S2369 Adherence to Guidelines for Screening of Pulmonary Metastasis in Patients With Hepatocellular Carcinoma: A Quality Improvement Study

Introduction: Hepatocellular Carcinoma (HCC) adds a significant burden in the care of patients with end-stage liver disease. At the time of diagnosis, extra-hepatic metastasis, commonly pulmonary, is present in approximately 10-15% of cases mandating metastatic work-up by thoracic CT at the time of diagnosis before embarking on treatment with trans-arterial chemoembolization (TACE), radiofrequency ablation (RFA), surgical resection, and liver transplantation. We aimed to evaluate adherence to guidelines for thoracic metastatic work-up in patients with HCC before treatment. Methods: We designed a quality improvement project to evaluate and improve adherence to guidelines regarding exclusion of pulmonary metastasis by chest CT scan in HCC patients prior to palliative treatment at our institution. Available baseline patient data included demographics, tumor characteristics, liver function, and information regarding thoracic CT were recording retrospectively for the period 2013-2018. The initial performance outcomes of the retrospective data were analyzed and highlighted with the management teams involved at our weekly gastrointestinal (GI) tumor board. Subsequently, performance characteristics were again gathered for the year 2018-2024 to evaluate for any improvement. Results: At baseline (2013–2018), 144 patients with suspected HCC (mean age 58.2, 93.8% man) were identified; 89.6% had HCV-related cirrhosis and the mean MELD-Na score was 11.2, consistent with the standard calculation methodology utilized during that period. HCC was diagnosed in 67.4% of cases; 46.4% received palliative TACE, 19.6% RFA, and 23.6% surgical resection. Only 54.6% of HCC patients had chest CT for metastasis evaluation. Following quality improvement efforts, 134 new patients (2018–2024) were evaluated (mean age 63.2, 97% man), with 96.3% HCV-related cirrhosis and a mean MELD-3.0 score of 11.5. HCC was diagnosed in 124 patients; 50.0% received TACE, 15.3% RFA, and 9.7% resection. Chest CT was performed in 91.9% of cases at diagnosis, a significant increase from 54.6% (P < 0.0001). Among the 114 patients who had chest CT, 51 had pulmonary nodules needing further evaluation. Conclusion: Our QI intervention of educating teams on the importance of workup for pulmonary metastasis before initiating palliative treatments significantly improved the adherence to guidelines and thus impacting the care of patients with HCC.