All patients with hepatocellular carcinoma should be evaluated for the possibility of radical treatment (hepatic resection, liver transplantation, and for smaller tumors, ablation). For patients who cannot undergo radical surgical treatment, local treatment should be considered, which can also be used as a bridge treatment before other radical treatments. Ruiqing Liu, Department of Interventional Medicine, Henan Provincial People’s Hospital Local treatments are mainly divided into two categories: ablation and hepatic artery intervention, in addition to external radiation radiotherapy (EBRT). Among them, ablation and hepatic artery intervention are 2A level recommendations, and EBRT is 2B level recommendations. 1.Ablation: Ablation specifically includes chemical ablation (percutaneous ethanol/acetic acid injection, the former referred to as PEI) and thermal ablation (radiofrequency ablation [RFA], microwave ablation [MWA], cryoablation), of which RFA and PEI are most commonly used. ①All tumors can be ablated. In addition to ablating tumors, thermal ablation can also ablate normal tissues at the tumor margins, but percutaneous ethanol injection will not affect normal tissues at the tumor margins. ②The location of the tumor should be located in the path of the percutaneous/laparoscopic/open ablation operation. ③The operation should be performed with extra caution when the lesion is adjacent to large blood vessels, bile ducts, diaphragm and other abdominal organs. (iv) For tumors ≤3 cm, cure can be achieved with ablation alone. In selected cases, ablation may be used as definitive treatment for smaller and appropriately located tumors. 3-5 cm lesions may have prolonged survival with hepatic artery intervention, which may be combined with ablation in appropriately located cases. ⑤ For unresectable/inoperable lesions >5 cm, hepatic artery intervention or systemic chemotherapy should be considered. ⑥For patients with good liver function and proven residual/recurrence after ablation but not suitable for other local treatments, sorafenib may be applied as long as the bilirubin level is reduced to baseline levels. The use of sorafenib as an adjuvant therapy after ablation is being studied in clinical trials for its safety and efficacy. 2. Hepatic artery intervention: ①Tumors in any location can receive hepatic artery intervention, as long as the arterial blood supply to the tumor can be isolated without excessive impact on non-target tissues. (ii) Hepatic arterial interventions include transarterial embolization (TAE), transarterial embolization chemotherapy (TACE), TACE combined with drug-eluting beads (DEB-TACE), and 90-yttrium microsphere radioembolization (RE). ③ Bilirubin >3 mg/dL is a relative contraindication to all hepatic arterial interventions unless segmental injections can be performed.90 Yttrium microsphere RE increases the risk of radiographic liver disease in patients with bilirubin >2 mg/dL. ④ Portal trunk embolism and liver function Child-Pugh class C are relative contraindications to hepatic artery intervention. ⑤ It is up to the operator to select the contrast endpoint for arterial embolization. ⑥Sorafenib may be applied in patients with good liver function who have proven residual/recurrence after hepatic artery intervention but are not candidates for other local therapies, as long as bilirubin levels are reduced to baseline levels. Two randomized clinical trials on the safety and efficacy of sorafenib in conjunction with hepatic artery intervention have demonstrated no significant benefit, and additional phase III clinical trials to further explore combination treatment options are ongoing. External beam radiotherapy (EBRT): ①EBRT (stereotactic body radiotherapy [SBRT], intensity-modulated radiotherapy [IMRT] or three-dimensional conformal radiotherapy [3D-CRT]) can be performed for tumors in any location. ②SBRT is an advanced EBRT technique using high-dose radiotherapy. ③There is growing evidence supporting the role of SBRT in patients with HCC. SBRT can be used as an alternative to the ablation/embolization techniques described above or in cases where ablation/embolization therapy has failed or is contraindicated. ④ SBRT is commonly used in patients with 1-3 tumors. SBRT can be used for larger or more extensive lesions as long as there is an adequate healthy liver and as long as the radiation tolerated dose to the liver allows. However, it is required that there are no extrahepatic lesions, or that the extrahepatic lesions are small enough to be included in a treatment plan. Data from studies of radiotherapy for HCC are primarily from the group of patients with Child-Pugh class A liver function, and safety data for patients with Child-Pugh class B or worse liver function are limited. With dose adjustments and strict dose restrictions, radiotherapy can be safely administered to HCC patients with combined cirrhotic liver function in Child-Pugh class B. The safety of liver radiotherapy has not been demonstrated in HCC patients with liver function Child-Pugh Class C in combination with cirrhosis, as few clinical trials have included patients with liver function Child-Pugh Class C. ⑤ Proton beam therapy (PBT) may also be an appropriate treatment option in certain circumstances. ⑥ Palliative EBRT may control and/or prevent symptoms associated with complications of metastatic HCC (e.g., bone or brain). Update points: 1. Unresectable hepatocellular carcinoma with inadequate hepatic functional reserve (Child-Pugh score) or difficult tumor location is first evaluated for transplantation, where local treatment is preferred for those not suitable for transplantation. 2. HCC with lesions confined to the liver or with only limited extrahepatic metastases, but unresectable due to low PS score and comorbidities, local treatment is preferred. 3. 90 yttrium microsphere radioembolization (referred to as RE) has been added to hepatic artery intervention. As a new radiotherapy technique, PBT may be an appropriate option in certain circumstances. The choice of local treatment depends on the extent and location of the lesion, the functional reserve of the liver, and the capabilities of the patient’s study center.