Clinical Commander

Back to dossier
gi.hcc.core.v1PRODUCTION
gi.hcc.core.v1

Hepatocellular Carcinoma (HCC, BCLC-staged)

gastroenterologychronicadult
Hard-required inputs
0 / 15
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm HCC scope: surveillance program entry vs new lesion workup vs known HCC staging/treatment (AASLD 2023 Singal)

Inputs
1
Actions
0
Advance rule
Set
Advance when

pathway assigned: surveillance, diagnostic workup, or treatment planning

Patient inputs (17)

Treatment candidacy; BCLC performance status assessment (AASLD 2023 Singal)

HCC risk varies by etiology (HBV > HCV > MASH > alcohol); HBV can cause HCC without cirrhosis (AASLD 2023 Singal)

HCC surveillance biomarker; AFP >400 diagnostic; AFP response to treatment (AASLD 2023 Singal)

Child-Pugh component; liver function for treatment candidacy (AASLD 2023 Singal)

Child-Pugh component; nutritional status (AASLD 2023 Singal)

Child-Pugh component; coagulopathy assessment (AASLD 2023 Singal)

MELD-Na for transplant prioritization; renal clearance for systemic therapy (AASLD 2023 Singal)

Portal hypertension severity; thrombocytopenia impacts procedural risk (AASLD 2023 Singal)

Baseline for systemic therapy toxicity monitoring (NCCN 2024)

LI-RADS characterization: arterial hyperenhancement + washout + capsule appearance (AASLD 2023 Singal)

Staging — exclude pulmonary metastases (NCCN 2024)

Child-Pugh A/B/C determines treatment eligibility (BCLC algorithm) (AASLD 2023 Singal)

ECOG performance status is BCLC staging component (AASLD 2023 Singal)

Portal vein thrombosis/invasion is BCLC-C criterion; contraindicates TACE (AASLD 2023 Singal; EASL 2018)

Milan criteria (single <=5cm or <=3 lesions each <=3cm) for transplant eligibility (AASLD 2023 Singal)

Staging — if bone pain or elevated ALP; exclude bone metastases (NCCN 2024)

Sorafenib/lenvatinib dosing; nutritional status (AASLD 2023 Singal)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningtumor_rupture
    Spontaneous HCC rupture with hemoperitoneum — acute abdomen, hypotension, dropping Hgb (AASLD 2023 Singal)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggi_bleed_on_bevacizumab
    GI bleeding (variceal or non-variceal) while on bevacizumab (IMbrave150)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereportal_vein_tumor_thrombus
    Macrovascular invasion of main portal vein by HCC — BCLC-C, contraindicates TACE (AASLD 2023 Singal; EASL 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereirae_grade3_4
    Grade 3-4 immune-related adverse event on atezolizumab-bevacizumab or durvalumab-tremelimumab (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
Loading…

Recommended regimen

BCLC-staged HCC treatment — AASLD 2023 Singal + NCCN 2024
axis: hcc_bclc_treatment_axisstep BCLC-0/A - BCLC 0 (very early) / A (early) — curative-intent
Selected step "BCLC 0 (very early) / A (early) — curative-intent" — Single lesion <=5 cm or up to 3 lesions each <=3 cm; Child-Pugh A/B; ECOG 0
  • surgical resection
    first line
    curative_surgery
    triggers: single_lesion, preserved_liver_function_Child_Pugh_A, no_portal_hypertension
    AASLD 2023 Singal — resection preferred for single HCC in non-cirrhotic or compensated cirrhosis without portal HTN
  • radiofrequency ablation (RFA)
    first line
    local_ablation
    triggers: lesion_<=3cm, not_surgical_candidate, Child_Pugh_A_or_B
    AASLD 2023 Singal — RFA for lesions <=3 cm with equivalent survival to resection in select patients
  • microwave ablation (MWA)
    first line
    local_ablation
    triggers: lesion_<=3cm
    AASLD 2023 Singal — MWA alternative to RFA; faster ablation, fewer heat-sink effects
  • liver transplantation
    first line
    transplant
    triggers: within_Milan_criteria, Child_Pugh_B_or_C
    AASLD 2023 Singal — transplant cures both HCC and underlying cirrhosis; Milan criteria (single <=5cm or <=3 each <=3cm, no vascular invasion, no extrahepatic disease)

outpatient playbook — drug actions (5)

  1. 1. AFP + US surveillance
    AFP serum + abdominal US • lab + imaging • q6mo
    trigger: Cirrhosis (any etiology) or chronic HBV without cirrhosis
    AASLD 2023 Singal — surveillance reduces HCC mortality
  2. 2. Atezolizumab + bevacizumab (first-line advanced)
    Atezo 1200 mg + bev 15 mg/kg IV • IV • q3w
    trigger: BCLC-C, Child-Pugh A, no high-risk varices
    IMbrave150 Finn NEJM 2020
  3. 3. Durvalumab + tremelimumab STRIDE (first-line alternative)
    Treme 300 mg IV x1 + durva 1500 mg IV q4w • IV • q4w
    trigger: BCLC-C, bevacizumab contraindicated
    HIMALAYA Abou-Alfa NEJM 2022
  4. 4. Sorafenib (second-line or IO-ineligible)
    400 mg PO BID • PO • BID
    trigger: IO contraindication or progression
    SHARP Llovet 2008; AASLD 2023 Singal
  5. 5. Lenvatinib (alternative TKI)
    12 mg (>=60kg) or 8 mg (<60kg) PO daily • PO • daily
    trigger: First-line if IO ineligible or sorafenib intolerant
    REFLECT Kudo 2018

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Suspicious liver lesion on surveillance US (AASLD 2023 Singal); Elevated AFP >20 ng/mL in cirrhotic patient (AASLD 2023 Singal); Liver mass on CT/MRI (incidental or surveillance recall).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hepatocellular Carcinoma (HCC, BCLC-staged)** (gi.hcc.core.v1).
Phenotype framing: 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)
Scope: Confirm HCC scope: surveillance program entry vs new lesion workup vs known HCC staging/treatment (AASLD 2023 Singal)

No severity triggers fired against current inputs.

Plan

Regimen axis: **BCLC-staged HCC treatment — AASLD 2023 Singal + NCCN 2024** — step "BCLC 0 (very early) / A (early) — curative-intent".
1. surgical resection (curative_surgery, first line) — AASLD 2023 Singal — resection preferred for single HCC in non-cirrhotic or compensated cirrhosis without portal HTN
2. radiofrequency ablation (RFA) (local_ablation, first line) — AASLD 2023 Singal — RFA for lesions <=3 cm with equivalent survival to resection in select patients
3. microwave ablation (MWA) (local_ablation, first line) — AASLD 2023 Singal — MWA alternative to RFA; faster ablation, fewer heat-sink effects
4. liver transplantation (transplant, first line) — AASLD 2023 Singal — transplant cures both HCC and underlying cirrhosis; Milan criteria (single <=5cm or <=3 each <=3cm, no vascular invasion, no extrahepatic disease)

Setting playbook (outpatient) — HCC surveillance in at-risk populations (AFP + US q6mo); diagnosis via LI-RADS; BCLC staging; systemic therapy administration and toxicity monitoring; post-treatment surveillance
5. AFP + US surveillance AFP serum + abdominal US lab + imaging q6mo — Cirrhosis (any etiology) or chronic HBV without cirrhosis (AASLD 2023 Singal — surveillance reduces HCC mortality)
6. Atezolizumab + bevacizumab (first-line advanced) Atezo 1200 mg + bev 15 mg/kg IV IV q3w — BCLC-C, Child-Pugh A, no high-risk varices (IMbrave150 Finn NEJM 2020)
7. Durvalumab + tremelimumab STRIDE (first-line alternative) Treme 300 mg IV x1 + durva 1500 mg IV q4w IV q4w — BCLC-C, bevacizumab contraindicated (HIMALAYA Abou-Alfa NEJM 2022)
8. Sorafenib (second-line or IO-ineligible) 400 mg PO BID PO BID — IO contraindication or progression (SHARP Llovet 2008; AASLD 2023 Singal)
9. Lenvatinib (alternative TKI) 12 mg (>=60kg) or 8 mg (<60kg) PO daily PO daily — First-line if IO ineligible or sorafenib intolerant (REFLECT Kudo 2018)

Non-pharmacologic actions:
- Multidisciplinary tumor board review before treatment initiation (NCCN 2024)
- Transplant evaluation for patients within Milan criteria (AASLD 2023 Singal)
- Locoregional bridging therapy (TACE/RFA) while awaiting transplant (AASLD 2023 Singal)
- Nutritional support and protein supplementation in cirrhosis (EASL 2018)
- Hepatitis B antiviral therapy if HBV-related HCC (AASLD 2023 Singal)
- Hepatitis C DAA therapy if HCV-related (coordinate with oncology) (AASLD 2023 Singal)
- Palliative care early integration for BCLC-C/D (NCCN 2024)

AVOID / contraindication checks:
- Bevacizumab contraindicated with untreated or high risk esophageal varices — EGD required before starting atezolizumab bevacizumab (IMbrave150 Finn NEJM 2020)
- Immunotherapy contraindicated in active autoimmune disease or solid organ transplant (other than liver) — use TKI instead (NCCN 2024)
- TACE contraindicated with main portal vein thrombosis — consider Y90 or systemic therapy (EASL 2018)
- Sorafenib hand foot syndrome — dose reduce to 200 mg BID or switch to lenvatinib (AASLD 2023 Singal)
- Child Pugh B8+ or C — no systemic therapy benefit; BSC only (AASLD 2023 Singal)
- Lenvatinib weight based dosing — 12 mg if >=60 kg, 8 mg if <60 kg (REFLECT Kudo 2018)

Monitoring

Regimen monitoring:
- Post-treatment multiphase CT/MRI per mRECIST at 1 month then q3mo x2yr then q6mo (AASLD 2023 Singal)
- AFP trend q3mo (if elevated at baseline) (AASLD 2023 Singal)
- Immunotherapy toxicity: LFTs q3w, TFTs q6w, glucose, lipase (NCCN 2024)
- TKI toxicity: BP q2w (hypertension), hand-foot skin reaction, diarrhea, LFTs (NCCN 2024)
- Bevacizumab: proteinuria (urine dipstick q cycle), BP monitoring, wound healing assessment (IMbrave150)
- Post-transplant: immunosuppression levels, AFP + imaging q3mo x2yr for recurrence (AASLD 2023 Singal)

Setting (outpatient) monitoring:
- AFP q3mo during treatment (AASLD 2023 Singal)
- Multiphase CT/MRI q3mo per mRECIST (AASLD 2023 Singal)
- LFTs q3w on immunotherapy (NCCN 2024)
- TFTs q6w on immunotherapy (NCCN 2024)
- BP + proteinuria on bevacizumab (IMbrave150)
- Hand-foot reaction + BP + LFTs on TKI (NCCN 2024)

Follow-up plan: Multidisciplinary tumor board review; transplant center coordination; palliative care integration for BCLC-D; survivorship if complete response; ongoing cirrhosis management (AASLD 2023 Singal)
- Close-out criterion: follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — HCC surveillance in at-risk populations (AFP + US q6mo); diagnosis via LI-RADS; BCLC staging; systemic therapy administration and toxicity monitoring; post-treatment surveillance

Disposition criteria:
- Outpatient for surveillance, systemic therapy, post-treatment monitoring (AASLD 2023 Singal)
- Inpatient for resection, TACE, Y90, transplant, or acute complications (NCCN 2024)

Escalation triggers (move to higher acuity):
- Tumor rupture (acute abdomen, hypotension) then ED + emergent TAE (AASLD 2023 Singal)
- Immune-related adverse event grade 3-4 then hold IO + high-dose steroids (NCCN 2024)
- Variceal bleed on bevacizumab then discontinue bev permanently + manage bleed (IMbrave150)
- Decompensation (new ascites, HE, jaundice) then reassess Child-Pugh and BCLC (AASLD 2023 Singal)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Spontaneous HCC rupture with hemoperitoneum — acute abdomen, hypotension, dropping Hgb (AASLD 2023 Singal)
- [LIFE_THREATENING] GI bleeding (variceal or non-variceal) while on bevacizumab (IMbrave150)
- [SEVERE] Macrovascular invasion of main portal vein by HCC — BCLC-C, contraindicates TACE (AASLD 2023 Singal; EASL 2018)

Citations

- AASLD Practice Guidance on Diagnosis, Staging and Management of HCC (Marrero, Hepatology 2018) + landmark systemic-therapy RCTs (SHARP, IMbrave150, HIMALAYA) [PMID:29624699](https://pubmed.ncbi.nlm.nih.gov/29624699/)
- Cited evidence (PMID 18650514) [PMID:18650514](https://pubmed.ncbi.nlm.nih.gov/18650514/)
- Cited evidence (PMID 32402160) [PMID:32402160](https://pubmed.ncbi.nlm.nih.gov/32402160/)
- Cited evidence (PMID 38319892) [PMID:38319892](https://pubmed.ncbi.nlm.nih.gov/38319892/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD Practice Guidance on Diagnosis, Staging and Management of HCC (Marrero, Hepatology 2018) + landmark systemic-therapy RCTs (SHARP, IMbrave150, HIMALAYA) — PMID:29624699
  • Cited evidence (PMID 18650514) — PMID:18650514
  • Cited evidence (PMID 32402160) — PMID:32402160
  • Cited evidence (PMID 38319892) — PMID:38319892