OpenOnco · Treatment Plan

Treatment plan — Hepatocellular carcinoma

PLAN-VAR-HCC-FRAIL-V1 · v1 · 2026-05-13

Patient

VAR-HCC-FRAIL · Algorithm: ALGO-HCC-SYSTEMIC-1L

DiagnosisHepatocellular carcinoma

MOH / ICD-10C22.0

ICD-O-38170/3; C22.0

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

⚠️ Not included in plan

Biomarker	Status
BIO-AFP	BIO definition in KB; no ESCAT BMA entry — verify with clinician

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-HCC-SYSTEMIC-1L-SORAFENIB

Regimen

Sorafenib monotherapy

Drugs + NSZU

Sorafenib (DRUG-SORAFENIB) 400 mg PO BID (start 200 mg BID; escalate to 400 mg if tolerated) · Continuous · PO ⚠ NSZU — not for this indication

Reason

Primary current-line option selected by ALGO-HCC-SYSTEMIC-1L at step 2; branch-driving red flag: RF-HCC-FRAILTY-AGE.

Other current-line alternatives (2 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Standard plan

Indication

IND-HCC-SYSTEMIC-1L-ATEZO-BEV

Regimen

Atezolizumab + Bevacizumab

Drugs + NSZU

Atezolizumab (DRUG-ATEZOLIZUMAB) 1200 mg · IV q3w · IV ⚠ NSZU — not for this indication
Bevacizumab (DRUG-BEVACIZUMAB) 15 mg/kg · IV q3w (concurrent) · IV ⚠ NSZU — not for this indication

Hard contraindications

CI-PEMBROLIZUMAB-AUTOIMMUNE

Reason

Current-line alternative presented for HCP consideration

Aggressive plan

Indication

IND-HCC-SYSTEMIC-1L-DURVA-TREME

Regimen

Durvalumab + Tremelimumab (STRIDE)

Drugs + NSZU

Tremelimumab (DRUG-TREMELIMUMAB) 300 mg · IV — single priming dose only (cycle 1 day 1) · IV ✗ Not registered in UA
Durvalumab (DRUG-DURVALUMAB) 1500 mg · IV q4w (cycle 1 with tremelimumab; subsequent cycles mono) · IV ⚠ NSZU — not for this indication

Hard contraindications

CI-PEMBROLIZUMAB-AUTOIMMUNE

Reason

Current-line alternative presented for HCP consideration

Why this branch was chosen

Triggers from the patient profile that fired and drove the chosen branch.

Step 2 → branch IND-HCC-SYSTEMIC-1L-SORAFENIB

RF-HCC-FRAILTY-AGE ★ winner: Frailty profile precluding intensified 1L systemic in HCC: ECOG ≥3, OR (age ≥75 + Child-Pugh B7 + sarcopenia), OR composite (Karnofsky <70 + active hepatic encephalopathy + albumin <2.8). Triggers BSC discussion + palliative-care referral; sorafenib reduced-dose (200 mg BID) acceptable for selected CP-A frail patients. SRC-NCCN-HCC-2025SRC-AASLD-HCC-2023

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-AFP	AFP serum	Critical	lab	CSD Lab: B001	all tracks
TEST-CHILD-PUGH-CALCULATION	Child-Pugh classification calculation	Critical	clinical_assessment	—	all tracks
TEST-CT-CHEST-ABDOMEN-PELVIS	CT chest + abdomen + pelvis with IV contrast	Critical	imaging	—	all tracks
TEST-EGD-VARICES-SCREENING	Esophagogastroduodenoscopy with varices assessment	Critical	imaging	—	standard
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	standard
TEST-HCV-ANTIBODY	HCV Antibody	Critical	lab	—	standard
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	standard

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Patient with active or incompletely controlled pre-existing autoimmune or inflammatory disease (sarcoidosis, rheumatoid arthritis, IBD, SLE, autoimmune hepatitis, inflammatory myopathy, myasthenia gravis, or similar) is considered for immune checkpoint inhibitor (ICI) therapy — elevated risk of immune-related adverse events (irAE) flare or de-novo grade 3-4 irAE. Requires specialist (rheumatology / pulmonology / gastroenterology) pre-treatment review; prefer lower-irAE-burden backbone when options exist (pembrolizumab mono > ipilimumab+nivolumab). RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK
Child-Pugh B or C cirrhosis in HCC patient. CP-A is the only fully- studied class for ICI combinations (atezo+bev, durva+treme); CP-B has partial sorafenib/lenvatinib data but worse safety; CP-C generally precludes systemic therapy (focus on supportive care + transplant evaluation if liver-limited disease). RF-HCC-CHILD-PUGH-B-C
Active or recent (≤6 months) variceal hemorrhage in HCC patient with cirrhosis. Mandates EGD assessment + variceal band ligation BEFORE any bevacizumab-containing regimen (atezo+bev, IMbrave150 prerequisite). Active bleeding is an absolute hold on systemic therapy until controlled. RF-HCC-VARICEAL-BLEED

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Pembrolizumab (and other PD-1/PD-L1 inhibitors) augment T-cell responses; in patients with active autoimmunity or post-transplant immunosuppression, this can precipitate severe organ-specific flares (colitis, hepatitis, pneumonitis, transplant rejection) that may be fatal or require transplant loss. CI-PEMBROLIZUMAB-AUTOIMMUNE

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-HCC-SYSTEMIC-1L-SORAFENIB)

Do NOT continue through hepatic decompensation onset
Do NOT delay HFSR prophylaxis (urea cream, emollient, friction avoidance)

Standard plan (IND-HCC-SYSTEMIC-1L-ATEZO-BEV)

Do NOT initiate without EGD within 6 months — high-risk varices must be ligated/banded first (perforation/bleed risk)
Do NOT use in Child-Pugh B/C — atezo+bev not studied; mortality risk
Do NOT skip HBV prophylaxis in HBsAg+ / anti-HBc+ patients (entecavir or TDF) — HBV reactivation reported under anti-VEGF + ICI; continue ≥12 mo post-therapy
Do NOT delay HCV-DAA in HCV-RNA+ patients — initiate sofosbuvir/velpatasvir before or concurrently with atezo+bev; SVR12 reduces decompensation risk and may improve OS in HCC-on-HCV-cirrhosis
Do NOT combine sofosbuvir with amiodarone — severe bradycardia / cardiac arrest
Do NOT continue bevacizumab through Grade 3+ HTN or proteinuria >3.5 g/24h

Aggressive plan (IND-HCC-SYSTEMIC-1L-DURVA-TREME)

Do NOT use in Child-Pugh B/C
Do NOT skip HBV prophylaxis
Do NOT continue through Grade 3+ irAE without permanent discontinuation consideration (CTLA-4 colitis can be fatal)

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Atezolizumab + Bevacizumab

21-day cycles × Until progression / unacceptable toxicity

Aggressive plan

Induction · Durvalumab + Tremelimumab (STRIDE)

28-day cycles × Until progression / unacceptable toxicity

MDT brief

Discussion questions (1, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (3 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
3	palliative_care	Specialist review	Reduced performance status / decompensated comorbidity — goals-of-care assessment needed.

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Palliative care recommended
Reduced performance status / decompensated comorbidity — goals-of-care assessment needed.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 3/3 known (100%), 0 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-HCC-AFP-RAPID-RISE, RF-HCC-CHILD-PUGH-B-C, RF-HCC-FRAILTY-AGE, RF-HCC-HBV-REACTIVATION-RISK, RF-HCC-HIGH-RISK-BIOLOGY, RF-HCC-VARICEAL-BLEED

Technical MDT skill metadata (2/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-AASLD-HCC-2023: AASLD Practice Guidance on HCC (2023)
SRC-HIMALAYA-ABOU-ALFA-2022: Tremelimumab plus Durvalumab in Unresectable Hepatocellular Carcinoma ()
SRC-IMBRAVE150-FINN-2020: Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma ()
SRC-NCCN-HCC-2025: NCCN Hepatocellular Carcinoma (v.3.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-13.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT04792801	PET TDM FDG-Choline as a Decision-making Tool for Routine Care on the Liver Transplant List for HCC	N/A	RECRUITING	University Hospital, Lille	—	Single country
NCT06904170	Durvalumab and Tremelimumab With or Without Hepatic Arterial Infusion of Chemotherapy in Hepatocellular Carcinoma	PHASE2 / PHASE3	RECRUITING	UNICANCER	—	Single country
NCT07170345	Computer-Aided Diagnosis for Hepatocellular Carcinoma Microvascular Invasion	N/A	RECRUITING	Chinese Academy of Sciences	—	Single country
NCT05444478	Microwave Ablation Simultaneously Combined With Lenavatinib for Recurrent Hepatocellular Carcinoma	NA	RECRUITING	Sun Yat-sen University	—	Single country
NCT04525833	Liver Disease and Other Systemic Diseases	N/A	RECRUITING	Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation	—	Single country
NCT06031285	Perioperative Sintilimab Plus Bevacizumab Biosimilar and TACE-HAIC for HCC Patients With PVTT: A Phase-2 Clinical Trial	PHASE2	RECRUITING	Sun Yat-sen University	—	Small N (<50) Single country
NCT06914648	The Dragon PLC Trial (DRAGON-PLC)	NA	RECRUITING	Maastricht University	—	—
NCT06334965	Multi-modal Characterisation of Hepatocellular Carcinoma (HCC) Treated With Targeted Radionuclide Therapy (TRT): Prospective Interventional Multicentre National Cohort	NA	RECRUITING	Assistance Publique - Hôpitaux de Paris	—	Single country
NCT05516628	Deep, Multi-omics Phenotyping to Predict Response, Resistance and Recurrence to Adjuvant Atezolizumab Plus Bevacizumab in Resected Hepatocellular Carcinoma	PHASE2	RECRUITING	National Cancer Centre, Singapore	—	Small N (<50) Single country
NCT06999174	Multiparametric MRI for Characterization of Hepatocellular Carcinoma	N/A	RECRUITING	University Hospital Muenster	—	Surrogate endpoint only Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Sorafenib monotherapy (REG-SORAFENIB-MONO)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Atezolizumab + Bevacizumab (REG-ATEZO-BEV)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan Durvalumab + Tremelimumab (STRIDE) (REG-DURVA-TREME-STRIDE) 1/2 component drug(s) not registered in Ukraine +1	✗ not registered	✗ out-of-pocket	₴-? — verify pathway	not recorded
Trial · NCT04792801 PET TDM FDG-Choline as a Decision-making Tool for Routine Care on the Liver Transplant List for HCC No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06904170 Durvalumab and Tremelimumab With or Without Hepatic Arterial Infusion of Chemotherapy in Hepatocellular Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07170345 Computer-Aided Diagnosis for Hepatocellular Carcinoma Microvascular Invasion No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05444478 Microwave Ablation Simultaneously Combined With Lenavatinib for Recurrent Hepatocellular Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04525833 Liver Disease and Other Systemic Diseases No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06031285 Perioperative Sintilimab Plus Bevacizumab Biosimilar and TACE-HAIC for HCC Patients With PVTT: A Phase-2 Clinical Trial No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06914648 The Dragon PLC Trial (DRAGON-PLC) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06334965 Multi-modal Characterisation of Hepatocellular Carcinoma (HCC) Treated With Targeted Radionuclide Therapy (TRT): Prospective Interventional Multicentre National Cohort No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05516628 Deep, Multi-omics Phenotyping to Predict Response, Resistance and Recurrence to Adjuvant Atezolizumab Plus Bevacizumab in Resected Hepatocellular Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06999174 Multiparametric MRI for Characterization of Hepatocellular Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-13.

plan_id: PLAN-VAR-HCC-FRAIL-V1 | version: 1 | generated: 2026-05-13T10:01:52.070110+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.