Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Jian Zhou¹, Huichuan Sun¹, Zheng Wang¹, Wenming Cong², Mengsu Zeng³, Weiping Zhou⁴, Ping Bie⁵, Lianxin Liu⁶, Tianfu Wen⁷, Ming Kuang⁸, Guohong Han⁹, Zhiping Yan¹⁰, Maoqiang Wang¹¹, Ruibao Liu¹², Ligong Lu¹³, Zhenggang Ren¹, Zhaochong Zeng¹⁴, Ping Liang¹⁵, Changhong Liang¹⁶, Min Chen¹⁷, Fuhua Yan¹⁸, Wenping Wang¹⁹, Jinlin Hou²⁰, Yuan Ji²¹, Jingping Yun²², Xueli Bai²³, Dingfang Cai²⁴, Weixia Chen²⁵, Yongjun Chen²⁶, Wenwu Cheng²⁷, Shuqun Cheng⁴, Chaoliu Dai²⁸, Wengzhi Guo²⁹, Yabing Guo³⁰, Baojin Hua³¹, Xiaowu Huang¹, Weidong Jia³², Qiu Li³³, Tao Li³⁴, Xun Li³⁵, Yaming Li³⁶, Yexiong Li³⁷, Jun Liang³⁸, Changquan Ling³⁹, Tianshu Liu⁴⁰, Xiufeng Liu⁴¹, Shichun Lu⁴², Guoyue Lv⁴³, Yilei Mao⁴⁴, Zhiqiang Meng⁴⁵, Tao Peng⁴⁶, Weixin Ren⁴⁷, Hongcheng Shi⁴⁸, Guoming Shi¹, Ming Shi⁸, Tianqiang Song⁴⁹, Kaishan Tao⁵⁰, Jianhua Wang¹⁰, Kui Wang⁴, Lu Wang⁵¹, Wentao Wang⁷, Xiaoying Wang¹, Zhiming Wang⁵², Bangde Xiang⁵³, Baocai Xing⁵⁴, Jianming Xu⁵⁵, Jiamei Yang⁴, Jianyong Yang⁵⁶, Yefa Yang⁵⁷, Yunke Yang²⁴, Shenglong Ye¹, Zhenyu Yin⁵⁸, Yong Zeng⁷, Bixiang Zhang⁵⁹, Boheng Zhang¹, Leida Zhang⁶⁰, Shuijun Zhang⁶¹, Ti Zhang⁵¹, Yanqiao Zhang⁶², Ming Zhao⁶³, Yongfu Zhao⁶¹, Honggang Zheng⁶⁴, Ledu Zhou⁶⁵, Jiye Zhu⁶⁶, Kangshun Zhu⁶⁷, Rong Liu¹⁰, Yinghong Shi¹, Yongsheng Xiao¹, Lan Zhang¹, Chun Yang³, Zhifeng Wu¹⁴, Zhi Dai¹, Minshan Chen⁸, Jianqiang Cai⁶⁸, Weilin Wang⁶⁹, Xiujun Cai²³, Qiang Li⁴⁹, Feng Shen⁴, Shukui Qin⁴¹, Gaojun Teng⁷⁰, Jiahong Dong⁷¹, Jia Fan¹

Affiliations

¹ Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
² Department of Pathology, The Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
³ Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴ The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
⁵ Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China.
⁶ Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.
⁷ Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China.
⁸ Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.
⁹ Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
¹⁰ Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
¹¹ Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China.
¹² Department of Interventional Radiology, The Tumor Hospital of Harbin Medical University, Harbin, China.
¹³ Department of Interventional Oncology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
¹⁴ Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
¹⁵ Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China.
¹⁶ Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
¹⁷ Editorial Department of Chinese Journal of Digestive Surgery, Chongqing, China.
¹⁸ Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.
¹⁹ Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.
²⁰ Department of Infectious Diseases, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China.
²¹ Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China.
²² Department of Pathology, Tumor Prevention and Treatment Center, Sun Yat-sen University, Guangzhou, China.
²³ Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
²⁴ Department of Integrative Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
²⁵ Department of Radiology, West China Hospital of Sichuan University, Chengdu, China.
²⁶ Department of Hematology, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
²⁷ Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China.
²⁸ Department of Hepatobiliary and Spleenary Surgery, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China.
²⁹ Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
³⁰ Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China.
³¹ Graduate School, Beijing University of Chinese Medicine, Beijing, China.
³² Department of Hepatic Surgery, Affiliated Provincial Hospital, Anhui Medical University, Hefei, China.
³³ Department of Oncology, West China Hospital, Sichuan University, Chengdu, China.
³⁴ Department of General Surgery, Qilu Hospital, Shandong University, Jinan, China.
³⁵ The First Hospital of Lanzhou University, Lanzhou, China.
³⁶ Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China.
³⁷ Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³⁸ Department of Oncology, Peking University International Hospital, Beijing, China.
³⁹ Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University, Shanghai, China.
⁴⁰ Department of Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴¹ Department of Medical Oncology, PLA Cancer Center, Nanjing Bayi Hospital, Nanjing, China.
⁴² Institute and Hospital of Hepatobiliary Surgery of Chinese PLA, Chinese PLA Medical School, Chinese PLA General Hospital, Beijing, China.
⁴³ Department of General Surgery, The First Hospital of Jilin University, Jilin, China.
⁴⁴ Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China.
⁴⁵ Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
⁴⁶ Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
⁴⁷ Department of Interventional Radiology the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
⁴⁸ Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴⁹ Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
⁵⁰ Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
⁵¹ Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China.
⁵² Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China.
⁵³ Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China.
⁵⁴ Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, China.
⁵⁵ Department of Gastrointestinal Oncology, Affiliated Hospital Cancer Center, Academy of Military Medical Sciences, Beijing, China.
⁵⁶ Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
⁵⁷ Department of Hepatic Surgery and Interventional Radiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
⁵⁸ Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China.
⁵⁹ Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
⁶⁰ Department of Hepatobiliary Surgery Institute, Southwest Hospital, Third Military Medical University, Chongqing, China.
⁶¹ Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, ZhengZhou, China.
⁶² Department of Gastrointestinal Medical Oncology, The Affiliated Tumor Hospital of Harbin Medical University, Harbin, China.
⁶³ Minimally Invasive Interventional Division, Liver Cancer Group, Sun Yat-Sen University Cancer Center, Guangzhou, China.
⁶⁴ Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
⁶⁵ Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.
⁶⁶ Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China.
⁶⁷ Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
⁶⁸ Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁶⁹ Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
⁷⁰ Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China.
⁷¹ Department of Hepatobiliary and Pancreas Surgery, Beijing Tsinghua Changgung Hospital (BTCH), School of Clinical Medicine, Tsinghua University, Beijing, China.

PMID: 37901768
PMCID: PMC10601883
DOI: 10.1159/000530495

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Jian Zhou et al. Liver Cancer. 2023.

. 2023 Apr 5;12(5):405-444.

doi: 10.1159/000530495. eCollection 2023 Oct.

Authors

Affiliations

¹ Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
² Department of Pathology, The Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
³ Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴ The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
⁵ Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China.
⁶ Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.
⁷ Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China.
⁸ Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.
⁹ Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
¹⁰ Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
¹¹ Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China.
¹² Department of Interventional Radiology, The Tumor Hospital of Harbin Medical University, Harbin, China.
¹³ Department of Interventional Oncology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
¹⁴ Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
¹⁵ Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China.
¹⁶ Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
¹⁷ Editorial Department of Chinese Journal of Digestive Surgery, Chongqing, China.
¹⁸ Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.
¹⁹ Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.
²⁰ Department of Infectious Diseases, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China.
²¹ Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China.
²² Department of Pathology, Tumor Prevention and Treatment Center, Sun Yat-sen University, Guangzhou, China.
²³ Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
²⁴ Department of Integrative Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
²⁵ Department of Radiology, West China Hospital of Sichuan University, Chengdu, China.
²⁶ Department of Hematology, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
²⁷ Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China.
²⁸ Department of Hepatobiliary and Spleenary Surgery, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China.
²⁹ Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
³⁰ Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China.
³¹ Graduate School, Beijing University of Chinese Medicine, Beijing, China.
³² Department of Hepatic Surgery, Affiliated Provincial Hospital, Anhui Medical University, Hefei, China.
³³ Department of Oncology, West China Hospital, Sichuan University, Chengdu, China.
³⁴ Department of General Surgery, Qilu Hospital, Shandong University, Jinan, China.
³⁵ The First Hospital of Lanzhou University, Lanzhou, China.
³⁶ Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China.
³⁷ Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
³⁸ Department of Oncology, Peking University International Hospital, Beijing, China.
³⁹ Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University, Shanghai, China.
⁴⁰ Department of Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴¹ Department of Medical Oncology, PLA Cancer Center, Nanjing Bayi Hospital, Nanjing, China.
⁴² Institute and Hospital of Hepatobiliary Surgery of Chinese PLA, Chinese PLA Medical School, Chinese PLA General Hospital, Beijing, China.
⁴³ Department of General Surgery, The First Hospital of Jilin University, Jilin, China.
⁴⁴ Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China.
⁴⁵ Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
⁴⁶ Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
⁴⁷ Department of Interventional Radiology the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
⁴⁸ Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
⁴⁹ Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China.
⁵⁰ Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
⁵¹ Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China.
⁵² Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China.
⁵³ Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China.
⁵⁴ Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, China.
⁵⁵ Department of Gastrointestinal Oncology, Affiliated Hospital Cancer Center, Academy of Military Medical Sciences, Beijing, China.
⁵⁶ Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
⁵⁷ Department of Hepatic Surgery and Interventional Radiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
⁵⁸ Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China.
⁵⁹ Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
⁶⁰ Department of Hepatobiliary Surgery Institute, Southwest Hospital, Third Military Medical University, Chongqing, China.
⁶¹ Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, ZhengZhou, China.
⁶² Department of Gastrointestinal Medical Oncology, The Affiliated Tumor Hospital of Harbin Medical University, Harbin, China.
⁶³ Minimally Invasive Interventional Division, Liver Cancer Group, Sun Yat-Sen University Cancer Center, Guangzhou, China.
⁶⁴ Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
⁶⁵ Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.
⁶⁶ Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China.
⁶⁷ Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
⁶⁸ Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
⁶⁹ Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
⁷⁰ Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China.
⁷¹ Department of Hepatobiliary and Pancreas Surgery, Beijing Tsinghua Changgung Hospital (BTCH), School of Clinical Medicine, Tsinghua University, Beijing, China.

PMID: 37901768
PMCID: PMC10601883
DOI: 10.1159/000530495

Abstract

Background: Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary: Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key messages: The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

Keywords: China; Diagnosis; Guidelines; Hepatocellular carcinoma; Primary liver cancer; Treatment.

PubMed Disclaimer

Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

**Fig. 1.**
Schematic diagram of the recommended baseline specimen sampling protocol for liver tumors. A, B, C, and D indicators denote the 12, 3, 6, and 9 o’clock positions, respectively, along the boundary between cancer and adjacent non-neoplastic liver tissue; E: tumor area; F: proximal non-neoplastic adjacent liver tissue; G: distal non-neoplastic adjacent liver tissue.

**Fig. 2.**
Pathway for the diagnosis of HCC. Typical presentation: significant enhancement of the lesion in the arterial phase (late major arterial phase), with decreased enhancement in the portal venous and/or delayed phases, in a “wash-in, wash-out” pattern. Atypical presentation: lack of lesion enhancement in the arterial phase or no or insignificant decrease in the enhancement during the portal venous and delayed phases, or even a slight increase in enhancement, etc. US, ultrasonography; MRI, multiparametric MRI; CT, dynamic contrast-enhanced CT scan; CEUS, contrast-enhanced ultrasonography, which uses ultrasound contrast to visualize the real-time blood perfusion in normal and diseased tissues. EOB-MRI: MRI scan enhanced with hepatocyte-specific contrast agent gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA). AFP (+): serum AFP test exceeding normal value.

**Fig. 3.**
Clinical staging and treatment pathway for HCC in China. Systemic antitumor therapy includes first-line and second-line therapy. First-line therapy: atezolizumab + bevacizumab, sintilimab + biosimilar of bevacizumab (BYVASDA^®); donafenib, lenvatinib, sorafenib; FOLFOX4. Second-line therapy: regorafenib, apatinib, camrelizumab, tislelizumab

See this image and copyright information in PMC

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Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Affiliations

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources

Medical