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gi.hcc.core.v1

Hepatocellular Carcinoma (HCC, BCLC-staged)

gastroenterologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

HCC dossier (chronic, BCLC-staged). STEP 3 deepened (2026-05-16): design brief + research bundle authored (§5.5 items 1-2); §5.5.1 effect sizes wired (IMbrave150 atezo-bev OS HR ~0.58, median OS ~19.2 vs 13.4 mo; HIMALAYA STRIDE OS HR ~0.78; SHARP sorafenib OS 10.7 vs 7.9 mo HR ~0.69; resection/ablation 5-yr ~50-70%; transplant within Milan 5-yr ~70%); §5.5.2 Bayesian (LI-RADS 5 ~95-100% spec/PPV diagnostic without biopsy, AFP low-sensitivity conditional note, BCLC→treatment routing thresholds, Child-Pugh systemic-eligibility gate, gi.cirrhosis routing); INITIAL_WORKUP action panel.bmp→panel.renal reconciled to STEP-2 repoint. last_reconciled 2026-05-16 (AASLD 2023 / EASL 2018 / NCCN 2024 floor). Re-promoted SCAFFOLDED→PRODUCTION (design_brief present; all completeness tiers satisfied; verified via dossier:audit). RxCUIs pending research:rxnav drug-data commit.

Entry points (5)

  • imaging
    Suspicious liver lesion on surveillance US (AASLD 2023 Singal)
    liver_lesion_surveillance
  • lab_abnormality
    Elevated AFP >20 ng/mL in cirrhotic patient (AASLD 2023 Singal)
    afp_elevated
  • imaging
    Liver mass on CT/MRI (incidental or surveillance recall)
    ct_mri_liver_mass
  • problem_list
    Known HCC on problem list (follow-up, staging, treatment response)
    hcc_known
  • problem_list
    Cirrhosis patient entering HCC surveillance program (AASLD 2023 Singal)
    cirrhosis_hcc_risk

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Treatment candidacy; BCLC performance status assessment (AASLD 2023 Singal)
  • cirrhosis_etiologyrequired
    history • used at CONTEXT
    HCC risk varies by etiology (HBV > HCV > MASH > alcohol); HBV can cause HCC without cirrhosis (AASLD 2023 Singal)
  • child_pugh_classrequired
    history • used at RISK_STRATIFICATION
    Child-Pugh A/B/C determines treatment eligibility (BCLC algorithm) (AASLD 2023 Singal)
  • ecog_psrequired
    history • used at RISK_STRATIFICATION
    ECOG performance status is BCLC staging component (AASLD 2023 Singal)
  • weight
    vital • used at TREATMENT
    Sorafenib/lenvatinib dosing; nutritional status (AASLD 2023 Singal)
  • afprequired
    lab • used at INITIAL_WORKUP
    HCC surveillance biomarker; AFP >400 diagnostic; AFP response to treatment (AASLD 2023 Singal)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Child-Pugh component; liver function for treatment candidacy (AASLD 2023 Singal)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Child-Pugh component; nutritional status (AASLD 2023 Singal)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Child-Pugh component; coagulopathy assessment (AASLD 2023 Singal)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    MELD-Na for transplant prioritization; renal clearance for systemic therapy (AASLD 2023 Singal)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Portal hypertension severity; thrombocytopenia impacts procedural risk (AASLD 2023 Singal)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline for systemic therapy toxicity monitoring (NCCN 2024)
  • multiphase_ct_or_mrirequired
    imaging • used at INITIAL_WORKUP
    LI-RADS characterization: arterial hyperenhancement + washout + capsule appearance (AASLD 2023 Singal)
  • chest_ctrequired
    imaging • used at INITIAL_WORKUP
    Staging — exclude pulmonary metastases (NCCN 2024)
  • bone_scan
    imaging • used at BRANCHING_WORKUP
    Staging — if bone pain or elevated ALP; exclude bone metastases (NCCN 2024)
  • portal_vein_statusrequired
    history • used at RISK_STRATIFICATION
    Portal vein thrombosis/invasion is BCLC-C criterion; contraindicates TACE (AASLD 2023 Singal; EASL 2018)
  • transplant_candidacyrequired
    history • used at TREATMENT
    Milan criteria (single <=5cm or <=3 lesions each <=3cm) for transplant eligibility (AASLD 2023 Singal)

12-phase flow (12)

  1. 1FRAME
    Confirm HCC scope: surveillance program entry vs new lesion workup vs known HCC staging/treatment (AASLD 2023 Singal)
    inputs: cirrhosis_etiology
    advance: pathway assigned: surveillance, diagnostic workup, or treatment planning
  2. 2ENTRY
    Recognize HCC trigger: surveillance US abnormality, elevated AFP, incidental liver mass, or known HCC follow-up (AASLD 2023 Singal)
    inputs: afp
    advance: entry trigger confirmed
  3. 3CONTEXT
    Cirrhosis etiology, Child-Pugh class, ECOG PS, prior HCC treatments, transplant listing status, comorbidities (AASLD 2023 Singal)
    inputs: age, cirrhosis_etiology, child_pugh_class, ecog_ps
    advance: clinical context captured
  4. 4RED_FLAGS
    Tumor rupture (acute abdomen + hemodynamic instability), variceal bleed in setting of HCC, portal vein tumor thrombus with decompensation, rapidly progressive liver failure (AASLD 2023 Singal)
    inputs: portal_vein_status
    advance: acute complications excluded or escalated
  5. 5INITIAL_WORKUP
    AFP (limited sensitivity ~60% at >20 ng/mL — adjunct to imaging + surveillance trend, NOT standalone; a normal AFP does not lower HCC probability enough to stop imaging), LFTs (bilirubin, albumin, INR), CBC, renal panel, multiphase CT or MRI liver — LI-RADS 5 in a cirrhotic = ~95-100% specificity/PPV for HCC, diagnostic WITHOUT biopsy; chest CT for staging (AASLD HCC practice guidance PMID 29624699)
    inputs: afp, total_bilirubin, albumin, inr, creatinine, platelets, cbc, multiphase_ct_or_mri, chest_ct
    actions: panel.lft, panel.cbc, panel.renal
    advance: LI-RADS category assigned and staging imaging complete
  6. 6BRANCHING_WORKUP
    LI-RADS 3 indeterminate = short-interval follow-up or alternative modality; LI-RADS 4-5 = probable/definite HCC; biopsy only if atypical imaging (non-cirrhotic, LR-M); bone scan if symptomatic; PET not standard (AASLD 2023 Singal)
    inputs: bone_scan
    actions: workup.abnormal_lft
    advance: HCC diagnosis confirmed (LI-RADS 5) or alternative diagnosis established
  7. 7DIFFERENTIAL
    HCC (LI-RADS 5) vs cholangiocarcinoma (LR-M wash-in without washout) vs metastatic disease vs hemangioma vs FNH vs dysplastic nodule (AASLD 2023 Singal)
    advance: diagnosis confirmed
  8. 8RISK_STRATIFICATION
    BCLC staging (0/A/B/C/D) is the load-bearing routing variable: tumor burden, liver function (Child-Pugh — gates systemic eligibility; atezo-bev evidence is Child-Pugh A only), performance status (ECOG), portal vein invasion, extrahepatic spread. Treatment-routing thresholds: 0/A→curative (5-yr ~50-70%; transplant within Milan 5-yr ~70%); B→locoregional; C→systemic; D (Child-Pugh C/ECOG >2)→BSC (AASLD HCC practice guidance PMID 29624699)
    inputs: child_pugh_class, ecog_ps, portal_vein_status
    actions: calc.meld3, calc.meld_na
    advance: BCLC stage assigned and treatment candidacy determined
  9. 9TREATMENT
    BCLC-staged: 0/A = resection/ablation/transplant (curative). B = TACE/Y90. C = systemic 1L atezolizumab-bevacizumab (IMbrave150 Finn NEJM 2020 PMID 32402160 — OS HR ~0.58 vs sorafenib, median OS ~19.2 vs 13.4 mo; manage varices before bevacizumab) OR durvalumab-tremelimumab STRIDE if bevacizumab contraindicated (HIMALAYA Abou-Alfa NEJM Evid 2022 PMID 38319892 — OS HR ~0.78); TKI alternative sorafenib (SHARP Llovet NEJM 2008 PMID 18650514 — OS 10.7 vs 7.9 mo, HR ~0.69) or lenvatinib. D = best supportive care (AASLD HCC practice guidance)
    inputs: transplant_candidacy, weight
    advance: treatment initiated or BSC plan documented
  10. 10DISPOSITION
    Outpatient for surveillance and systemic therapy; inpatient for resection, TACE, Y90; multidisciplinary tumor board mandatory (AASLD 2023 Singal; NCCN 2024)
    advance: care setting assigned
  11. 11MONITORING
    Post-treatment imaging (multiphase CT/MRI) per mRECIST at 1 mo then q3mo; AFP trend; systemic therapy toxicity monitoring (LFTs, TFTs for immunotherapy, proteinuria for bevacizumab); post-transplant immunosuppression and recurrence surveillance (AASLD 2023 Singal; NCCN 2024)
    inputs: afp, total_bilirubin
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Multidisciplinary tumor board review; transplant center coordination; palliative care integration for BCLC-D; survivorship if complete response; ongoing cirrhosis management (AASLD 2023 Singal)
    advance: follow-up scheduled