Initiate antiviral therapy in patients with cirrhosis and chronic HBV infection or HCV infection to prevent cirrhosis progression and decompensation. B As per ESMO 2018 guidelines, initiate early antiviral treatment of viral HBV and HCV infections to prevent chronic liver disease and HCC. B Chemoprevention: do not use chemoprevention therapies, such as statins, aspirin, and metformin, solely to reduce the risk of HCC. D Lifestyle modifications: 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. B Coffee: consider advising coffee consumption in patients with chronic liver disease as it has been associated with decreased risk of HCC development. C 11. Follow-up and surveillance Surveillance for hepatic nodules: As per AASLD 2023 guidelines, consider obtaining repeat short-interval ultrasound and AFP measurement in approximately 3-6 months in patients with a < 1 cm lesion on ultrasound. B Consider returning to semiannual surveillance with ultrasound and AFP if the lesion is stable for 2 follow-up ultrasounds. C Show 4 more As per EASL 2018 guidelines, obtain surveillance ultrasound at 4-month intervals in the first year in high-risk patients with hepatic nodules measuring < 1 cm in diameter. Consider returning https://web.pathway.md/diseases/recURgzrLYpU9qco8 14/17 6/24/23, 12:42 PM Hepatocellular carcinoma Pathway surveillance to the usual 6-month interval if there is no increase in the size or number of nodules. B Assessment of treatment response: As per EASL 2018 guidelines: Use mRECIST criteria to assess the response to loco-regional therapies for HCC. B Use mRECIST and RECIST1.1 criteria to assess the response to systemic therapies for HCC. B As per ESMO 2018 guidelines: Obtain dynamic CT or MRI for the assessment of viable tumor, defined as uptake of contrast agent in the arterial phase. B Consider using the mRECIST to include not only tumor diameters but also lesion viability in therapy decision-making. Use the mRECIST for the assessment of response to locoregional therapies. C Post-treatment follow-up: As per AASLD 2023 guidelines: Obtain routine postoperative surveillance with contrast-enhanced multiphasic CT or MRI every 3-6 months to detect recurrence in all patients with HCC following liver resection. B Consider obtaining post-transplant surveillance with multiphasic contrast-enhanced abdominal CT or MRI and chest CT to detect recurrence in patients with HCC following liver transplantation. B As per EASL 2018 guidelines, obtain follow-up (every 3-4 months for the first year) in patients after curative-intent liver resection because of high rates of treatable recurrence. A As per ESMO 2018 guidelines: Obtain clinical evaluation of liver decompensation and dynamic CT or MRI every 3 months during the first 2 years and every 6 months thereafter for early detection of recurrence in patients treated with radical treatments (resection or radiofrequency ablation). B Obtain clinical evaluation for signs of liver decompensation and dynamic CT or MRI every 3 months for tumor progression to guide therapy decisions in patients with more advanced stages of HCC treated with transarterial chemoembolization or systemic therapy. B Management of recurrence: As per AASLD 2023 guidelines: Consider offering post-progression treatment after adjuvant therapy based on the recurrence pattern. C Avoid using immune checkpoint inhibitors in patients with recurrent HCC after liver transplantation, given the increased risk of graft loss and death. D Consider offering sorafenib or lenvatinib as first-line therapy in these patients. As per ASTRO 2022 guidelines, consider offering palliative hypofractionated EBRT directed to the liver and/or macrovascular tumor thrombus, alone or sequenced with systemic therapy or catheter-based therapies, in patients with symptomatic locally advanced HCC. C https://web.pathway.md/diseases/recURgzrLYpU9qco8 15/17 6/24/23, 12:42 PM Hepatocellular carcinoma Pathway References 1. Grace L. Su, Osama Altayar, Robert O Shea et al. AGA Clinical Practice Guideline on Systemic Therapy for Hepatocellular Carcinoma. Gastroenterology. 2022 Mar;163 3 920 934. Open 2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018 Jul;69 1 182 236. Open 3. 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