Prospective Multicenter Evaluation of Hepatocellular Carcinoma Surveillance under American Association for the Study of Liver Diseases Version 2023 Guidance.

Background The 2023 update of the American Association for the Study of Liver Diseases (AASLD version 2023 [hereafter, v2023]) guidance introduced new triggers for hepatocellular carcinoma (HCC) surveillance, incorporating US visualization score, increasing α-fetoprotein (AFP) level, and lesion growth, but has not yet been validated. Purpose To assess the surveillance performance of AASLD v2023 for HCC detection in comparison to Liver Imaging Reporting and Data System (LI-RADS) version 2017 (hereafter, v2017) and AASLD version 2018 (hereafter, v2018) in participants at high risk of HCC. Materials and Methods This prospective study consecutively enrolled high-risk participants undergoing US and AFP surveillance across three institutions between July 2023 and October 2024. Surveillance performance of US LI-RADS v2017, AASLD v2018, and AASLD v2023 for HCC detection was compared through sensitivity, specificity, positive predictive value, and negative predictive value (NPV). Multivariable logistic regression helped identify predictors of false-negative and false-positive classifications. Results Among 953 participants (median age, 51 years; IQR, 45-58 years; 658 men), 5% (50 of 953) had HCC. The new surveillance triggers (visualization score VIS-C, increasing AFP level, and lesion growth) demonstrated sensitivities ranging from 8% (four of 50 participants) to 48% (24 of 50 participants), with high specificities of 94% (849 of 903 participants) to 99.4% (898 of 903 participants). As an integrated algorithm, AASLD v2023 achieved a sensitivity of 94% (47 of 50 participants) and NPV of 99.6% (758 of 761 participants) for HCC detection, surpassing US LI-RADS v2017 (sensitivity, 60% [30 of 50 participants], < .001; NPV, 98% [814 of 834 participants], = .001) and AASLD v2018 (sensitivity, 76% [38 of 50 participants], = .02; NPV, 98.5% [805 of 817 participants], = .04). Specificity was lower than that with US LI-RADS v2017 (84% [758 of 903 participants] vs 90% [814 of 903 participants], < .001) and AASLD v2018 (84% [758 of 903 participants] vs 89% [805 of 903 participants], = .001). For early HCC, sensitivity remained superior to that of other algorithms ( < .001, = .04). At multivariable analysis, AFP level of less than 20 ng/mL (odds ratio, 11.76; < .001) and absence of cirrhosis (odds ratio, 2.45; = .03) were independently associated with false-positive findings for AASLD v2023. Conclusion AASLD v2023 improved the sensitivity and NPV for HCC surveillance, outperforming US LI-RADS v2017 and AASLD v2018. Chinese Clinical Trial Registry no. ChiCTR2100054330 © RSNA, 2026