Hepatocellular Carcinoma: From Diagnosis to Treatment

Hepatocellular Carcinoma (HCC): AASLD 2023 Practice Guidelines – Structured Summary

1. Main Clinical Topics Discussed

• Updated AASLD (American Association for the Study of Liver Disease) 2023 HCC Practice Guidelines
• HCC surveillance, screening thresholds, and recall algorithms
• Biomarkers in HCC detection and risk stratification
• LI-RADS diagnostic criteria
• Multidisciplinary team (MDT) care in HCC management
• BCLC staging system and systemic therapy landscape

2. Key Learning Points, Guidelines, and Recommendations

Multidisciplinary Care

• Strong recommendation: All HCC patients should be discussed and managed within an MDT setting
• MDT should include: hepatologists, oncologists, interventional radiologists, surgeons, nurses, and palliative care
• Management changes in up to 42% of patients when presented at MDT tumor conference vs. those managed without MDT review
• UT Southwestern data demonstrated improved overall survival across BCLC stages with MDT involvement
• Palliative care should be involved early, regardless of transplant intent, given dropout rates from disease progression

HCC Surveillance – Updated Thresholds

• New cost-effectiveness threshold: surveillance recommended for patients with any-cause cirrhosis (Child-Pugh A or B) when annual HCC incidence exceeds >1% (reduced from prior threshold of 1.5%)
• Child-Pugh C patients who are not transplant candidates: surveillance is not recommended (1-year survival ~45%)
• For non-cirrhotic Hepatitis B patients: the PAGE-B score (incorporating age, gender, platelet count) is now endorsed for risk stratification
• AFP + ultrasound now re-endorsed as standard surveillance

Surveillance Modality

• Ultrasound alone: sensitivity of 53% for early HCC detection
• Ultrasound + AFP: sensitivity increases to 63%
• AFP-L3 and DCP: approved in the US for risk stratification only, not surveillance

Recall Algorithm (Post-Ultrasound)

• New ultrasound visualization scoring system:

- Score A (no/minimal limitation): repeat ultrasound in 6 months if AFP normal

- Score B (moderate limitation): ultrasound every 3–6 months; after two stable studies, return to 6-month intervals

- Score C (severe limitation): proceed directly to diagnostic CT or MRI, even without a visible lesion

• AFP "increasing" defined as: doubling of AFP, OR rising AFP over two consecutive tests, OR AFP >20 ng/mL

LI-RADS Diagnostic Categories

• LR-1 (Definitely benign): Routine surveillance
• LR-2 (Probably benign): Routine surveillance
• LR-3 (Intermediate ~20–40%): MDT discussion; consider biopsy
• LR-4 (Probably HCC ~70%): MDT discussion; biopsy consideration
• LR-5 (Definitely HCC ~95%): Diagnostic; proceed to staging
• LR-M (Probable malignancy ~33% HCC): Biopsy required
• LI-RADS does not apply to cirrhosis from vascular etiologies (e.g., Budd-Chiari, cardiac cirrhosis) → biopsy required
• AFP is not used for HCC diagnosis; AFP can be normal in up to 40% of HCC patients

3. Specific Clinical Data and Statistics Cited

• HCC incidence-to-mortality ratio: 0.92 — among the highest of all cancers
• MDT involvement changes management in up to 42% of cases
• Ultrasound sensitivity: 53% alone, 63% with AFP
• Child-Pugh C non-transplant candidates: 1-year survival ~45%

4. Practical Takeaways for Clinicians

• Refer all HCC patients to an MDT tumor board — it changes management nearly half the time
• Lower your threshold for surveillance: any cirrhotic with >1% annual HCC risk qualifies
• Re-add AFP to your ultrasound surveillance — it meaningfully improves sensitivity
• Use the new ultrasound visualization score to guide recall decisions, especially in obese patients or those with poor acoustic windows
• Do not use AFP alone to diagnose or rule out HCC — always confirm with imaging
• Involve palliative care early regardless of transplant candidacy