A relationship between the pathogenesis of hepatocellular carcinoma (HCC) and various types of underlying liver disease has been clearly demonstrated. Presently, this knowledge has not led to efficacious screening programmes for identifying patients with curable primary liver cancer at an early stage. Screening strategies should be improved in order to realize optimal management of patients with HCC. Detection and staging of primary liver cancer is hampered by the quality of imaging techniques and treatment is restricted by access to modalities such as liver transplantation. In this review recent developments in the management of hepatocellular carcinoma are discussed and an algorithm is proposed to define the most optimal approach for screening, diagnosis and surgical treatment.