Episode two works hepatocellular carcinoma as one continuous algorithm built on a single override: a new lesion in a cirrhotic or chronic hepatitis B liver is HCC until proven otherwise. Surveillance goes to every Child-Pugh A or B cirrhotic and to high-risk hepatitis B, by ultrasound and AFP every six months timed to the tumor doubling time and the curative-size cutoffs. LI-RADS turns that finding into a diagnosis, with the definite category diagnostic by imaging alone and the two special categories forcing biopsy or excluding transplant. The BCLC system then turns the diagnosis into the treatment the physiology will actually permit, from resection and ablation, through transplant within Milan, to locoregional therapy and first-line atezolizumab plus bevacizumab for advanced disease. Topics covered Surveillance eligibility and Child-Pugh cutoffs Non-cirrhotic hepatitis B risk triggers Ultrasound plus AFP every six months The role and limits of AFP LI-RADS categories and the diagnostic five Major features and their mechanisms BCLC staging and curative options Milan and UCSF criteria and down-staging Locoregional and systemic therapy Key decisions Surveil every patient with Child-Pugh A or B cirrhosis of any cause including cured hepatitis C, and surveil Child-Pugh C only when the patient is a transplant candidate. The modality is right-upper-quadrant ultrasound with AFP every six months, substituting MRI or CT when severe obesity or steatosis makes the ultrasound useless; AFP is never stand-alone, but a value over two hundred nanograms per milliliter with arterial enhancement strongly supports HCC. LI-RADS five requires a lesion at least one centimeter with arterial-phase hyperenhancement plus a major feature, namely washout, an enhancing capsule, or threshold growth of fifty percent or more in six months, and in a cirrhotic liver that is a diagnosis without biopsy. A rim-enhancing, peripheral-washout, targetoid lesion is the malignant-but-not-HCC category that you biopsy, because intrahepatic cholangiocarcinoma over two centimeters is a transplant contraindication; an arterially enhancing tumor thrombus takes the patient out of transplant criteria and is not anticoagulated. Milan criteria are a single lesion at most five centimeters, or up to three lesions each at most three centimeters, with no extrahepatic spread and no macrovascular invasion; UCSF widens this and patients beyond Milan can be down-staged with locoregional therapy and three to six months of imaging stability before listing. Cirrhotic resection requires a normal bilirubin and a hepatic venous pressure gradient under ten, and thermal ablation substitutes for tumors under three centimeters, limited by the heat-sink effect near vessels. First-line advanced therapy is atezolizumab plus bevacizumab, requiring a mandatory upper endoscopy within six months with high-risk varices treated first, and durvalumab plus tremelimumab is the alternative when bevacizumab is contraindicated. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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