does not automatically mean the situation is beyond surgery.

Haemangiomas (benign blood vessel tangles) and focal nodular hyperplasia (FNH) are common incidental findings on imaging; most need only monitoring. Hepatic adenomas, particularly large ones, may warrant surgery due to a small risk of rupture or malignant change.

Primary liver cancer is often silent in its early stages, which is why regular surveillance in high-risk patients is so important. When symptoms do appear, they may include:

• Pain or fullness in the upper-right abdomen — a dull ache or sense of pressure under the right ribs
• Unexplained weight loss — significant and progressive
• Jaundice — yellowing of the skin or whites of the eyes
• Loss of appetite and persistent fatigue
• A palpable lump in the upper abdomen
• Worsening liver function in a patient already known to have cirrhosis or hepatitis

Patients with known cirrhosis or chronic hepatitis B or C should be on a formal 6-monthly ultrasound surveillance programme — HCC detected at this stage is often small and potentially curable.

For primary liver cancer (HCC), the most significant risk factors are:

• Chronic hepatitis B or C infection — the commonest underlying cause worldwide
• Liver cirrhosis — from any cause, including alcohol, hepatitis, or non-alcoholic fatty liver disease (NAFLD)
• Non-alcoholic fatty liver disease (NAFLD/NASH) — increasingly common; can progress to cirrhosis even without heavy alcohol use
• Heavy, long-term alcohol use
• Aflatoxin exposure — a naturally occurring mould toxin found in some foodstuffs, particularly in tropical regions
• Family history — first-degree relatives with HCC or hereditary liver conditions

For secondary liver tumours (metastases), the risk factor is having an existing primary cancer elsewhere — most commonly colorectal (bowel) cancer, which frequently spreads to the liver via the portal circulation. Staging scans after a bowel cancer diagnosis routinely assess the liver for this reason.

An accurate diagnosis requires careful imaging and, in most cases, specialist multi-disciplinary discussion before any treatment decision is made. The assessment typically includes:

• Ultrasound — usually the first-line test; identifies a lesion and prompts further imaging
• Triple-phase CT scan or MRI with contrast — the gold standard for characterising liver lesions; the enhancement pattern during different vascular phases is often diagnostic for HCC without the need for biopsy
• AFP (alpha-fetoprotein) — a blood marker that is elevated in many (though not all) HCC cases; useful alongside imaging
• Liver biopsy — not always required; used selectively when imaging is indeterminate or to confirm the primary site for metastatic disease
• Assessment of liver function — essential before any surgery; tests include Child-Pugh score, MELD score, and volumetric assessment of the future liver remnant (FLR)
• Multidisciplinary tumour board (MDT) — every case should be reviewed by a team including HPB surgeon, hepatologist, oncologist, and radiologist

The right treatment depends on the type of tumour, its size and location, the number of lesions, and the underlying health of the liver. Options include:

Surgery remains the best curative treatment for both primary liver cancer and resectable colorectal liver metastases. The extent of resection is tailored to the tumour — a segmentectomy removes one segment of the liver, while a hemihepatectomy removes an entire lobe (left or right). The liver has a remarkable ability to regenerate, so large resections are possible provided adequate liver function is preserved.

Where the tumour location and patient fitness allow, keyhole (laparoscopic) liver resection offers the same oncological outcome with less blood loss, a shorter hospital stay, and faster recovery. Dr Kumar performs laparoscopic liver resections in suitable cases.

For small tumours (typically under 3 cm), radiofrequency ablation (RFA) or microwave ablation can destroy the lesion using heat delivered via a needle under imaging guidance. Ablation is sometimes used alongside surgery or in patients who cannot undergo resection.

When bowel cancer has spread to the liver, treatment often involves chemotherapy combined with surgery. Some patients require downstaging — shrinking the tumour with chemotherapy first to make resection possible. The MDT reviews timing and sequencing of surgery on the bowel and the liver, which may be simultaneous or staged.

In selected patients with HCC within strict criteria (the Milan criteria) on a background of cirrhosis, liver transplantation offers both a cure for the cancer and replacement of the diseased liver. Where appropriate, Dr Kumar will refer to a transplant centre and support the process.

Dr Ameet Kumar is a high-volume HPB surgeon trained at AIIMS New Delhi with an FRCS (Glasgow) — specialising in complex liver, pancreatic, and biliary surgery. His approach to liver cancer combines technical expertise with honest, patient-centred communication:

• Careful volumetric assessment — calculating the future liver remnant (FLR) before surgery to ensure sufficient liver remains post-resection
• Patient selection — matching the right operation to the right patient, considering both tumour biology and underlying liver health
• Keyhole liver resection where suitable — laparoscopic approach for appropriate tumour locations, reducing recovery time
• MDT-driven planning — every complex case reviewed with hepatology, oncology, and radiology before any decision
• Honest counselling — clear explanation of what surgery can and cannot achieve; no false promises, no alarm

He is in private practice in Bengaluru and sees patients from across India for second opinions, complex resections, and multidisciplinary planning.

The liver has a unique capacity to regenerate — even after removing a significant portion, the remaining liver grows back to near its original volume over several weeks. This is what makes large liver resections safe in patients with a healthy liver. Key points about recovery:

• Hospital stay — typically 3–7 days for laparoscopic resection, 5–10 days for open surgery, depending on the extent of the resection
• Return to normal activity — most patients are back to light activities within 4–6 weeks
• Follow-up imaging — regular CT or MRI scans in the months and years after surgery to monitor for any recurrence
• Liver function monitoring — blood tests to track liver recovery in the early post-operative period

For patients with underlying cirrhosis, recovery requires closer monitoring as the remaining liver has less reserve. The pre-operative assessment specifically plans for this.