To validate the effectiveness of the 2023 American Association for the Study of Liver Diseases (AASLD) guidance for hepatocellular carcinoma (HCC) surveillance in high-risk populations, and to compare it with ultrasound (US) alone and US combined with alpha-fetoprotein (AFP) monitoring, in order to assess their clinical utility.

This prospective study retrospectively included 451 high-risk individuals who underwent HCC surveillance at the First Affiliated Hospital of Sun Yat-sen University between January 2018 and August 2022. All patients underwent US combined with AFP screening. The performance of US alone, US combined with AFP, and the 2023 AASLD guidance for HCC surveillance was evaluated and compared using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Among the 451 participants, 38 (38/451, 8%) were confirmed as having HCC. The 2023 AASLD guidance achieved an AUC of 0.87 for HCC detection, with a sensitivity of 95% and an NPV of 99%, which were significantly higher than those of US surveillance alone (AUC, 0.72, P＜0.001; sensitivity, 55%, P＜0.001; NPV, 96%, P=0.002) and US combined with AFP surveillance (AUC, 0.77, P=0.007; sensitivity, 68%, P=0.006; NPV, 97%, P=0.014). However, the specificity of the 2023 AASLD guidance (80%) was slightly lower than that of US surveillance alone and US combined with AFP surveillance (90%, P＜0.001; 86%, P=0.015), indicating a potential risk of over-referral among non-HCC individuals.

Although the specificity of the AASLD 2023 guidance is slightly reduced, its sensitivity and NPV for HCC detection are significantly higher than those of US alone and US combined with AFP. These findings suggest that the visualization score and recall strategy proposed in the 2023 AASLD guidance may have clinical utility for the early detection and management of HCC in high-risk populations. However, in clinical implementation, the risk of false-positive results should be carefully considered.