Hepatocellular Carcinoma: A Practical Anatomy-Based Guide for Staging and Treatment Planning, From the AJR Special Series on Critical Anatomy

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide and is rising in incidence. Treatment is complex and rapidly evolving but is also highly algorithmic. Radiologic imaging (primarily CT and MRI) guides treatment at each management step, and radiologists command a central role across the continuum of HCC care, from early detection during surveillance to diagnosis, staging, treatment, and response assessment. Recent updates to major guidelines, including the 2022 Barcelona Clinic Liver Cancer staging system and the 2023 American Association for the Study of Liver Diseases guidelines, reflect significant advances in surgical approaches, interventional techniques, and systemic therapies. Radiologists must accurately assess tumor burden, background liver, and vascular anatomy to determine eligibility for each treatment pathway. This review provides an overview of clinically relevant anatomic considerations for HCC staging and treatment planning, informed by recent major treatment advances. We present a practical anatomy-based approach to radiology reporting that aligns with clinical decision-making pathways. By incorporating these elements, radiologists can effectively communicate relevant findings, facilitate appropriate therapy selection, and guide multidisciplinary discussions.