Clinical algorithm for surgery-centered precision management of hepatocellular carcinoma. (IMAGE)
Caption
Clinical algorithm for surgery-centered precision management of hepatocellular carcinoma. This diagram delineates the specific elements of each domain of the integrated management strategy. The early detection domain encompasses conventional screening combining US with AFP measurement, which has inherent limitations including suboptimal sensitivity for small lesions and frequent AFP-negative cases in 30%–40% of early-stage HCC. Multi-parameter early detection models address these shortcomings through the GALAD score, integrating gender, age, AFP-L3, AFP, and DCP, alongside the more cost-effective ASAP model, incorporating age, sex, AFP, and PIVKA-II. Both achieve AUROC values exceeding 0.85 across various etiologies. Liquid biopsy innovations further augment surveillance capabilities through ctDNA methylation profiling, CTC enumeration, and EV analysis. The precision surgery domain highlights risk prediction systems incorporating novel calculators, frailty scores, and textbook outcome metrics to optimize patient selection. Refined staging systems address the limitations of the BCLC classification, which was not designed for surgical prognostication, and TNM staging, which lacks biological information. The CNLC system provides intermediate-stage subclassification adapted to China’s population, whereas Eastern staging enables precise BCLC B/C subtyping. Precision surgical strategies encompass anatomical approaches, 3D surgery navigation, and fluorescence-guided techniques enhancing tumor localization and margin determination. The recurrence control domain delineates MRD monitoring through serum biomarkers, liquid biopsy platforms, and imaging methods enabling detection of molecular relapse preceding radiological confirmation. Risk-stratified surveillance protocols incorporate patient-related, tumor-related, and perioperative factors to tailor follow-up intensity. Novel therapeutic approaches spanning targeted therapy, immunotherapy combinations, and nanomedicine delivery systems represent the expanding armamentarium for adjuvant intervention. AFP, alpha-fetoprotein; ASAP, age, sex, AFP, and PIVKA-II; AUROC, area under the receiver operating characteristic curve; BCLC, Barcelona Clinic Liver Cancer; CNLC, China Liver Cancer; CTC, circulating tumor cell; ctDNA, circulating tumor DNA; DCP, des-gamma-carboxy prothrombin; EV, extracellular vesicle; GALAD, gender, age, AFP-L3, AFP, and DCP; HCC, hepatocellular carcinoma; MRD, minimal residual disease; PIVKA-II, protein induced by vitamin K absence or antagonist-II; TNM, tumor-node-metastasis; 3D, 3-dimensional; US, ultrasound.
Credit
Cancer Biology & Medicine
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