Primary hepatocellular carcinoma (HCC) is a common neoplasm in East Asia, Africa, and the Mediterranean countries, with an age adjusted incidence rate of up to 20–28 cases per 10⁵ in men. Major progress has been made in the prevention of HCC through universal vaccination of neonates and children at risk worldwide, yet available treatment options for patients with established tumours rarely lead to complete cure. HCC is recognised for its heterogeneous clinical and biological presentation, variable natural course, and its relationship to defined risk factors and aetiologic agents, as well as the difficulty in predicting response to different modes of treatment. The time interval from an undetectable tumour to a 2 cm lesion may vary between four and 12 months which leaves a relatively narrow window for optimal intervention in already established tumours with a fast doubling time. In the past decade, a number of new palliative and potentially curative means of treatment have been introduced in the clinical management of HCC. However, evaluation of efficacy of interventions such as surgical resection, ablative procedures including alcohol injection, chemoembolisation, radiofrequency, and others, or liver transplantation is difficult without agreement on universal surveillance and staging systems for early identification and follow up of HCC.

Randomised controlled trials for assessment of surveillance and intervention become exceedingly difficult to perform in the presence of a plethora of new treatment modalities, frequently of unproven …