Liver cancer continues to pose a serious public health challenge in India, with incidence rates estimated at 3 to 5 per 100,000 people and more than 4,000 liver transplants performed annually in 2022-23.
It ranks among the more common cancers in the country and is seen significantly more often in men than women. Even after a tumour is surgically removed, many patients treated for hepatocellular carcinoma (HCC) — the most common form of primary liver cancer — are left with a lingering concern: can the disease return?
The answer is yes, and recurrence is not uncommon. Let’s understand why liver cancer comes back, who faces the highest risk, and how doctors track it after surgery is crucial to improving long-term survival and peace of mind.
What Is Hepatocellular Carcinoma And How Surgery Helps
Hepatocellular carcinoma develops in the main cells of the liver, often in people who already have chronic liver disease. In India and globally, hepatitis B and C infections, alcohol-related liver damage, non-alcoholic fatty liver disease (NAFLD), obesity and diabetes are major risk factors.
When detected early, HCC can sometimes be treated with curative intent. Surgical resection by removing the tumour-bearing portion of the liver remains one of the main treatment options for patients whose cancer is confined and whose liver function is strong enough to tolerate surgery. In selected cases, liver transplantation may be considered, especially when cirrhosis is advanced.
“HCC is the most frequent type of primary liver cancer and often occurs in patients with chronic liver disease or cirrhosis. As an oncosurgeon, surgical intervention is one of the most successful curative therapies when the cancer is diagnosed at an early stage and the liver is functioning properly. Surgical intervention involves the removal of the cancerous part of the liver. In selected patients, liver transplantation is a unique treatment modality because it removes both the cancer and the diseased liver,” said Dr Dr Tirathram Kaushik, Senior Consultant GI, HPB, Gastrointestinal & Thoracic Oncology and Robotic Surgery, HCG Cancer Centre, in Mumbai.
The liver has a remarkable ability to regenerate, which allows surgeons to remove a significant portion if needed. The goal is complete removal of visible tumour tissue with clear margins. However, even after what appears to be successful surgery, the story does not necessarily end there.
How Common Is Recurrence After Surgery?
Liver cancer has one of the highest recurrence rates among solid tumours. Studies show that up to 50% of patients may experience recurrence within two to three years after curative surgery. By five years, recurrence rates can reach as high as 60-70% in some populations.
“Even after successful surgery, the rate of recurrence of HCC is not very low. In fact, globally, it has been estimated that almost 50-70% of patients can develop recurrence of HCC in five years, particularly in patients with associated cirrhosis and aggressive tumour biology. Recurrence of HCC can be either early (within two years, due to microscopic residual tumour) or late (due to new tumours developing in a chronically diseased liver),” said Dr Kaushik.
The first two years after surgery are considered the highest-risk period. Many recurrences occur during this window, which is why follow-up is particularly intensive during this time.
It is important to understand that recurrence does not always mean the original surgery failed. In many cases, the tumour was completely removed. The problem lies deeper, in the biology of the disease and the condition of the liver itself.
Why Does Liver Cancer Return?
There are two main reasons for recurrence. The first is microscopic residual disease. Even with advanced imaging and careful surgical technique, tiny clusters of cancer cells may remain undetected in the liver at the time of surgery. Over time, these cells can grow into new tumours.
The second mechanism is the development of new tumours in diseased liver tissue. Many patients with HCC have underlying cirrhosis or chronic inflammation caused by viral hepatitis, fatty liver disease or alcohol use. This damaged environment creates fertile ground for new cancers to form independently of the original tumour.
Tumour biology also plays a role. Aggressive cancers with vascular invasion, where cancer cells enter blood vessels, are more likely to recur. Larger tumours and those with poor differentiation under the microscope are also linked to higher relapse risk.
“Recurrence can occur because of both biological and lifestyle-related reasons,” explained Dr Kaushik. He said microscopic tumour deposits can be missed at the time of surgery. Aggressive tumour characteristics such as vascular invasion is also known to increase the chances of recurrence. Furthermore, chronic inflammation of the liver due to Hepatitis B, Hepatitis C, fatty liver disease, or alcohol-induced cirrhosis leads to a pro-tumoral environment.
“On the lifestyle side, alcohol use, obesity, poorly controlled diabetes, and smoking are also known to increase the chances of recurrence. Controlling the underlying liver disease is as important as removing the tumour,” Dr Kaushik pointed out.
In short, recurrence is often a combination of tumour behaviour and the ongoing health of the liver.
What Symptoms Should Patients Watch For?
In many cases, recurrent liver cancer does not cause symptoms in its early stages. That is precisely why regular follow-up is essential.
“The patient needs to be vigilant for symptoms such as abdominal pain, weight loss, jaundice, abdominal swelling, and fatigue. However, recurrence may be asymptomatic at first. Regular follow-ups with blood work (including AFP levels) and imaging studies every 3 to 6 months are essential. Early recurrence can greatly improve treatment modalities and outcomes. As surgeons, we strongly advocate the importance of surveillance programmes because early detection of recurrence can turn an otherwise advanced disease into a curable or manageable one,” stressed Dr Kaushik.
Surveillance is designed to detect recurrence before symptoms develop, when treatment options are broader and outcomes are better.
Why Follow-Up Monitoring Matters
After surgery, patients are typically placed on a structured surveillance plan. This often includes imaging tests such as ultrasound, contrast-enhanced CT scans or MRI every three to six months during the first two years, and then at longer intervals thereafter.
Blood tests are also important. Alpha-fetoprotein (AFP), a tumour marker elevated in many HCC cases, is commonly monitored. A rising AFP level may signal recurrence even before imaging shows a visible lesion.
Follow-up appointments also assess liver function, manage underlying liver disease and reinforce lifestyle modifications that may reduce risk.
Adherence to this schedule can make a significant difference. Early detection of recurrence opens the door to potentially curative treatments again.
How Is Recurrence Managed?
“If HCC recurs, the treatment options would depend on the size and number of the tumour, as well as the patient’s liver function and overall health status. These include resection of the tumour surgically in selected patients, liver transplantation (if the criteria are met) or minimally invasive therapies like radiofrequency ablation or microwave ablation in patients with small tumours. In some case, transarterial chemoembolization (TACE) or systemic therapies (targeted drugs and immunotherapy) would be recommended. The approach is always individualised, aiming to balance cancer control with preservation of liver function,” Dr Kaushik explained.
In some cases, repeat surgical resection may be possible. Selected patients may become candidates for liver transplantation if recurrence meets specific criteria.
Importantly, recurrence does not automatically mean the end of curative intent. With timely detection and appropriate therapy, long-term control is possible in selected patients.
How To Reduce The Risk Of Recurrence And Long-Term Survival Mechanics
While not all recurrences can be prevented, certain steps may help lower risk.
Controlling hepatitis B or C with antiviral therapy is crucial. Patients with fatty liver disease should work on weight management, improved diet and blood sugar control. Alcohol abstinence is strongly recommended in those with liver damage.
Regular exercise, a balanced diet and management of metabolic conditions such as diabetes and hypertension can support overall liver health.
Close communication with healthcare providers is essential. Survivorship care is not passive observation; it is an active partnership between patient and doctor.
Liver cancer is no longer viewed solely as an acute surgical challenge but as a chronic condition requiring long-term monitoring and management. Early detection of recurrence offers a second window of opportunity.
