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Hepatocellular carcinoma

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Updated 2024 BSG guidelines for the diagnosis and management of hepatocellular carcinoma.

Background

Overview

Definition
HCC is a disease occurring due to malignant transformation of normal hepatocytes within the liver parenchyma.
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Pathophysiology
The risk factors that induce malignant transformation of normal hepatocytes include chronic infections of HBV and/or HCV, aflatoxin toxin, cirrhosis, or consumption of large amounts of alcohol. Underlying liver cirrhosis is present in about 80-90% of patients.
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Epidemiology
HCC accounts for 75-85% of all liver malignancies. In the US, the incidence of HCC is estimated at 7.7 cases per 100,000 person-years.
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Disease course
Clinical manifestations relate to local mass effect (abdominal pain, distension, loss of appetite, palpable masses), hepatic dysfunction (jaundice, ascites, gastrointestinal bleeding, splenomegaly, and encephalopathy), and constitutional effects of malignancy.
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Prognosis and risk of recurrence
Multiple treatment modalities exist; however, only orthotopic liver transplantation or surgical resection is curative. The overall prognosis for HCC in the US is poor with a 2-year survival < 50% and a 5-year survival of only 10%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hepatocellular carcinoma are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2024), the British Society of Gastroenterology (BSG 2024), the Surgical Infection Society (SIS 2024), the American Association for the Study of Liver Diseases (AASLD 2023), the Asian Pacific Association for the ...
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Screening and diagnosis

Indications for screening, liver cirrhosis: as per BSG 2024 guidelines, consider obtaining surveillance for HCC with 6-monthly ultrasound and α-fetoprotein measurement in patients with liver cirrhosis.
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  • Indications for screening (hemochromatosis)

  • Indications for screening (viral hepatitis)

  • Indications for screening (occupational liver disease)

  • Indications for screening (MASLD)

  • Indications for screening (liver transplant candidates)

  • Choice of screening tests

  • Diagnostic criteria

Classification and risk stratification

Staging: as per BSG 2024 guidelines, consider using the Liver Imaging Reporting and Data System classification system to standardize the reporting of radiological findings and guide further management.
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Diagnostic investigations

Tumor biomarkers: as per AASLD 2023 guidelines, avoid obtaining biomarkers, including α-fetoprotein alone, to diagnose HCC.
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  • Diagnostic imaging (CT/MRI)

  • Diagnostic imaging (contrast-enhanced ultrasound)

  • Imaging for staging (contrast-enhanced ultrasound)

  • Imaging for staging (PET)

  • Evaluation for portal hypertension

Diagnostic procedures

Liver biopsy: as per BSG 2024 guidelines, consider performing lesional biopsy for the diagnosis of HCC in patients with liver cirrhosis if noninvasive radiological criteria are not fulfilled.
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  • Ancillary testing

Medical management

General principles: as per BSG 2024 guidelines, discuss cases of HCC in a multidisciplinary team meeting providing access to the full range of treatment options for HCC.
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  • Expectant management

  • Neoadjuvant therapy

  • Adjuvant therapy

  • Primary systemic therapy (first-line therapy)

  • Primary systemic therapy (second-line therapy)

  • Primary systemic therapy (third-line therapy)

  • Management of pain

  • Palliative care (general principles)

  • Palliative care (radiotherapy)

Nonpharmacologic interventions

Psychosocial and nutritional support: as per EASL 2018 guidelines, provide psycho-oncological support and counseling on adequate nutrition according to the patients' condition.
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Therapeutic procedures

Local ablation: as per BSG 2024 guidelines, offer thermal ablative therapy, with radiofrequency or microwave, as first-line treatment in selected patients with solitary < 2 cm HCC in compensated cirrhosis. Decide on the choice between ablation and resection in patients with this tumor stage based on evaluation of tumor location, liver function associated with the extent of portal hypertension, and performance status.
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  • Transarterial therapies (transarterial embolization/chemoembolization)

  • Transarterial therapies (selective internal radiotherapy)

  • Transarterial therapies (combination with systemic therapy)

  • Percutaneous ethanol injection

  • External beam radiation therapy (indications)

  • External beam radiation therapy (technical considerations)

Perioperative care

Preoperative care, counseling
As per ERASS 2023 guidelines:
Provide preoperative information and counseling regarding the upcoming liver surgery. Consider using brochures and multimedia support to improve verbal counseling.
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Advise preoperative smoking cessation at least 4 weeks before hepatectomy. Advise alcohol cessation in heavy drinkers (> 24 g/day for females or > 36 g/day for males) 4-8 weeks before surgery.
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  • Preoperative care (nutrition)

  • Preoperative care (rehabilitation)

  • Preoperative care (biliary drainage)

  • Preoperative care (antibiotic prophylaxis)

  • Preoperative care (corticosteroids)

  • Preoperative care (preanesthetic medication)

  • Intraoperative care (anesthesia and analgesia)

  • Intraoperative care (fluid management)

  • Intraoperative care (temperature management)

  • Postoperative care (thromboprophylaxis)

  • Postoperative care (early mobilization)

  • Postoperative care (nutrition)

  • Postoperative care (antiemetics)

  • Postoperative care (laxatives)

Surgical interventions

Surgical resection, indications: as per BSG 2024 guidelines, perform surgical resection as the primary treatment for HCC in patients without liver cirrhosis.
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  • Surgical resection (technical considerations)

  • Liver transplantation (indications)

  • Liver transplantation (bridging therapy)

Specific circumstances

Pregnant patients: as per EASL 2023 guidelines, maintain ultrasound surveillance for HCC in patients with cirrhosis in accordance with screening outside of pregnancy.
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Preventative measures

Lifestyle modifications: as per AASLD 2023 guidelines, counsel patients with chronic liver disease to maintain a healthy weight, adopt a balanced diet, avoid tobacco and alcohol use, and achieve adequate control of comorbid conditions, including components of the metabolic syndrome, as a healthy lifestyle has multiple benefits and may decrease the risk of HCC.
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  • Coffee

  • Chemoprevention

  • Hepatitis B immunization

  • Management of viral hepatitis

  • Management of chronic liver disease

Follow-up and surveillance

Surveillance for hepatic nodules: as per AASLD 2023 guidelines, consider obtaining repeat short-interval ultrasound and α-fetoprotein measurement in approximately 3-6 months in patients with a < 1 cm lesion on ultrasound.
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consider returning to semiannual surveillance with ultrasound and α-fetoprotein if the lesion is stable for ≥ 2 follow-up ultrasounds.
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  • Assessment of treatment response

  • Post-treatment follow-up

  • Management of recurrence

Quality improvement

Public health measures: as per BSG 2024 guidelines, implement national policies to prevent transmission of viral hepatitis, reduce alcohol abuse, and encourage lifestyle changes to minimize risks of obesity and metabolic syndrome.
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