**Background:** Liver cancer is the fourth most prevalent and second most lethal cancer in China, with an estimated 431,000 new cases projected by 2025. Hepatocellular carcinoma (HCC) accounts for 75–85% of primary liver cancer cases, and approximately 55% of patients in China are initially diagnosed at advanced stages, compared to only 12% in North America. HBV-associated HCC predominates in China and is molecularly characterized by a proliferation subclass with poor differentiation and high aggressiveness. Breakthroughs in HCC treatment over the past three years prompted the 2022 update of Chinese guidelines, which this review compares to contemporaneous updates from the BCLC, JSH, and NCCN guidelines.
**Methods:** This is a narrative review summarizing the 2022 Chinese guidelines on HCC management. The authors reviewed updates across five domains: surveillance and diagnosis, staging, treatment (including hepatectomy, liver transplantation, locoregional therapies, and systemic therapy), HCC rupture management, and future perspectives. Discrepancies between Chinese, BCLC, JSH, and NCCN guidelines are discussed, supported by data from key clinical trials.
**Surveillance & Diagnosis:** The aMAP scoring system (age-Male-ALBI-Platelets) is newly recommended for risk stratification; patients with aMAP scores >60 have an annual HCC incidence of 1.6–4% and warrant intensive surveillance. Ultrasound plus AFP every 6 months remains the standard. The 7-miRNA panel (miR-122, miR-192, miR-21, miR-223, miR-26a, miR-27a, miR-801) and GALAD score are recommended to assist early detection, particularly for AFP-negative patients. For diagnosis, nodules >2 cm require typical imaging features on one modality; nodules ≤2 cm require confirmation by at least two imaging methods.
**Staging:** The CNLC staging system uses Child-Pugh A/B as a prerequisite for anti-tumor therapy, while the 2022 BCLC system advocates comprehensive liver function evaluation using ALBI score, Child-Pugh, MELD 3.0, and AFP. PS 0–2 is used in CNLC versus PS 0 for early/middle-stage in BCLC.
**Hepatectomy:** Indicated for CNLC Ia, Ib, and IIa HCC. Prerequisites include Child-Pugh A, ICG-R15 <30%, and future remnant liver volume >40% (with cirrhosis) or >30% (without). Chinese experts prefer hepatectomy over ablation for 1–3 tumors ≤3 cm, citing better OS. For CNLC IIb (≥4 tumors), hepatectomy is reserved for tumors localized in the same segment or lobe. Conversion therapy using TKIs plus PD-1 inhibitors, TACE, FOLFOX-HAIC, or combinations is advocated for initially unresectable HCC. Conversion rates ranged from 23.3% to 50.0% across cited studies. The FOLFOX-HAIC plus cTACE combination achieved a 48.8% conversion rate versus 9.5% with cTACE alone. Postoperative recurrence occurs in up to 80% of patients. Adjuvant TACE is established in China, and 1–2 cycles of FOLFOX-HAIC significantly improved RFS (27.0 vs. 11.3 months, P=0.001) for patients with microvascular invasion.
**Liver Transplantation:** UCSF criteria (solitary tumor ≤6.5 cm or ≤3 nodules ≤4.5 cm plus total tumor diameter ≤8 cm) are advocated in China. AFP >1,000 ng/mL is set as a contraindication for LT in the 2022 BCLC guidelines. The 5-5-500 criteria (≤5 cm, ≤5 tumors, AFP ≤500 ng/mL) are used in Japan. mTOR inhibition with sirolimus for ≥3 months is recommended post-LT.
**Locoregional Treatments:** Proton radiotherapy showed comparable local tumor control to RFA (2-year local PFS: 94.8% vs. 83.9%, P<0.001 for non-inferiority). TACE is indicated for CNLC IIb, IIIa, and some IIIb HCC. The TACTICS trial showed sorafenib plus TACE improved PFS (22.8 vs. 13.5 months, P=0.020) but mOS did not reach significance (36.2 vs. 30.8 months, P=0.40). FOLFOX-HAIC improved mOS versus sorafenib (14.5 vs. 7.0 months, P<0.001). Triple therapy (FOLFOX-HAIC, PD-1 inhibitor, TKI) achieved ORR of 66.7% and 70.96% in two prospective studies.
**Systemic Therapy:** Atezolizumab-bevacizumab (Atezo-Bev) showed ORR 35% vs. 14% and mOS 19.2 vs. 13.4 months (HR=0.66, P<0.001) versus sorafenib; in the Chinese cohort, mOS reached 24.0 months. Sintilimab plus bevacizumab biosimilar showed mOS not reached vs. 10.4 months (P<0.001). Donafenib showed 12.1 vs. 10.3 months (P=0.024). The LEAP-002 trial (lenvatinib plus pembrolizumab) showed 21.2 vs. 19.0 months (P=0.023, not meeting pre-specified significance). The RESCUE trial (camrelizumab plus apatinib) showed mOS 22.1 vs. 15.2 months (P<0.001) and PFS 5.6 vs. 3.7 months (P<0.001). Second-line options in China include regorafenib, apatinib, camrelizumab, and tislelizumab. Ramucirumab (AFP >400 ng/mL) and cabozantinib are approved in Western countries but not yet marketed in China.
**Clinical Implications:** The 2022 Chinese guidelines reflect a more aggressive treatment philosophy than Western guidelines, particularly regarding expanded surgical indications, conversion therapy, and early integration of systemic therapies with locoregional treatments. The emphasis on conversion therapy addresses the late-stage presentation common in China. While Atezo-Bev is prioritized in BCLC guidelines, Chinese guidelines list six first-line options without priority. The recommendation for antiviral therapy (entecavir, tenofovir, tenofovir alafenamide fumarate) throughout HCC treatment addresses the HBV-predominant population. Over 20 phase III trials are investigating ICI-based therapies across all HCC stages, and novel agents including LAG-3 inhibitors and bispecific antibodies represent future opportunities.