Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and one of the leading causes of cancer mortality worldwide. Its peculiarity is that in almost 80–90% of cases, it develops against the background of an already diseased organ — on cirrhotic liver, most often after prolonged viral hepatitis B or C, non-alcoholic steatohepatitis (NASH/MASH), or alcoholic liver disease. The tumor is both a malignant neoplasm and a complication of chronic liver disease, so the success of treatment depends not only on the precision of the surgeon or radiologist but also on how well the organ's function is assessed and the strategy is selected within the stage.
At the Ichilov Medical Center (Sourasky), the largest multidisciplinary hospital in Israel located in the center of Tel Aviv, the treatment program for HCC is based on the international BCLC staging system and the recommendations of EASL and AASLD. The clinic's arsenal includes anatomical liver resection, transplantation according to the Milan criteria, local thermal ablation (RFA, MWA), transarterial chemoembolization (TACE), yttrium-90 radioembolization (TARE), and a full range of modern targeted and immuno-oncological regimens. Below is a detailed analysis of how Ichilov approaches the diagnosis, staging, and selection of treatment methods for liver cancer.
What is this disease
Hepatocellular carcinoma is a malignant tumor that develops from the main liver cells, hepatocytes. It accounts for about 75–85% of all primary malignant neoplasms of the liver; the remaining part consists of intrahepatic cholangiocarcinoma (bile duct cancer), hepatoblastoma, and rare sarcomas. Approximately 900,000 new cases of HCC are registered worldwide each year, and the incidence continues to rise, largely due to the "epidemic" of non-alcoholic fatty liver disease.
The main risk factors are well known and allow for the identification of observation groups. The most significant among them are chronic viral hepatitis B (the risk remains even without cirrhosis), chronic hepatitis C leading to cirrhosis, alcoholic cirrhosis, non-alcoholic steatohepatitis, hemochromatosis, alpha-1-antitrypsin deficiency, autoimmune hepatitis, and primary biliary cholangitis. A separate risk group includes patients exposed to aflatoxin B1 (mold toxins), as well as individuals with obesity, type 2 diabetes, and metabolic syndrome. Male gender and age over 50–55 years further increase the risk.
The clinical insidiousness of HCC is that in the early stages, it is almost asymptomatic. Initial complaints include heaviness and dull pain in the right upper quadrant, unexplained weight loss, weakness, decreased appetite, and subfebrile temperature — these appear when the tumor has already reached several centimeters. Increasing jaundice, ascites, and bleeding from esophageal varices are often manifestations not only of the tumor itself but also of progressive liver failure against the background of cirrhosis. That is why in most countries, patients in the risk group are recommended to undergo screening — liver ultrasound and alpha-fetoprotein (AFP) determination every 6 months.
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Diagnosis at Ichilov
The diagnosis of HCC at Ichilov is based on the international rule of "non-invasive diagnosis": in a patient with cirrhosis or chronic hepatitis B, a nodule in the liver can be considered hepatocellular carcinoma without biopsy if it demonstrates typical behavior on contrast imaging — early arterial contrast enhancement and its "washout" in the venous or delayed phase. The clinic's task is to obtain this picture as reliably as possible and within understandable timeframes.
The standard diagnostic protocol at Sourasky includes several blocks. Laboratory assessments include AFP, PIVKA-II (DCP), a complete biochemical liver profile, coagulation profile, viral markers (HBsAg, anti-HCV, HBV/HCV PCR if necessary), kidney function markers, and the overall condition of the patient according to the Child-Pugh and MELD scales — this is critically important for selecting the treatment method. Instrumental diagnostics begin with targeted liver ultrasound with contrast enhancement (CEUS), followed by multiphase MRI of the liver with hepatospecific contrast based on gadobenate dimeglumine (EOB, Primovist). EOB-MRI is currently considered the "gold standard" for detecting small foci of HCC on cirrhotic liver measuring from 1 cm and differentiating them from dysplastic regenerative nodules.
Additionally, a CT scan of the chest, abdomen, and pelvis with intravenous contrast is performed to assess extrahepatic spread, the volume of functioning parenchyma, and vascular anatomy (arterial, portal, venous) — this data is necessary for planning resection, TACE, and radioembolization. In case of controversial findings or suspicion of atypical histology (combined HCC-cholangiocellular carcinoma, fibrolamellar carcinoma), targeted liver biopsy is performed under ultrasound or CT guidance. PET-CT is not very informative in classical HCC but is used when distant metastases are suspected, in intrahepatic cholangiocarcinoma, and in assessing response to systemic therapy.
All data is discussed at the weekly multidisciplinary council of the hepatobiliary center at Ichilov, which includes a hepatologist, transplant surgeon, oncologist, interventional radiologist, radiation therapist, and pathologist. It is the council that formulates the stage according to BCLC (0, A, B, C, D) and recommends a specific line of treatment. The complete diagnostic package — from the first visit to the formal conclusion — usually takes 4–6 working days.
Treatment Methods
The choice of treatment for HCC is determined by three parameters: the stage according to BCLC, the functional reserve of the liver (Child-Pugh, MELD, ALBI), and the overall somatic status of the patient. Ichilov employs a full "continuum" of modern methods — from radical surgery to systemic immuno-oncology.
Liver resection. Anatomical resection of a segment, bisegmentectomy, lobectomy, or extended hemigastrectomy is primarily considered for patients with a solitary nodule, preserved liver function (Child-Pugh A, without clinically significant portal hypertension), and sufficient future liver remnant volume (FLR ≥ 30–40% depending on background pathology). Surgeons at Sourasky use laparoscopic and robot-assisted approaches to resection, intraoperative ultrasound, and ICG fluorescence for navigation along the tumor boundaries and segments, and if necessary, preoperative portal vein embolization (PVE) or ALPPS to increase future remnant volume. The five-year survival rate after radical resection for HCC stage BCLC 0/A exceeds 60–70% according to various series.
Liver transplantation. For selected patients, transplantation solves two problems at once — it removes the tumor and "cures" cirrhosis. The classic Milan criteria (one nodule up to 5 cm or up to 3 nodules, each up to 3 cm, without vascular invasion and extrahepatic metastases) remain fundamental; in some cases, extended protocols (UCSF, up-to-seven) are considered with favorable tumor biology. Ichilov participates in the national Israeli transplantation program; some patients from the CIS are also considered candidates for transplantation from a living donor.
Radiofrequency (RFA) and microwave (MWA) ablation. Local thermal destruction of the tumor under ultrasound or CT navigation is indicated for small HCCs (usually up to 3 cm, with favorable localization — up to 4 cm). For nodules ≤2 cm, RFA/MWA is comparable to resection in oncological outcomes but is significantly gentler in terms of recovery and preservation of parenchyma. Microwave ablation provides a larger zone of necrosis in a shorter time and is less dependent on the "cooling effect" of nearby vessels, which is why it is actively used at Ichilov for perivascular nodules.
Transarterial chemoembolization (TACE). TACE is the standard for BCLC-B (intermediate stage): multiple nodules or nodules inaccessible for ablation, with preserved liver function and no vascular invasion. Through a catheter inserted into the femoral artery, the interventional radiologist selectively catheterizes the feeding branches of the hepatic artery and injects either lipiodol with doxorubicin (cTACE) or microspheres loaded with cytostatic (DEB-TACE). Both options are available at Ichilov; the choice depends on the size and localization of the foci, the presence of arterio-portal shunts, and the tolerability of the procedure.
Yttrium-90 radioembolization (TARE, Y-90). Selective internal radiotherapy with Y-90 microspheres is used for larger or multifocal nodules, in the case of tumor thrombus in the portal vein (including lobar), as well as as a "bridge" to resection or transplantation and as a method of "radiation lobectomy" for hypertrophy of the contralateral lobe before resection. TARE is performed in two stages: first, a mapping angiography with macroaggregates of albumin labeled with technetium-99m is performed to calculate the dose and exclude shunting to the lungs, then the actual embolization with Y-90 microspheres is done. The method is well tolerated and often allows for tumor control for months and years.
Stereotactic body radiation therapy (SBRT). For technically inoperable nodules and in cases of contraindications to ablation and TACE, as well as in the case of tumor thrombus in the portal vein, SBRT is considered — targeted high-dose irradiation in 3–5 fractions on machines with respiratory control. The method complements rather than replaces locoregional approaches.
First-line systemic therapy. For advanced HCC (BCLC-C — vascular invasion, extrahepatic metastases) or after progression on locoregional therapy, the standard first-line treatment today is the combination of atezolizumab + bevacizumab (PD-L1 inhibitor and anti-angiogenic drug). It has shown an advantage in overall survival compared to sorafenib in the IMbrave150 study. An alternative is the combination of durvalumab + tremelimumab (STRIDE regimen) for patients with contraindications to bevacizumab (e.g., recent variceal bleeding). For patients for whom immunotherapy is contraindicated, multi-kinase inhibitors lenvatinib or sorafenib are used.
Second and subsequent lines. After progression on the first line, regorafenib, cabozantinib, ramucirumab (for AFP ≥ 400 ng/ml), as well as immuno-oncological approaches — nivolumab, pembrolizumab, and the combination of pembrolizumab + lenvatinib are discussed. The choice depends on prior therapy, tolerability, and liver functional status.
Cholangiocarcinoma — a brief remark. If the diagnosis is revised in favor of intrahepatic cholangiocarcinoma based on the examination results, the tactics change. The standard first line is chemotherapy with gemcitabine + cisplatin, to which today durvalumab (TOPAZ-1 regimen) or pembrolizumab (KEYNOTE-966) is added. In localized forms, resection and, in some patients, transplantation with neoadjuvant chemoradiotherapy are discussed.
Treatment Program — Stages
The program at Ichilov is structured so that patients from the CIS can plan their time and logistics while staying in Tel Aviv. Below is a typical sequence.
Stage 1. Preliminary assessment (remotely). The international department receives discharge summaries, disks with CT/MRI, histological slides and blocks if a biopsy has already been performed. The curator forms a cost estimate, sets dates, and assists with the medical visa if necessary.
Stage 2. Diagnosis and revision (3–6 days). Consultation with a hepatologist and oncologist, revision of histology in the Sourasky pathology laboratory, EOB-MRI of the liver, CT scan of the chest and pelvis, complete laboratory profile, and if necessary, targeted biopsy under CT. The outcome of this stage is a conclusion from the multidisciplinary council with the BCLC stage and treatment plan.
Stage 3. Treatment. Depending on the stage — resection, ablation under imaging control, TACE, Y-90 radioembolization, initiation of systemic therapy, or preparation for transplantation. Some procedures are performed on an outpatient basis, while others require hospitalization from 2 to 7 days.
Stage 4. Early control and adjustment. After 4–8 weeks — control EOB-MRI or CT, laboratory control (AFP, liver function), assessment of response according to mRECIST criteria. In the case of partial response or progression, the council adjusts the strategy: adds a second locoregional procedure, switches to systemic therapy, or, conversely, raises the question of resection/transplantation after a successful "bridge".
Stage 5. Long-term follow-up. For the first 2 years — imaging every 3 months, then every 6 months; simultaneously, antifibrotic and antiviral treatment of the underlying liver disease is continued. Follow-up can be conducted jointly with the local physician with telemedicine consultations from Ichilov specialists.
Prices and Costs
The exact cost of the program is always calculated individually based on the results of the preliminary assessment, as for HCC, the price is determined not so much by the "diagnosis name" but by the stage, accompanying cirrhosis, and the chosen method. Below are approximate ranges in US dollars as of 2025–2026; the actual estimate from Sourasky may differ.
Diagnostic package (consultations with a hepatologist and oncologist, EOB-MRI of the liver, CT scan of 3 areas, laboratory profile, histology revision, council) — approximately 4,500–7,500 USD. If a targeted biopsy under CT is necessary — an additional 1,800–2,800 USD.
Local methods. RFA/MWA of a solitary nodule — approximately 15,000–22,000 USD including one-day hospitalization. TACE — from 12,000 to 22,000 USD depending on the type (cTACE or DEB-TACE) and the number of sessions. Y-90 radioembolization — approximately 45,000–70,000 USD including mapping angiography and microspheres.
Surgery. Laparoscopic segmental liver resection — approximately 40,000–65,000 USD; open extended hemigastrectomy — from 55,000 to 90,000 USD including resuscitation and hospitalization. The cost of liver transplantation is calculated separately; candidacy is discussed individually.
Systemic therapy. The cost of one month of treatment with atezolizumab + bevacizumab or the combination of durvalumab + tremelimumab is approximately 8,000–14,000 USD; targeted therapy with lenvatinib or sorafenib — 2,500–5,000 USD per month. Many medications can be continued on an outpatient basis at home under supervision.
The final estimate is always documented in writing before treatment begins. The Sourasky clinic is a public institution, so prices are transparent and not "caught up" after the fact.
Leading Specialists in the Field
The HCC treatment program at Ichilov is led by a multidisciplinary team from the hepatobiliary center. It includes the head of the hepatobiliary and transplant surgery department, leading hepatologists from the Liver Disease Institute, oncologists from the Rosenfeld Oncology Division, interventional radiologists from the angiography department, and radiation therapists from the Oncology Institute. It is the joint decision of the council, not the "opinion of one professor," that determines the treatment line — this is the clinic's principled position.
The personal composition of the team for a specific case is confirmed by the international department after receiving the discharge summaries: the physician is selected based on the tumor profile (for example, for candidates for transplantation, the leading specialist becomes the transplant surgeon, for BCLC-C — the hepatologist-oncologist). Indicating specific names without document analysis would be incorrect, so the names of treating physicians and specialized consultants are sent by the clinic along with the final program and estimate.
Frequently Asked Questions (FAQ)
In what language will I communicate with the doctors and coordinator?
Ichilov has an international department with Russian-speaking coordinators who assist the patient from the first email to follow-up examinations. Some doctors speak Russian; when consulting with Hebrew-speaking specialists, a medical translator is present. All documents — conclusions, discharge summaries, histological reports — are issued in English and can be translated into Russian upon request.
What documents should I send in advance?
The optimal package: recent discharge summaries from the hospital and outpatient records, disks with the latest CT and MRI of the liver (no older than 3 months), results of AFP and biochemistry, viral markers (HBsAg, anti-HCV), slides and paraffin blocks from the biopsy if it was performed. The more complete the package, the more accurate the preliminary assessment and estimate.
How long will treatment in Tel Aviv take?
Approximately 5–7 days are needed for diagnosis and the council. Then, depending on the method: RFA/MWA or TACE — hospitalization for 1–2 days and observation for 5–7 days; Y-90 radioembolization — 2 visits with an interval of 2–3 weeks; liver resection — hospitalization for 5–8 days and outpatient observation for up to 3 weeks; transplantation is discussed separately.
Is an advance payment required?
Yes, the standard practice at Sourasky is to prepay the confirmed estimate (diagnostics and the first stage of treatment) to the hospital's account. All payments are made directly with the clinic, without intermediaries; any unused funds are refunded, and any overspending is discussed in advance.
Can I get a second opinion before arriving?
Yes. The clinic provides a remote opinion from specialists at the hepatobiliary center based on the submitted documents and images. This is a separate service; it is especially useful to understand whether it makes sense to fly to Tel Aviv and which method is considered primary.
Who makes the final decision about the treatment method?
The multidisciplinary council of the hepatobiliary center. It includes a hepatologist, transplant surgeon, oncologist, interventional radiologist, radiation therapist, and pathologist. The decision is documented in writing and discussed with the patient and their family. There is no single "chief" physician whose opinion outweighs the council; this is an international norm for HCC.
Does Ichilov work with medical insurance?
Ichilov collaborates with several international insurance companies. For patients from the CIS whose treatment is covered by insurance (e.g., when working for an international company), the international department assists in obtaining pre-authorization and directly bills the insurer. Patients paying independently work with a transparent estimate in USD.
How is follow-up organized after returning home?
After completing the active treatment phase, the clinic formulates a detailed follow-up plan: schedule for imaging, laboratory tests, AFP monitoring, continuation of antiviral or antifibrotic therapy. Online consultations with the treating physician and repeat visits to Ichilov every 6–12 months for control EOB-MRI are possible.
How to obtain a treatment program
To receive an individual program and estimate for hepatocellular carcinoma at Ichilov (Sourasky), simply submit a request on the website or contact the international department in any convenient way. The coordinator will request discharge summaries and images, pass them to the relevant specialists at the hepatobiliary center, and within 2–4 working days, you will receive a preliminary conclusion, an approximate treatment plan according to the BCLC stage, and a written estimate in USD. Further steps — coordinating arrival dates in Tel Aviv, arranging a medical visa if necessary, and logistics for accommodation — are handled by the international department.
Early HCC at stage I according to BCLC with radical treatment provides a 5-year survival rate, according to international series, of over 70%, and in certain transplantation scenarios according to Milan criteria — comparable results with the prognosis of a "healthy" population of the same age. That is why, when suspecting liver cancer, it is crucial not to delay: the sooner the patient reaches the council, the wider the window for radical methods and the higher the chance of preserving not only life but also the quality of liver function for years to come.