The value of biopsy in the diagnosis and management of hepatocellular carcinoma: guideline interpretation and recent advances

Hepatocellular carcinoma (HCC) remains one of the most prevalent malignancies worldwide, and early detection combined with accurate therapeutic strategies is essential for improving patient prognosis. Current international guidelines on liver disease generally recommend dynamic contrast-enhanced imaging in combination with serum tumor markers as the primary non-invasive diagnostic approach. However, liver biopsy continues to hold indispensable value in specific, complex clinical circumstances. This review systematically examines the diagnostic criteria for HCC and the recommended indications for liver biopsy as outlined in the Chinese Clinical Practice Guideline for Primary Liver Cancer (CNLC), the National Comprehensive Cancer Network (NCCN), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver (APASL), and the Japan Society of Hepatology (JSH). This review emphasizes that validated non-invasive criteria, including the Liver Imaging Reporting and Data System (LI-RADS) and EASL imaging hallmarks, achieve a diagnostic specificity exceeding 95% for typical lesions, thereby minimizing the need for routine invasive procedures. It further delineates between diagnostic biopsy and molecular profiling biopsy to guide systemic therapy, emphasizing that the clinical indications for the former are predicated on inconclusive non-invasive results. Furthermore, advances in diagnostic technology are analyzed with regard to their clinical applications and potential future directions, aiming to provide clinicians with evidence-based guidance.