Synopsis
Diagnose hepatocellular carcinoma through risk-based imaging or tissue when required, stage tumour and liver reserve together and select resection, transplantation, ablation, transarterial, radiotherapy or systemic treatment safely.
- Surveillance-detected lesion is a pivotal clue in Hepatocellular carcinoma: Many potentially curable tumours are asymptomatic and found on six-monthly ultrasound in eligible people with cirrhosis.
- Immediate priority in unstable Hepatocellular carcinoma: Resuscitate, activate major-haemorrhage and hepatology pathways as indicated, obtain urgent multiphase imaging and involve interventional radiology and hepatobiliary surgery for haemostasis while treating precipitating liver failure.
- Surveillance ultrasound is used early to detect early HCC in people with cirrhosis who could benefit from treatment. Perform every 6 months in the eligible surveillance population; a new lesion at least 1 cm needs dedicated contrast imaging rather than serial routine ultrasound.
Key red flags
A patient with cirrhosis develops unexplained decompensation, weight loss, right-upper-quadrant pain or a new liver lesion.
Abrupt severe abdominal pain, shock and haemoglobin fall with haemoperitoneum is a life-threatening presentation.
Investigation priorities
Detect early HCC in people with cirrhosis who could benefit from treatment.
Management branches
Surveillance or symptom-directed imaging identifies a new liver lesion in a person at risk of HCC.
- Obtain specialist multiphase CT or contrast MRI and review the lesion through a hepatobiliary radiology and cancer MDT.
- Accept a non-invasive diagnosis only when risk context and enhancement pattern meet current criteria; biopsy atypical or non-cirrhotic disease when it changes care.
Key medicines
Atezolizumab with bevacizumabA licensed adult schedule is atezolizumab 1,200 mg intravenously followed by bevacizumab 15 mg/kg intravenously on day 1 every 3 weeks, continued while benefit and tolerability persist under the commissioned HCC pathway.
LenvatinibFor eligible adults weighing under 60 kg, use 8 mg orally once daily; for 60 kg or above, use 12 mg once daily, with dose interruption and reduction for toxicity.