EASL Clinical Practice Guidelines


In oncology, the benefits of treatments should be assessed through randomized controlled trials and meta-analysis. Other sources of evidence, such as non-randomized clinical trials or observational studies are considered less robust. Few medical interventions have been thoroughly tested in HCC, in contrast with other cancers with a high prevalence worldwide, such as lung, breast, colorectal and stomach cancer. As a result, the strength of evidence for most interventions in HCC is far behind the most prevalent cancers worldwide. The level of evidence for efficacy according to trial design and end-points for all available treatments in HCC and the strength of recommendations according to GRADE are summarized in Fig. 4.

Fig. 4 Representation of EASL–EORTC recommendations for treatment according to levels of evidence (NCI classification [2]) and strength of recommendation (GRADE system). RF, radiofrequency ablation; PEI, percutaneous ethanol injection; OLT, orthotopic liver transplantation; LDLT, living donor liver transplantation.

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In principle, recommendations in terms of selection for different treatment strategies are based on evidence-based data in circumstances where all potential efficacious interventions are available. Multidisciplinary HCC teams including hepatologists, surgeons, oncologists, radiologists, interventional radiologists, pathologists and translational researchers are encouraged to apply these guidelines. Strategic recommendations should be adapted to local regulations and/or team capacities and cost–benefit strategies.