Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Association for the Study of the Liver.

Management of Hepatocellular Carcinoma

European Association for the Study of the Liver

Publication Date: Dec 17, 2024

Page Last Updated: Apr 27, 2026

Patients with HBV infection should be treated with nucleoside or nucleotide analogues to reduce the risk of developing HCC (both de novo and recurrence) and the type and time of treatment should follow EASL guidelines on HBV infection (LoE 2, strong recommendation, strong consensus)
Patients with HCV infection and liver fibrosis should be treated with direct-acting antivirals to reduce the risk of cirrhosis-related complications, including HCC (LoE 2, strong recommendation, strong consensus).
Patients with HCV infection and a diagnosis of HCC under complete tumour response after surgical or locoregional therapies can be treated with antiviral therapy although the impact on the risk of HCC recurrence is inconclusive (LoE 3, weak recommendation, strong consensus).
Patients with HBV and HCV co-infection can be treated following the same criteria as for mono-infected patients (LoE 3, weak recommendation, strong consensus).
Should lifestyle modifications be recommended for patients with cirrhosis to reduce their risk of HCC?
Weight loss in patients with obesity, alcohol cessation, and tobacco cessation are recommended to reduce the risk of liver-related and other adverse outcomes and may be recommended to reduce the risk of HCC (LoE 3, weak recommendation, strong consensus).
Coffee consumption may be recommended to reduce the risk of HCC (LoE 3, weak recommendation, consensus).
Should prescription drugs be recommended for patients with cirrhosis to reduce their risk of HCC?
Owing to a lack of evidence, the use of statins, aspirin and metformin cannot currently be recommended to reduce the risk of HCC development (LoE 3, weak recommendation, strong consensus).
Should HBV vaccination be given to all high-risk seronegative people?
High-risk seronegative people should be vaccinated against HBV to decrease HCC incidence and HCC-related death and improve overall survival (LoE 3, strong recommendation, strong consensus).
Should patients with cirrhosis be offered surveillance for HCC?
Patients with cirrhosis should be offered surveillance for HCC unless they have a relatively high risk of death from non-HCC causes, or they could not be offered a curative-intent treatment for HCC (e.g., patients with Child-Pugh class C cirrhosis ineligible for liver transplantation) (LoE 2, strong recommendation, strong consensus).
Should patients with chronic liver disease and advanced fibrosis without cirrhosis be offered surveillance for HCC?
Patients with chronic liver disease and advanced fibrosis without cirrhosis have a higher risk of HCC than the general population, but HCC surveillance cannot currently be recommended in this group owing to insufficient evidence (LoE 3, weak recommendation, strong consensus).
Which is the best test (or combination of tests) for HCC screening?
An ultrasound examination of the liver every 6 months is recommended for screening of HCC. The combined use of ultrasound with AFP increases sensitivity while decreasing specificity and is a reasonable option. There is limited data to support the use of other promising imaging modalities such as abbreviated MR or serum biomarkers (LoE 3, strong recommendation, consensus).

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Diagnosis

The LI-RADS should be used to favour standardisation in the acquisition, description and reporting of liver imaging examinations (LoE 3, strong recommendation, strong consensus).
Non-invasive diagnosis of HCC should be based on the LI-RADS CT/MR v2018 or the LI-RADS CEUS v2017 criteria. With CT/MRI, the following major imaging features are combined to reach the diagnosis: tumour size, rim and non-rim arterial hyperenhancement, peripheral and non-peripheral washout (in the portal venous or delayed phases on CT and MRI using extracellular contrast agents or gadobenate dimeglumine, or in the portal venous phase only with MRI using gadoxetic acid), enhancing capsule and threshold growth. With CEUS, non-rim arterial hyperenhancement with late-onset (>60 s) and washout of mild intensity are combined to reach the diagnosis (LoE 1, strong recommendation, strong consensus).
Is the LI-RADS more accurate than the 2018 EASL algorithm for the non-invasive diagnosis of HCC?
The LR-5 category and the 2018 EASL algorithm have similar performance for the non-invasive diagnosis of HCC. However, LI-RADS should be preferred because it introduces valuable refinements (e.g., LR-M and LR-TIV categories) and allows for an estimation of the probability of HCC in nodules that do not meet the LR-5 category (LoE 3, strong recommendation, strong consensus).
Should contrast-enhanced MRI be preferred to contrast-enhanced CT for the non-invasive diagnosis of HCC?
Multiphasic CT or dynamic contrast-enhanced MRI are recommended, without preference, for the non-invasive diagnosis of HCC (LoE 1, strong recommendation, consensus).
Is hepatospecific contrast-enhanced MRI more accurate than extracellular contrast-enhanced MRI for the non-invasive diagnosis of HCC?
Extracellular contrast agents should be favoured over gadoxetic acid for the non-invasive diagnosis of HCC using MRI (LoE 1, strong recommendation, consensus).
Should CEUS be used as a first-line examination for the non-invasive diagnosis of HCC?
CT or MRI should be preferred over CEUS as a first-line examination for the non-invasive diagnosis of HCC because of their higher sensitivity and their utility for analysis of the whole liver (LoE 3, strong recommendation, consensus).
When used for the non-invasive diagnosis of HCC, CEUS should be performed according to the LI-RADS technical recommendations (LoE 4, strong recommendation, strong consensus).
Should imaging-based non-invasive criteria for the diagnosis of HCC be used in patients without cirrhosis?
The non-invasive criteria should only be applied to patients with cirrhosis, chronic HBV infection or a history of HCC. In other patients, the diagnosis of HCC should be confirmed by biopsy (LoE 1, strong recommendation, consensus).
If a biopsy is obtained, should HCC subtyping be performed on biopsy material, including immunostainings with hepatocellular and cholangiocellular markers?
Pathological diagnosis of HCC should be based on the International Consensus recommendations using the required histological and immunohistochemical analyses (LoE 1, strong recommendation, strong consensus).
If a biopsy is obtained, relevant prognostic features should be reported, including tumour differentiation and HCC subtyping per the WHO classification (LoE 1, strong recommendation, strong consensus).
Should the non-tumoural liver parenchyma be systematically sampled in patients undergoing biopsy for the diagnosis of HCC?
In patients undergoing tumour biopsy for the diagnosis of HCC, it is suggested to simultaneously obtain a sample of the non-tumoural liver parenchyma to facilitate the diagnosis (LoE 3, weak recommendation, consensus).
Should biopsy sampling systematically include material for further molecular biology techniques?
Until therapeutic decisions can be reliably informed by molecular analysis of tumours, routine molecular analysis is not recommended (LoE 3, strong recommendation, strong consensus).

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In candidates for TACE, DEB-TACE and cTACE should be considered equivalent (LoE 2, strong recommendation, strong consensus).
In candidates for TACE, bland TAE should be considered an alternative to cTACE or DEB-TACE (LoE 1, strong recommendation, consensus).
Radiation segmentectomy can be considered an alternative to percutaneous ablation for single tumours within Milan criteria that are unsuitable for resection or transplantation, when there is a significant risk of post-ablation recurrence based on size (>3 cm) or location (v.g. in contact with large vessels) (LoE 3, weak recommendation, strong consensus).
EBRT can be considered an alternative to percutaneous ablation for single tumours within Milan criteria unsuitable for resection or transplantation, when there is a significant risk of post-ablation recurrence based on size (>3 cm) or location (v.g. in contact with large vessels) (LoE 4, weak recommendation, consensus).
SIRT can be considered an alternative to TACE in patients with a single HCC unsuitable for thermal ablation or recurrent after ablation, particularly when the intention is to bridge to transplant or facilitate a subsequent liver resection in patients with initially unresectable HCC (LoE 3, weak recommendation, strong consensus).
EBRT can be considered an alternative to TACE in selected patients with single unresectable tumours which are unsuitable for thermal ablation or recurrent after ablation. Patients most likely to benefit from EBRT are those at high risk of complications from TACE/TAE (LoE 3, weak recommendation, consensus).
In candidates for TACE, there is insufficient evidence in Western patients to support the combination of EBRT and TACE in favour of TACE alone. Therefore, combination therapy is not recommended. (LoE 3, strong recommendation, strong consensus).
In patients with lesions not showing a response to one or two consecutive TACE treatments and with preserved liver function other therapies should be considered (LoE 3, strong recommendation, strong consensus).
TACE/TAE should be preferred to systemic therapy for liver-confined disease when a selective approach is possible (based on low tumour size and number, no infiltrative gross appearance, and preserved portal flow) (LoE 4, strong recommendation, strong consensus).
Neither prognostic nor predictive scores should be used to support clinical decision-making between embolic and systemic therapy, though these scores may be useful for identifying those patients unlikely to derive meaningful benefit from either (LoE 3, strong recommendation, strong consensus).
In patients with multiple tumours in the intermediate stage who are not fit for TACE/TAE or surgery, SIRT cannot currently be recommended as an alternative to systemic therapy, although it is an acceptable option if systemic therapy is contraindicated, provided a lobar approach is possible (LoE 4, weak recommendation, consensus).
In patients in the advanced stage due to segmental or lobar portal vein invasion but free from extrahepatic spread, EBRT cannot currently be recommended as an alternative to systemic therapy with immune checkpoint-based combinations, and there is limited data to recommend EBRT or the combination of EBRT with TKIs in preference to TKIs alone (LoE 3, weak recommendation, consensus).
In patients in the advanced stage due to segmental or lobar portal vein invasion but free from extrahepatic spread, SIRT is not recommended as an alternative to systemic therapy (LoE 3, strong recommendation, consensus).
In patients in the intermediate stage with a large tumour burden, intra-arterial therapy (TACE/TAE or SIRT) should not be combined with systemic therapy using TKIs. There is insufficient evidence to provide a recommendation for the combination of intra-arterial therapy (TACE/TAE or SIRT) with immunotherapy using checkpoint inhibitors (LoE 2, strong recommendation, consensus).

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Level of Evidence and Grades of Recommendation

Level	Criteria	Simple model for high, intermediate and low evidence
1	Systematic reviews (SR) (with homogeneity) of randomised-controlled trials (RCT)	Further research is unlikely to change our confidence in the estimate of benefit and risk
2	RCT or observational studies with dramatic effects; SR of lower quality studies (i.e. non-randomised, retrospective)
3	Non-randomised-controlled cohort/follow-up study/control arm of randomised trial (systematic review is generally better than an individual study)	Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate
4	Case-series, case-control, or historically controlled studies (systematic review is generally better than an individual study)
5	Expert opinion (mechanism-based reasoning)	Any estimate of effect is uncertain

Document Overview

Document Title: Management of Hepatocellular Carcinoma

Authoring Society: European Association for the Study of the Liver

Document Publication Date: Dec 17, 2024

Page Last Reviewed/Updated: Apr 27, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: www.journal-of-hepatology.eu/article/S0168-8278(24)02508-X/fulltext

Source Citation: European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma. J Hepatol. 2025 Feb;82(2):315-374. doi: 10.1016/j.jhep.2024.08.028. Epub 2024 Dec 17. PMID: 39690085.

Document Scope, Criteria, and Use Cases

Document Objectives: To provide useful guidance that could help physicians, nurses and other allied health providers, health-policy makers and patients make decisions that are based on scientific evidence and result in the delivery of optimal patient care in dealing with hepatocellular carcinoma (HCC).

Scope: Management

Diseases/Conditions (MeSH): D006528 - Carcinoma, Hepatocellular

Keywords: hepatocellular carcinoma, liver cancer

Target Patient Population: Patients with hepatocellular carcinoma (HCC).

Target Provider Population: Clinicians of all specialties who may deal with the management and care of patients with hepatocellular carcinoma (HCC).

Inclusion Criteria: Male, Female, Adult, Older Adult

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Grade	Wording	Criteria
Strong	Shall, should, is recommended.	Evidence, consistency of studies, risk-benefit ratio, patient preferences, ethical obligations, feasibility
	Shall not, should not, is not recommended.
Weak or open	Can, may, is suggested.
	May not, is not suggested.

Management of Hepatocellular Carcinoma

Summary of Recommendations

Prevention and Surveillance

Fig. 1 Opportunities for the prevention of premature death related to HCC

Diagnosis and Staging

Diagnosis

Staging

Fig. 2 A framework for the diagnosis and staging of patients with HCC.

A Multidisciplinary Approach to Treatment

Surgery

Preoperative Assessment of Surgical Candidacy for Liver Resection

Liver Resection in the Non-Cirrhotic Liver

Liver Resection in the Cirrhotic Liver

Surgical Technique in Liver Resection and Multimodal Treatment

Patient Selection for Liver Transplantation and Tumour Downstaging Strategies

List Priority, Living Donation, Marginal Graft and Dynamic Preservation Techniques in Liver Transplantation for HCC

Fig. 5 Multiparametric preoperative assessment for patients eligible for liver resection.

Fig. 6 Decision-making pathway in patients with HCC who are surgical candidates.

Fig. 7 Surgical decision-making framework for patients with HCC who are surgical candidates.

Other Locoregional Therapies

Systemic Therapies

Table 4. Risk assessment tools for liver function and post-hepatectomy liver failure.

Assessment of Clinical Endpoints in Research and Practice

Level of Evidence and Grades of Recommendation

Document Overview

Document Scope, Criteria, and Use Cases