Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in most Asian countries due to the high prevalence of hepatitis B viral infection.1 Surgical resection and liver transplantation are regarded as the main curative treatments for HCC. Many patients, however, are not eligible for resection due to locally advanced tumour, underlying liver cirrhosis with suboptimal liver reserve or metastatic disease on presentation.1

Puppala et al2 concisely summarise the modern image-guided therapy options for patients with advanced HCC, such as radiofrequency ablation (RFA), microwave ablation, percutaneous ethanol ablation (PEI), cryoablation, transarterial chemoembolisation (TACE) and yttrium-90 radioembolisation. However, most of these treatments are palliative in nature and the overall survival of HCC patients with locally advanced disease remains poor. The outcomes of these image-guided therapies depend on accurate tumour staging, the position of the tumour in the liver, as well as the expertise and available facilities of the individual treatment centres.

Accurate staging and selection of HCC patients for image-guided therapy is crucial for treatment success. The staging of HCC differs significantly from that of other tumour types as the underlying liver disease has …