Intended for healthcare professionals

Clinical Review State of the Art Review

New advances in the diagnosis and management of hepatocellular carcinoma

BMJ 2020; 371 doi: (Published 26 October 2020) Cite this as: BMJ 2020;371:m3544
  1. Ju Dong Yang, assistant professor of medicine1 2 3,
  2. Julie K Heimbach, professor of surgery4
  1. 1Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
  2. 2Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
  3. 3Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
  4. 4Division of Transplant Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
  1. Correspondence to: J K Heimbach Heimbach.julie{at}


Hepatocellular carcinoma is one of the leading causes of cancer related death in the world. Biannual surveillance for the disease in patients with cirrhosis and in high risk carriers of hepatitis B virus allows early stage cancer detection and treatment with good long term outcomes. Liver ultrasonography and serum α fetoprotein are the most commonly used surveillance tests. If suspicious results are found on the surveillance test, multiphasic computed tomography or magnetic resonance imaging should be undertaken to confirm the diagnosis of hepatocellular carcinoma. If radiologic tests show inconclusive results, liver biopsy or repeat imaging could be considered for confirmation of hepatocellular carcinoma. Management of the disease is complex. Patients should be evaluated by a multidisciplinary team, and the selection of treatment should consider factors such as tumor burden, severity of liver dysfunction, medical comorbidities, local expertise, and preference of patients. Early stage hepatocellular carcinoma is best managed by curative treatment, which includes resection, ablation, or transplantation. Patients with intermediate stage disease often receive locoregional treatment. Systemic treatment is reserved for patients with advanced disease. Several positive, phase III, randomized controlled trials have expanded the systemic treatment options for advanced hepatocellular carcinoma with promising long term outcomes, especially trials using combination treatments, which could also have eventual implications for the treatment of earlier stage disease.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: JDY and JKH contributed equally to the manuscript idea, literature search, and writing; JKH is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: No patients were involved in writing this review.

View Full Text

Log in

Log in through your institution


* For online subscription