Post-Hepatectomy Surveillance for Grade 2 HCC with Favorable Prognostic Features
For a patient with grade 2 HCC who has undergone right hepatectomy with normal AFP, normal liver function, and good background liver, implement intensive surveillance with multiphase CT or MRI every 3 months for the first 2 years, then every 6 months thereafter, combined with AFP measurement at each visit. 1, 2
Surveillance Imaging Protocol
First 2 Years (High-Risk Period)
- Perform multiphase CT or MRI every 3 months during the initial 24 months post-hepatectomy, as recurrence risk is 6.5 times higher in the first year compared to the second year 1
- The National Comprehensive Cancer Network and European Association for the Study of the Liver both support this 3-month interval for early detection when curative re-treatment remains feasible 1, 2
After 2 Years
- Transition to surveillance every 6 months with the same imaging modalities after completing the initial 2-year intensive surveillance period 1
- This reduced frequency is appropriate given the lower recurrence risk beyond 2 years 1
Technical Imaging Requirements
- Use four-phase imaging protocol: non-contrast, arterial, portal venous, and delayed phases 1, 2
- The non-contrast phase is particularly important for detecting new lesions and distinguishing them from post-surgical changes 1
- Include chest imaging to detect extrahepatic metastases, as these represent a significant pattern of recurrence 2
Biomarker Monitoring Strategy
AFP Surveillance
- Measure AFP at every surveillance visit (every 3 months for 2 years, then every 6 months), even though your patient currently has normal levels 1, 2
- Trending AFP is essential: rising AFP even within the "normal" range may indicate recurrence before imaging changes become apparent 2
- Normal preoperative AFP does not eliminate the need for ongoing monitoring, as AFP can become elevated with recurrence 3
Critical Pitfall to Avoid
- Do not rely solely on AFP for surveillance decisions, as approximately 30-40% of HCCs are AFP-negative 1
- Your patient's normal AFP is actually a favorable prognostic factor, but imaging remains the primary surveillance modality 1
Response Assessment Criteria
Use modified RECIST (mRECIST) criteria rather than standard RECIST to evaluate any suspicious lesions, as this measures viable tumor (arterial enhancement) rather than total lesion size 1, 2
Management of Detected Recurrence
Solitary Intrahepatic Recurrence
- Consider repeat resection if technically feasible and liver function remains adequate, as this offers the best chance for cure 2
- Radiofrequency ablation is an alternative for small recurrences (<2 cm) 1
Multifocal or Advanced Recurrence
- Proceed to systemic therapy with atezolizumab plus bevacizumab as first-line treatment if Child-Pugh A liver function is maintained 2
- TACE may be considered for intermediate-stage recurrence confined to the liver 1, 4
Prognostic Context for Your Patient
Your patient has several favorable prognostic factors that justify this intensive surveillance approach:
- Normal preoperative AFP (associated with better outcomes) 1
- Normal liver function tests (Child-Pugh A) 1
- Good background liver without significant cirrhosis 1
- Grade 2 differentiation (intermediate grade) 5
However, recurrence rates remain substantial even in favorable cases: 50-70% at 5 years post-hepatectomy, with early recurrences (<2 years) typically representing intrahepatic metastases and later recurrences representing de novo tumors 1
Additional Monitoring Considerations
- Assess for liver decompensation at each visit, as this determines eligibility for salvage treatments 1
- Monitor for portal hypertension development, which would impact treatment options for any recurrence 1
- Consider dual-tracer PET-CT (18F-FDG plus 18F-FCH) if AFP rises or imaging findings are equivocal, though this is not routine surveillance 1, 2