Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, presents with various clinical features that can help diagnose and stage the disease. These features, along with imaging studies and laboratory tests, aid in determining the extent and severity of HCC. Here are the key clinical features and staging considerations: Clinical Features: Abdominal Pain: HCC can cause pain or discomfort in the upper right abdomen due to liver enlargement or tumor growth. Jaundice: Yellowing of the skin and eyes (jaundice) may occur when the tumor affects liver function or obstructs the bile ducts. Weight Loss: Unintentional weight loss may result from factors such as decreased appetite or cancer-related wasting. Fatigue and Weakness: HCC patients often experience persistent fatigue and generalized weakness. Loss of Appetite and Nausea: HCC can lead to reduced appetite, resulting in nausea and vomiting. Abdominal Swelling: Ascites, the accumulation of fluid in the abdomen, may cause abdominal distension and discomfort. Enlarged Liver: As HCC progresses, the liver may become palpable due to its enlargement and the presence of a tumor. Staging: HCC staging helps determine the extent and spread of the cancer, guiding treatment decisions. The most commonly used staging system for HCC is the Barcelona

2. Hepatocellular Carcinoma (HCC), also known as liver cancer, is a primary malignancy originating
in the liver.
It is one of the most common and aggressive types of liver cancer and is associated with high
morbidity and mortality.
HCC typically arises in the context of chronic liver disease, such as cirrhosis or hepatitis B and C
infection.
Approximately 75 % of primary liver tumors are HCC, with cholangiocarcinoma comprising most
of the remaining cases
The use of antiviral therapy for patients with chronic HCV and an established diagnosis of HCC,
including data on reducing the risk of HCC recurrence .
Early detection and accurate staging of HCC are critical for effective management and improved
patient outcomes.

3. Cancer of the liver and intrahepatic bile ducts is the sixth most frequently diagnosed
malignancy worldwide.
With a five-year survival of approximately 21%, liver cancer is among the most lethal
gastrointestinal tumors
Estimated that 72 % of HCC cases occur in Asia, 10 % in Europe, 8 % in Africa, 5 % in North
America, and 5 % in Latin America
More frequently in men than in women, with a male to female ratio of approximately 3:1.

4. • common characteristic is injury to the liver parenchyma resulting in cirrhosis.
• Over 50 % of cases chronic HBV and 20 % of cases chronic HCV infection
• However, patients with chronic HBV infection are at risk for HCC even in the absence of
cirrhosis.
a. Cirrhosis
b. Viral hepatitis
c. Environmental toxins
d. Betel nut chewing
e. Iron overload in patients without genetic
susceptibility
f. Contaminated drinking water
g. Alcohol
h. Tobacco
i. Sugar-sweetened beverages
j. Nonalcoholic fatty liver disease
k. Diabetes mellitus
l. Obesity
m. Alpha-1 antitrypsin deficiency
n. Porphyria cutanea tarda (PCT)
PROTECTIVE FACTORS
• Vaccination for hepatitis B virus
(HBV) prevention
• Treatment for viral hepatitis
• Statins
• Aspirin and other nonsteroidal
anti-inflammatory drugs
• Metformin
• Coffee
• Physical activity

5. Cirrhosis :up to one-third of patients with cirrhosis will develop HCC during their lifetime, with an annual
incidence rate of 1 to 8%.
Hepatitis B virus —
Similarly, the annual incidence of HCC among those with HBV infection is higher in patients with cirrhosis
compared with no cirrhosis (3.2 vs 0.1 cases per 100 person-years).
• High viral load (ie, HBV DNA levels >106 copies /mL).
• HBeAg positivity (an indicator of a prolonged replication phase).
• HBsAg levels >1000 IU/mL in patients with HBeAg negative chronic HBV with low viral
load (ie, inactive chronic HBV)
• HBV genotype C
• Male sex (for patients who are HBsAg positive)
• Viral coinfection (HCV or hepatitis D virus, hepatitis E virus )
• HBsAg clearance – favorable prognosis, clearance of HBsAg did not eliminate the risk of
HCC .
• Young age of HBV acquisition or older age among those with chronic infection.
• Lifestyle factors –
• Alcohol or tobacco use.
• Blood group B (in males only).
• Family history of HCC.
Other factor
associated
with HCC
risk include

6. HCV infection is associated with an increased risk of HCC, primarily in patients with advanced hepatic fibrosis or cirrhosis.
The risk of developing HCC once cirrhosis has developed ranges from 1 to 4% per year.
In the United States, HCV accounts for approximately one-third of HCC cases. Successful treatment lowers but does not
eliminate HCC risk.
• Genotype 1b is associated with a higher risk of HCC compared to
genotypes 2a/c.
• Viral coinfection (HBV or HIV).
• Lifestyle factors like alcohol or tobacco use.
• Metabolic factors such as diabetes mellitus and obesity.
Additional risk factors for HCC in HCV-
infected individuals include:
HCC in the context of HCV is believed to arise due to rapid cellular turnover and the chronic inflammatory state induced by
the virus.
The imbalance in liver microenvironments and cytokines in HCV-infected livers leads to increased inflammation and cell
turnover, ultimately resulting in cirrhosis.
Poorly differentiated hepatocytes proliferate and develop into dysplastic nodules and HCC

7. Non-Metastatic HCC:
1.Asymptomatic
2.Abdominal Pain
3.Hepatomegaly
4.Jaundice
5.Ascites
6.Weight Loss
Paraneoplastic syndromes
1.Erythrocytosis (Polycythaemia)
2.Hypercalcemia
3.Hypoglycaemia.
4.Hypertrophic Osteoarthropathy
5.Ectopic Adrenocorticotropic Hormone
(ACTH) Production
6.Diarrhoea

8. 1.Jaundice:
2.Pruritus (Itching): bile salts in the bloodstream.
3.Spider Angiomas (Telangiectasia
4.Palmar Erythema
5.Leukonychia
6.Nail Changes
7.Cutaneous Lymphoma
8.Dermatomyositis
9.Pemphigus Foliaceus

9. • Extrahepatic metastases —
• Present at the time of diagnosis in approx. 10 to 15% of cases .
• Common in patients with advanced stage primary tumors (>5 cm, large vessel vascular
invasion.
• Extrahepatic recurrence after locoregional therapy in approximately 5 to 25% of patients
Metastatic HCC:
1.Lung Metastasis: cough, shortness of breath, chest pain
2.Bone Metastasis: Bone pain, particularly in the spine or hips.
3.Neurological Symptoms: headaches, confusion, difficulty speaking, or seizures.
4.Abdominal Discomfort: pain, discomfort, or digestive issues.

10. Alpha-
Fetoprotein
(AFP):
Des-Gamma-
Carboxy
Prothrombin
(DCP or
PIVKA-II)
AFP-L3%
Hepatitis B
Surface
Antigen
(HBsAg)
Hepatitis C
Antibodies
and RNA
(HCV
Antibodies
and RNA)
FibroSure/Fibro
Test
Liver Function
Tests
AFP mRNA

11. • Hepatocellular Carcinoma (HCC)
• Cirrhosis
• Chronic Hepatitis B and C
• Non-Alcoholic Fatty Liver Disease (NAFLD.
• Alcoholic Liver Disease
• Pregnancy
• Germ Cell Tumors
• Yolk Sac Tumors
• Teratomas.
• Ataxia-Telangiectasia
• Pancreatic Cancer
• Neural Tube Defects

12. 1. Production by HCC: HCC cells can produce AFP, leading to elevated levels of this protein in the
bloodstream. AFP is often used as a tumor marker for HCC.
2. Tumor Screening and Diagnosis: AFP is a valuable tool for screening individuals at risk of HCC,
such as those with cirrhosis, chronic hepatitis B or C, or a family history of HCC
3. Monitoring and Surveillance: In patients already diagnosed with HCC, AFP is used for monitoring
the disease's progression and response to treatment. A rise in AFP levels over time can indicate
tumor growth or recurrence.
4. AFP Levels: The interpretation of AFP levels in the context of HCC is as follows:
1. Normal: Typically, AFP levels in healthy individuals are low (usually below 10 ng/mL).
2. Elevated but Non-specific: Elevated AFP alone is not specific to HCC and requires further
evaluation.
3. Significantly Elevated: A significant elevation of AFP, usually beyond 200 ng/mL, is more
strongly associated with HCC. However, not all HCC cases exhibit high AFP levels, and a
significant proportion of HCC cases have normal AFP levels.
4. AFP-L3%: Measuring the proportion of the specific form of AFP called AFP-L3% can improve
the specificity of AFP for HCC diagnosis. An AFP-L3% level of 10% or higher is often indicative
of HCC.
5. Combining AFP with Imaging: AFP is often used in conjunction with imaging studies such as
ultrasound, CT scans, or MRI for HCC diagnosis. Combining AFP with imaging results in a more
accurate assessment of the likelihood of HCC.

13. Aspect GALAD Score
Doylestown Algorithm (with
LMW Kininogen Modification)
Components Gender, Age, AFP-L3, AFP, DCP
Age, Gender, ALT, Alkaline
Phosphatase, AFP, LMW
Kininogen
Score Range Variable values
Variable values, modified with
inclusion of LMW Kininogen
Purpose Predicts HCC risk
Predicts HCC risk, improved
accuracy for low AFP values
Clinical Application
- Used for HCC risk assessment. -
Score values vary based on
individual factors.
- Used for HCC risk assessment. -
Modified version enhances
accuracy for patients with low
AFP values. - Score values vary
based on individual factors.

14. DIAGNOSTIC APPROACH
Patients at high risk for
HCC
Patients with chronic,
nonviral liver disease and
no cirrhosis
Patients without
chronic liver disease
Lesions <1
cm Lesions ≥1 cm
dynamic contrast-
enhanced CT or MRI of
the abdomen tailored for
liver lesion evaluation
monitored at short
intervals (eg, every three
to six months) for one to
two years
maging characteristics are
consistent with HCC and
the AFP is >400 ng/mL, a
biopsy may not be
necessary in all patients,
especially if the lesion
appears to be resectable.
tumor markers
(AFP, CA 19-9,
carcinoembryonic
antigen), and
imaging (a
contrast-
enhanced CT or
MRI of the
abdomen tailored
for liver lesion
evaluation)
biopsy can be
considered

15. HCC lesions show arterial hypervascularity and contrast "washout" in imaging.
HCC diagnosis involves multiphasic CT and MRI with contrast.
LI-RADS criteria apply to cirrhosis patients for CT or MRI diagnosis.
CEUS can solve indeterminate nodules but not recommended for full assessment.
CT and MRI are sensitive, with ultrasound being specific for HCC.
PET/CT predicts prognosis but lacks sensitivity for HCC detection.
MRI is more sensitive for HCC than CT, but specificity may not significantly differ.
Contrast MRI detects small lesions effectively (sensitivity 78%, specificity 92%).
Classical arterial enhancement in one imaging technique can diagnose small HCC.
NCCN Guidelines recommend CT or MRI for patients with HCC risk factors.
Gadolinium contrast is preferred for MRI.

16. 1.Imaging Technique: Triple-phase CT is a specialized imaging technique used for HCC
diagnosis and evaluation. It involves three distinct phases:
1. Non-contrast Phase: Initial scanning without contrast to assess baseline liver tissue and identify
lesions.
2. Arterial Phase: Contrast material is injected intravenously, and imaging is performed during the
arterial phase, capturing the early enhancement of the tumor.
3. Portal Venous Phase: Scanning is conducted during the portal venous phase, when the liver
parenchyma and most tumors reach peak enhancement.
2.Specificity in HCC Diagnosis: Triple-phase CT is highly specific for HCC diagnosis due
to several factors:
1. Arterial Phase: During this phase, HCC lesions typically show rapid and significant enhancement.
This is a key feature that distinguishes HCC from other liver lesions.
2. Washout Appearance: In the portal venous phase, HCC lesions demonstrate a "washout"
appearance, where the contrast agent is washed out of the tumor, making it less enhancing
compared to the surrounding liver tissue. This contrast washout is a hallmark of HCC.
3. Enhancement Pattern: The combination of arterial phase enhancement and portal venous phase
washout is a specific enhancement pattern for HCC, aiding in differentiation from other liver lesions.
3.Enhanced Accuracy: Triple-phase CT's ability to capture the dynamic enhancement
patterns of HCC greatly enhances its diagnostic accuracy and differentiation from benign
liver lesions.
4.Lesion Characterization: Besides diagnosis, triple-phase CT assists in characterizing
HCC lesions by assessing their size, number, and location, which is crucial for staging
and treatment planning.
5.Limitations: Despite its high specificity, triple-phase CT may not always detect early or
small HCC lesions.

17. Parameter Value
Sensitivity (All Lesions) 65%
Specificity (All Lesions) 96%
Sensitivity (Lesions <2
cm)
40%
Positive Predictive
Value (Lesions ≥2 cm in
Cirrhotic Patients)
92%
Study data shows : table 1:CT Scan ,2: Comparative
maging
Modality Sensitivity Specificity
Diagnostic
Accuracy
MRI 79% - 78%
CT 62% - 67%
CEUS (Any
Size)
78% 94% -
CEUS (≤3
cm)
77.5% 93% -

18. • Equipment: Requires a scanner with a magnet strength of ≥1.5 Tesla.
• Contrast Agent: Uses gadolinium-based contrast agents with precise injection
techniques and accurate timing for optimal results.
• Image Sets: Involves specific image sequences, including precontrast T1-weighted, T2-
weighted, and various post-contrast phases to characterize and differentiate HCC lesions.
• Superiority Over CT: Data suggests that MRI may outperform CT, especially for
diagnosing small HCC lesions (≤3 cm), with higher sensitivity and diagnostic accuracy.
• Special Considerations: Caution needed in patients with severe chronic kidney
impairment when using gadolinium contrast agents.
• Gadoxetate MRI: Utilizes gadoxetate disodium, a hepatobiliary-specific contrast agent,
for additional information through a hepatobiliary phase image set.
• Bilirubin Levels: Elevated bilirubin levels can affect the accuracy of MRI using
gadoxetate contrast, warranting caution in patients with bilirubin levels >3 mg/dL.

19. • Diagnostic Application: CEUS is used for HCC diagnosis, particularly in
lesions detected on non-contrast ultrasound.
• Limitations: CEUS cannot evaluate a patient as a liver transplantation
candidate and is generally limited to visualized lesions. To assess the
overall liver disease burden, additional imaging with CT or MRI is required.
• Continuous Imaging: CEUS involves continuous imaging for the first 60
seconds after contrast infusion, followed by intermittent imaging every 30
seconds for about four to five minutes. Comprehensive assessment of the
entire liver volume is not feasible with CEUS.
• Uncertainty in Results: Systematic reviews indicate some uncertainty
due to the risk of bias, study heterogeneity, and imprecision in results.

20. Should only be applied
Any of the following findings or risk factors:
• Cirrhosis (with exception)
• Chronic hepatitis B virus infection
• Lesion identified on a surveillance US
for HCC in a patient with cirrhosis
chronic hepatitis B virus infection, or
concurrent or prior diagnosis of HCC
Should not be applied
• No risk factors for HCC
• Age less than 18 years
• Cirrhosis related to congenital hepatic
fibrosis
• Cirrhosis secondary to a vascular
disorder Budd-Chiari syndrome, chronic
portal vein occlusion, cardiac
congestion, hereditary hemorrhagic
telangiectasia)
In vascular disorder, the altered hepatic blood flow results in formation of benign hypervascular
nodules that resemble and sometimes cannot be distinguished by imaging from HCC
LI-RADS patient criteria

21. LI-RADS Score Imaging Findings Likelihood of HCC Clinical Implications
LR-1 Definitely benign 0% No further workup, routine surveillance
LR-2 Probably benign 0% Most return to routine surveillance
LR-3 Intermediate risk 31% Repeat imaging every 3-6 months
LR-4 Probably HCC 64% Multidisciplinary discussion needed, biopsy
LR-5 Definitely HCC 95% Evaluation for treatment, no biopsy
LR-M
Probably/Definitely
malignant
33% Multidisciplinary discussion required, biopsy
LR-TIV Tumor in vein 54% Multidisciplinary discussion needed, biopsy
merit multidisciplinary discussion for individualized management, which may include follow-up or
alternative imaging, biopsy, or treatment as presumptive HCC (ie, resection) without biopsy

22. OPTN manages liver transplant waiting lists.
It employs imaging criteria to assess HCC patient eligibility for transplantation.
Imaging Diagnosis:
• OPTN criteria align with LI-RADS for HCC assessment.LR-5 (definite HCC) corresponds to
OPTN class 5.
Key Differences:
• OPTN covers paediatrics and non-cirrhosis causes.
• LI-RADS mainly focuses on cirrhotic adults.
• CEUS is LI-RADS-approved but excluded by OPTN.
• OPTN limits MRI agents with hepatobiliary excretion.
• LI-RADS allows more options.
• OPTN specifies size criteria for eligible HCC.
Transplant Eligibility : OPTN’s criteria ultimately determine transplant eligibility.
OPTN and LI-RADS:
• Understanding these differences ensures precise patient eligibility assessment.
• Improved coordination between OPTN and LI-RADS can optimize liver transplants for
HCC.

23. Patients Requiring Evaluation:
• Patients with LI-RADS LR-3, LR-4, and LR-M lesions may need further assessment to confirm HCC diagnosis.
Evaluation Options:
• Evaluation includes biopsy or follow-up imaging with the same or alternative methods.
• Biopsy is considered if it influences management decisions.
• For high-risk patients with LR-4 lesions, multidisciplinary discussion may allow presumptive HCC treatment.
Biopsy Considerations:
• Biopsy necessity is determined by clinical presentation and tumor marker levels.
• Individualized decision-making is recommended after multidisciplinary discussion.
• High alpha-fetoprotein levels (>400 ng/mL) and clinical factors might eliminate the need for biopsy.
• However, biopsy may still be required if it affects management (e.g., transplantation listing).
LR-3 Lesions:
• Most LR-3 lesions can be monitored through follow-up CT or MRI imaging.
• This monitoring continues until the lesion is definitively diagnosed as HCC, another malignancy, or a benign
condition.
LR-M Lesions:
• These lesions are complex, with about two-thirds being non-HCC malignancies.
• Biopsy often plays a critical role in determining malignancy type and guiding treatment decisions.

24. • Diagnosis in Low-Risk HCC Patients
• Specific Liver Conditions (e.g., cardiac
cirrhosis, congenital hepatic fibrosis)
• Elevated Tumor Markers (e.g., CA 19-
9, CEA) with suspicion of
cholangiocarcinoma (CCA) or mixed
HCC-CCA
• Confirming Metastatic Disease
• Histologic Grading and Molecular
Characterization
• Guiding Nonsurgical, Locoregional
Therapies (e.g., ablation)
• Liver Transplantation Evaluation
Biopsy is generally not
recommended for LR-1, LR-2, LR-
3, or LR-5 lesions.

25. • In small lesions (≤2 cm), the diagnostic yield can be as low as 70%,
and using core needles may enhance tissue collection.
• Risks of biopsy encompass immediate complications, tumor track
spread, and potential sampling errors leading to false negatives.
• Major complications include hemoperitoneum, hypotension,
pneumothorax, and biliary peritonitis, with a biopsy-related death
rate of 9 in 100,000 procedures.
• Needle track seeding risk with percutaneous biopsy is
approximately 2.7%.

26. Chest CT and Bone Scan in Hepatocellular Carcinoma
• Extrahepatic spread rate is low overall (except for tumors >5 cm)
• Routine chest CT and bone scan yield limited additional information
• Abnormal findings on chest CT and bone scan often overlap with liver imaging
• Staging chest CT and bone scans don't significantly impact management
• Routine chest CT recommended by OPTN for initial evaluation in transplant candidates
with HCC
Parameter Chest CT Bone Scan
Abnormal Findings 60% (229 out of 381) 53% (202 out of 381)
Patients with Documented
Metastatic Disease
30 (7.9% of 381) 8 (2.1% of 381)
Detection of the Same Lesions in
Chest CT or Chest Radiograph
19 patients (63.3% of
documented cases)
7 patients (87.5% of documented
cases)
Change in Staging
Only 3 patients shifted from B to C
(5% of BCLC stage B patients)
Data on staging shift not provided
in the context of bone scan
Additional Metastases Revealed
1.1% in T2 stage, 14% in T3a
stage, 5.6% in T3b stage
Data on additional metastases not
provided
Prospective cohort of 381 patients newly diagnosed with HCC at a Single Korean Institution

27. TNM
Staging:
•Use: TNM staging aids in
prognosis and treatment
planning.
•Disadvantage: It lacks
comprehensive
consideration of liver
function.
Okuda
System:
•Use: The Okuda system
provides a simple clinical
classification.
•Disadvantage: Its
simplicity may not
capture complex disease
presentations.
Cancer of
the Liver
Italian
Program
(CLIP)
Score:
•Use: CLIP predicts
survival using readily
available parameters.
•Disadvantage: Some
parameters may not be
universally accessible.
The
Barcelona
Staging
Classificatio
n:
•Use: BCLC guides
treatment decisions
based on multiple factors.
•Disadvantage: It
primarily serves for
treatment guidance.
Albumin-
Bilirubin
(ALBI)
Score:
•Use: ALBI assesses liver
function.
•Disadvantage: It doesn't
include tumor-specific
factors.
RETREAT
and MoRAL
Scores:
•Use: These scores predict
survival in TACE patients.
•Disadvantage: They
require further validation
and are tailored to TACE.

29. Advantages
• Accurate tumor classification: Precise
prognosis
• Validated for resection and
transplantation: Treatment planning
• Incorporates size and vascular invasion:
Improved risk stratification
• Fibrosis score as a prognostic factor:
Consideration of liver function
Disadvantages
• Not accounting for cirrhosis: Limited in
liver disease cases
• Survival affected by underlying cirrhosis:
Inferior for tumors in cirrhotic livers
• Less useful for large tumors in cirrhotic
patients: Alternative systems may be
better
• TNM stage alone may not reflect
prognosis accurately: Need for
additional prognostic facto

30. Content:
• Tumor number
(single/multiple).
• Ascites
(absent/mild/severe).
• Total bilirubin level.
• Serum albumin level.
• Hepatic encephalopathy
(absent/present).
Advantages:
• Simple and easy to use.
• Reflects liver function.
• Helps predict prognosis.
• Guides treatment
planning.
Disadvantages:
• Less suitable for early-
stage HCC.
• May not account for
tumor-specific factors.
• Limited ability to finely
stratify risk.
• Most effective for
advanced disease.

31. Content:
• Child-Pugh class (A/B/C).
• Tumor morphology
(uninodular/multinodula
r).
• Alpha-fetoprotein (AFP)
level (<400 ng/mL or
≥400 ng/mL).
• Portal vein thrombosis
(absent/present).
Advantages:
• Incorporates liver
function (Child-Pugh
class).
• Considers tumor size
and AFP level.
• Provides a single
numerical score.
• Predicts survival and
helps guide treatment.
Limitations:
• Doesn't consider
microvascular invasion.
• Limited accuracy for
early-stage HCC.
• Complexity for some
patients.
• May require advanced
diagnostics.

32. Disadvantages of BCLC Staging:
• Challenges in assessing liver function beyond conventional Child-Pugh score.
• Ongoing debates on the accuracy and applicability of the BCLC system in surgical therapy.

33. Stage C: Advanced-Stage HCC
•Characteristics:
• Diffuse, infiltrative, or portal vein invasion.
• Preserved liver function.
•Management:
• Options include systemic therapies or participation
in clinical trials.
• Curative treatments are not applicable.
Stage D: End-Stage HCC
•Characteristics:
• Poor performance status (ECOG 3-4) or
decompensated liver dysfunction.
•Management:
• Focused on supportive care, as prognosis is
extremely poor.
Stage 0: Very Early-Stage HCC
•Characteristics:
• Single nodule <2 cm.
•Management:
• Curative therapies such as resection,
transplantation, or percutaneous ablation.
Stage A: Early-Stage HCC
•Characteristics:
• Single nodule or up to three nodules, all ≤3 cm.
• Well-preserved liver function.
•Management:
• Suitable for curative therapies like resection,
transplantation, or ablation.
Stage B: Intermediate-Stage HCC
•Characteristics:
• Multinodular tumors.
• Preserved liver function.
•Management:
• May be candidates for liver transplantation or local
therapies like chemoembolization.
• Not suitable for curative treatments.

34. • It calculated based on the patient's bilirubin and albumin levels, which are significant
factors affecting survival in HCC.
• The ALBI score provides a way to predict prognosis and refine prognostic estimates for
HCC patients undergoing various treatments.
• It categorizes patients into three grades (ALBI grade I, grade II, and grade III) based on
their score, with lower scores indicating better liver function and better
• Advantage:
• Simple liver function assessment tool.
• Predicts prognosis in HCC.
• Objectively assesses bilirubin and albumin levels.
• Enhances prognostic accuracy in various treatments.
• Reduces interobserver variation.
• Disadvantage:
• Limited use for patients with very poor liver function (Child-Pugh C).

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