Synopsis
Deliver purposeful six-monthly surveillance, investigate suspicious lesions correctly, and match hepatocellular carcinoma treatment to tumour burden, liver reserve, performance and transplant potential.
- Offer eligible adults with cirrhosis ultrasound surveillance every six months, with or without AFP, when early detection could lead to meaningful treatment.
- Chronic hepatitis B can confer HCC risk without cirrhosis, so use the NICE hepatitis B risk-based surveillance recommendations alongside the cirrhosis pathway.
- AFP alone is neither sensitive nor specific enough to replace imaging, and a normal value cannot reassure after a suspicious scan.
- A new focal lesion requires timely multiphasic CT or contrast-enhanced MRI interpreted in a specialist liver-imaging and MDT setting.
- Characteristic arterial enhancement and later washout can establish HCC non-invasively in an appropriate high-risk liver; not every lesion should be biopsied.
- Treatment selection integrates tumour size, number and distribution with vascular invasion, extrahepatic spread, portal hypertension, liver function, frailty and performance status.
- Potentially curative options include resection, ablation and transplantation; locoregional and systemic treatments may control disease or bridge selected patients.
- Continue managing the underlying liver disease and decompensation because cancer control cannot compensate for failing hepatic reserve.
Key red flags
Worsening ascites, jaundice, encephalopathy or variceal bleeding can reflect tumour progression, portal-vein involvement or unrelated cirrhotic decline and requires expedited reassessment.
Sudden severe abdominal pain, hypotension, falling haemoglobin and intraperitoneal fluid suggest rupture and haemorrhage, demanding emergency resuscitation and interventional or surgical control.
Investigation priorities
Detect early focal liver cancer in eligible high-risk people before symptoms develop.
Management branches
An adult has cirrhosis or another guideline-defined HCC risk and would be eligible for treatment if early cancer were found.
- Explain the purpose and limits of surveillance, arrange ultrasound every six months with or without AFP according to the relevant NICE pathway, and record a dependable recall owner.
- At each episode, document technical adequacy and reconsider whether health status still permits meaningful HCC treatment, discussing any proposal to stop surveillance with the person.
- Actively recover missed appointments and escalate new lesions or inadequate studies through a time-defined diagnostic pathway rather than waiting for the next routine interval.