Cirrhosis, portal hypertension and hepatocellular carcinoma: a stage-based approach

Cirrhosis and hepatocellular carcinoma (HCC) are interconnected outcomes of chronic liver disease, with portal hypertension playing a key part in cirrhosis decompensation, and influencing HCC prognosis and treatment. Despite their overlap, current guidelines address portal hypertension and HCC separately, leading to suboptimal risk stratification and treatment selection. This Review proposes a stage-based, integrated approach to HCC management that incorporates the prognostic stages of cirrhosis and emphasizes clinically significant portal hypertension (CSPH) as a key stratifying factor in compensated cirrhosis. CSPH is associated with an increased risk of cirrhosis decompensation, and its presence often limits the feasibility of curative treatments such as surgical resection. Although CSPH is strictly defined as hepatic venous pressure gradient (HVPG) of ≥10 mmHg, non-invasive tools (liver stiffness and platelet count) have largely replaced HVPG in cirrhosis; in patients with HCC, emerging data suggest that these non-invasive tests are poised to replace HVPG and its traditional surrogates, imaging and endoscopy. We explore the management of both cirrhosis and HCC across all cirrhosis stages - compensated (with or without CSPH), decompensated, and further decompensated - in relation to all HCC stages (very early, early, intermediate and advanced). Future research should validate non-invasive CSPH assessment in HCC and support outcome trials stratified by cirrhosis and HCC stage to guide personalized therapy and improve outcomes.