Importance: Approximately half of newly-diagnosed hepatocellular carcinoma (HCC) cases in the world occur in China, with hepatitis B virus (HBV) infection being the predominant risk factor. Recently, the guidelines for the management of Chinese HCC patients were updated. Objective:The past decade has witnessed a great improvement in the management of hepatocellular carcinoma (HCC). This study reviews the recommendations in the 2019 Chinese guidelines and makes comparison with the practices from the Western world. Evidence Review: The updated recommendations on the surveillance, diagnosis, and treatment algorithm of HCC in the 2019 Chinese guidelines were summarized, and comparisons among the updated Chinese guidelines, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines were made. Findings: Besides imaging and pathological diagnoses, novel biomarkers like the seven-micro-RNA panel are advocated for early diagnoses and therapeutic efficacy evaluation in the updated Chinese guidelines. The China liver cancer (CNLC) staging system, proposed in the 2017 guidelines, continues to be the standard model for patient classification, with subsequent modifications and updates being made in treatment allocations. Compared to the Barcelona Clinic Liver Cancer (BCLC) system, the CNLC staging system employs resection, transplantation, and transarterial chemoembolization (TACE) for more progressed HCC. TACE in combination with other regional therapies like ablation or with systemic therapies like sorafenib are also encouraged in select patients in China. The systemic treatments for HCC have evolved considerably since lenvatinib, regorafenib, carbozantinib, ramucirumab and immune checkpoint inhibitors (ICIs)were first prescribed as first-line or second-line agents. Conclusions and Relevances: Novel biomarkers, imaging and operative techniques are recommended in the updated Chinese guideline. More aggressive treatment modalities are suggested for more progressed HBV-related HCC in China.

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Hepatocellular carcinoma (HCC) is the fourth most common and the third most lethal cancer in China. An updated version of consensus-based recommendations on the management of HCC has been recently published by a multidisciplinary group of Chinese experts including liver surgeons, hepatic oncologists, radiologists and pathologists. Major changes have been made to the diagnostic criteria. In addition to dynamic multi-detector computed tomography (CT) and magnetic resonance imaging (MRI), gadoxetic acid-enhanced MRI and contrast-enhanced ultrasound (CEUS) are added to the diagnostic imaging tests. Meanwhile, positive alpha-fetoprotein (AFP) no longer functions as a confirmatory test in nodules of 1-2 cm in diameter. For patients with chronic hepatitis B/C or cirrhosis of any cause, nodules more than 2 cm can be diagnosed with HCC based on typical features on one of the four imaging techniques, whereas nodules ≤2 cm need two typical imaging findings for diagnosis. Based on the increased evidences and clinical practices, a new staging system and treatment algorithm has been developed to be more comprehensible and suitable for use in China. Surgical resection, transplantation and local regional therapies (LRTs) are indicated for more progressed HCC in terms of tumor burden and for more diseased patients in terms of liver function in China than in western centers. Laparoscopic liver resections (LLRs) are not restricted by intrahepatic tumor locations and the volume of resected liver, provided lesions generally ≤10 cm. Future efforts involving prospective studies are essential to confirm the validity of the current Chinese guidelines for HCC.