AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma

Key guideline recommendations

1. Hepatitis B vaccination should be given to all newborns and to high-risk adults not vaccinated at birth, to reduce the risk of HCC.

   Level 2, Strong

2. Antiviral drugs should be given to all patients who meet treatment criteria for HBV and HCV infection according to AASLD guidelines; in chronic viral hepatitis, HBV suppression and HCV eradication reduce the risk of developing HCC.

   Level 2, Strong

3. Patients at high risk of HCC should be enrolled in surveillance programmes, provided they are candidates for HCC treatment.

   Level 2, Strong

4. HCC surveillance should be performed with ultrasound and AFP at six-monthly intervals (approximately every 6 months).

   Level 2, Strong

5. Patients with any suspicious lesion of 1 cm or larger on ultrasound should undergo diagnostic evaluation with multiphasic contrast-enhanced CT or MRI.

   Level 1, Strong

6. In at-risk patients with cirrhosis or chronic hepatitis B, the diagnosis of HCC should be based on non-invasive imaging criteria and/or pathology.

   Level 1, Strong

7. Although several staging systems exist, AASLD recommends the BCLC system; patients with HCC should be evaluated and managed in a multidisciplinary care setting.

   Level 5, Strong / Level 3, Strong

8. In patients with cirrhosis, surgical resection is the treatment of choice for patients with limited tumour burden, well-compensated cirrhosis without clinically significant portal hypertension, and an adequate future liver remnant.

   Level 2, Strong

9. AASLD recommends immune checkpoint inhibitor-based adjuvant systemic therapy in patients at high risk of recurrence after liver resection or local ablation. (Note: this recommendation was based on the early IMbrave050 results; in the updated 2026 analysis, the recurrence-free survival benefit was not sustained.)

   Level 2, Strong

10. Liver transplantation should be the treatment of choice for transplant-eligible patients with early-stage HCC in the setting of clinically significant portal hypertension and/or decompensated cirrhosis.

    Level 2, Strong

11. Patients who are transplant-eligible apart from an initial tumour burden beyond the Milan criteria (especially those meeting the UNOS downstaging criteria) should be considered for liver transplantation after successful downstaging to within the Milan criteria and an observation period of 3 to 6 months; patients with AFP above 1000 ng/mL must reach an AFP below 500 ng/mL to be considered successfully downstaged.

    Level 2, Strong

12. Thermal ablation (radiofrequency or microwave) should be the treatment of choice for early-stage HCC of 3 cm or smaller in patients who are not suitable for, or decline, surgery.

    Level 1, Strong

13. Patients with BCLC stage B HCC should be treated with transarterial chemoembolisation (TACE). AASLD does not recommend combining systemic therapy with arterial therapies in stage B outside a clinical trial.

    Level 1, Strong / Level 2, Strong

14. Radioembolisation is recommended as an alternative to chemoembolisation in patients with BCLC stage B HCC.

    Level 3, Strong

15. Systemic therapy should be offered to patients with preserved liver function (Child-Pugh A cirrhosis or selected Child-Pugh B patients) and ECOG PS 0 to 1 who have BCLC stage C HCC, or BCLC stage B HCC that is not amenable to, or has progressed after, locoregional therapy.

    Level 1, Strong

16. Patients with advanced HCC and Child-Pugh A cirrhosis should receive atezolizumab + bevacizumab or durvalumab + tremelimumab as preferred first-line options.

    Level 2, Strong

17. Patients being considered for atezolizumab + bevacizumab should undergo upper endoscopy (EGD) to assess high-risk stigmata of variceal or other gastrointestinal bleeding; patients with gastrointestinal bleeding within the past 6 months or high-risk stigmata should have their varices adequately treated before starting, or may be considered for durvalumab + tremelimumab.

    Level 5, Strong

18. In Child-Pugh A patients with contraindications to atezolizumab + bevacizumab and durvalumab + tremelimumab, first-line sorafenib or lenvatinib should be offered.

    Level 1, Strong

19. Selected patients with Child-Pugh B cirrhosis may be offered sorafenib, lenvatinib or single-agent anti-PD-1 or anti-PD-L1 checkpoint inhibitor therapy.

    Level 3, Weak

20. Second line after atezolizumab + bevacizumab or durvalumab + tremelimumab (in patients not eligible for a clinical trial): sorafenib or lenvatinib are the preferred agents; after atezolizumab + bevacizumab, cabozantinib, regorafenib or ipilimumab + nivolumab may also be used.

    Level 5, Weak

21. After sorafenib or lenvatinib (in patients not eligible for a clinical trial): cabozantinib or regorafenib (or ramucirumab in patients with AFP ≥400 ng/mL) are the preferred agents.

    Level 1, Strong

22. AASLD recommends against using immune checkpoint inhibitors in patients with HCC recurrence after liver transplantation, because of the increased risk of graft loss and death.

    Level 4, Strong

Study population

Clinical significance and place in guidelines

Limitations