Thread by @ChristianLHorn

Hepatocellular Carcinoma (HCC): a 🧵

Inspired by the recently developed @AASLDtweets guidance, available in preprint format (most images take from preprint)

🔗DOI.org/10.1097/HEP.00…

Screen in high risk patients (see picture) q6 mo using:
✅ RUQ U/S
✅ AFP
⚠️ AASLD does NOT recommend routine use of CT/MRI for screening

Stop screening if:
🛑 CPT C cirrhosis not eligible for transplant
🛑 Life limiting comorbidities

HCC screening in HCV s/p SVR:

🛑AASLD does not recommend screening for stage 3 fibrosis
👍 Screen patients with cirrhosis

@gnioannou, et al., showed continued HCC risk in:
🔹 Cirrhotics
🔹 If FIB-4 >3.25 at the time of SVR, with or without cirrhosis

🔗doi.org/10.1053/j.gast…

Ultrasound evaluation:

👀 Report degree of ultrasound visualization
⚠️ Sensitivity ⬇️ in patients with obesity
⚠️ Poor visualization ➡️ CT/MRI
Lesion <1 cm ➡️ repeat U/S in 3-6 mo

Order contrast-enhanced diagnostic CT/MRI;
✅ Poor visualization
✅ Lesion ≥1 cm
✅ AFP ≥20

LIRADS Scoring:
Based on contrast-enhanced dynamic CT/MRI

Phases:
1️⃣ Non-contrast
2️⃣ Late arterial phase
3️⃣ Portal venous phase
4️⃣ Delayed phase (5 mins post)

HCC features:
☢️ Arterial phase hyperenhancement
☢️ Size
☢️ Enhancing “capsule”
☢️ Portal venous washout
☢️ Growth

LIRADS scores:

LR-1 - Definitely benign ➡️ U/S in 6mo
LR-2 - Probably benign ➡️ U/S in 6mo
LR-3 - Intermediate ➡️ repeat CT/MRI in 3-6 mo
LR-4 - Probably HCC ➡️ repeat CT/MRI in 3 mo or biopsy
LR-5 - HCC confirmed ➡️ Treat
LR-M - Malignancy, unknown origin
LR-TV - Tumor in vein

Staging: Barcelona Clinic Liver Cancer (BCLC) guidelines, updated 2022:

Stage 0: Single ≤2cm
Stage A: Single >2cm or ≤3 nodules each ≤3cm (Milan criteria)
Stage B: Multinodular outside Milan criteria
Stage C: Advanced - in vein or metastatic
Stage D: Terminal, ESLD, PS 3-4

Treatment:
🔪 Resection (stage 0/A): 1️⃣ lesion, no portal HTN
🔥 Ablation - MWA/RFA (stage 0/A): Not 🔪 or tx candidate
🩸Endovascular - TACE/TARE (stage A/B): bridge to tx, downstaging, not 🔪 candidate
🤷🏻‍♂️ Systemic (stage B/C) - New Immunotherapies, TKIs
🛌 Palliative (stage D)

Liver Tx:
MELD exception points if in Milan Criteria:

MELD exception 🟰 higher MELD score: 3 points ⬇️ than median MELD at transplant (MMaT-3)

Milan criteria:
✅ 1️⃣ lesion ≤5cm
✅ 3️⃣ lesions ≤3cm
✅ 0️⃣ vascular invasion or metastasis

OPTN extended ➡️ can downstage to Milan

Thank you to @AASLDtweets for the updated guidance and thank you to the authors. #LiverTwitter #HCC #MedTwitter