The International Hepato-Pancreato-Biliary Association has issued a 2026 guideline on hepatocellular carcinoma for resource-constrained settings, developed through a global consensus process rather than a formal systematic review. Most HCC guidelines assume access to liver transplantation, specialist imaging and modern systemic therapy; this one sets out what to do when those are limited.
Diagnosis rests on ultrasound supported by cross-sectional imaging, with alpha-fetoprotein and liver synthetic function at baseline; biopsy is not required. Resection is the treatment of choice for a single tumour, or up to three lesions of 3 cm or less, with preserved liver function. Radiofrequency and microwave ablation are treated as equivalent where resection is unavailable, and ethanol injection is an option for small lesions when thermal ablation is not. TACE or bland embolisation can be used for intermediate-stage disease. Atezolizumab with bevacizumab is recommended first line, with sorafenib or lenvatinib when it is not an option.
The stated aim is to reduce default reliance on best supportive care alone. For Indian centres, where HCC often presents late and cost decides much of treatment, it offers a defensible ladder at each level of resource.
- Assess liver function and AFP at diagnosis alongside cross-sectional imaging
- Consider resection for a single HCC or up to three lesions ≤3 cm with preserved liver function
- Use radiofrequency or microwave ablation when resection is unavailable, ethanol injection only for small lesions
- Offer TACE or bland embolisation for intermediate-stage disease where available
- Use atezolizumab-bevacizumab first line, with sorafenib or lenvatinib if it is not an option
Why it matters
It gives a realistic standard for the settings where most of the world's HCC is treated.
Don't overread it
This is a consensus document, not a systematic review, so recommendation strength is not graded.
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