Clinically Significant Portal Hypertension in Hepatocellular Carcinoma: Non-Invasive Assessment Across the Continuum.

PURPOSE OF REVIEW: Clinically significant portal hypertension (CSPH) is a key determinant of surgical candidacy, locoregional therapy safety, and systemic treatment outcomes in hepatocellular carcinoma (HCC), yet its non-invasive assessment remains challenging because the Baveno criteria were derived in HCC-free cirrhosis. This review synthesises current evidence on non-invasive tests (NITs) for CSPH across the HCC care continuum, organised around three clinical scenarios: pre-operative assessment, on-treatment monitoring, and pre-immunotherapy evaluation.

RECENT FINDINGS: Liver stiffness-based Baveno rule-out retains value in early HCC but can miss haemodynamically confirmed CSPH in up to 23% of patients with favourable criteria. Spleen stiffness and imaging surrogates offer higher specificity, and longitudinal NIT monitoring is emerging as a need during locoregional and systemic therapy, which themselves can modify portal pressure. Real-world data report variceal bleeding in about 7% of patients receiving atezolizumab-bevacizumab, supporting variceal screening before anti-angiogenic treatment. AI-based multimodal models show promise in cirrhosis but lack HCC-specific validation. A scenario-based NIT strategy integrating liver stiffness, spleen stiffness, imaging collaterals, and selective HVPG measurement can guide CSPH assessment from surgical candidacy through systemic treatment. HCC-specific thresholds, longitudinal validation, and randomised evaluation of NSBB prophylaxis during immunotherapy are the highest-priority research areas.