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Work-up
History and clinical examination
Risk factors for chronic liver disease: intravenous drug abuse, alcohol intake, metabolic syndrome (obesity, diabetes, arterial hypertension)
Symptoms and signs of chronic liver disease: jaundice, ascites, encephalopathy, bleeding, splenomegaly
Performance status and nutritional state
Laboratory analysis
Etiology of liver disease: HBV (HBsAg, anti-HBc), HCV (anti-HCV), iron status, autoimmune disease, liver function: prothrombin time, albumin, bilirubin
Complete blood cell count including platelets
Tumor marker: serum alpha fetoprotein (AFP)
Assessment of portal hypertension
Imaging studies
Liver dynamic (multiple phase) MRI or CT for diagnosis and evaluation of tumor extent; number and size of nodules, vascular invasion, extrahepatic spread
CT of the chest, abdomen, and pelvis to rule out extrahepatic spread
Imaging performed, interpreted, and reported through the CT MRI Liver Imaging Reporting and Data System (CT/MRI LI-RADS)—an imaging-based diagnostic system used in patients at high risk of hepatocellular carcinoma (HCC). It assigns each liver abnormality a category that reflects the probability of the finding representing a benign cause, HCC, or other malignancy (see below)
Tumor biopsy
Vogel A et al. Ann Oncol 2018;29(Suppl 4):iv238–iv255
Diagnostic Criteria for HCC: CT/MRI LI-RADS
Diagnosis of HCC can be established based on imaging (without biopsy confirmation) in patients who have cirrhosis
Criteria on multiphase imaging to enable noninvasive diagnosis of HCC: nodule ≥1 cm, arterial phase hyperenhancement, and depending on size, a combination of washout in the venous or delayed phase, threshold growth, and capsule appearance
If criteria not met, liver biopsy should be considered
AFP and other serum biomarkers have a minor role in the diagnosis of HCC
At-risk patients with abnormal surveillance results or a clinical suspicion of HCC should undergo multiphase CT or MRI for diagnostic testing
LI-RADS system designates lesions to category codes according to the probability of being benign, HCC, or other hepatic malignant neoplasm (cholangiocarcinoma or combined) (Figure 1)
The probability of HCC associated with each LI-RADS category guides management
LI-RADS 1 and LI-RADS 2:
− Definitely benign (cysts and typical hemangiomas) and probably benign (atypical hemangiomas and focal parenchymal abnormalities) lesions, respectively
− LI-RADS 1 lesions have an average probability of HCC of 0%
− LI-RADS 2 lesions have an average probability of HCC of 11%
LI-RADS 3:
− Low probability of HCC (vascular pseudo-lesions and small HCCs, distinctive solid nodule with only some imaging features consistent with HCC diagnosis)
− Average probability of HCC of 33%
− Followed prospectively, ...