Teaching design for chapter “primary liver cancer” in surgery course based on the clinical theory and clerkship synchronization model in the era of New Medicine

Adapting to New Medical Education trends

The New Medicine emphasizes the integration of multiple disciplines, such as genomics, artificial intelligence, and bioinformatics, into traditional medical education. This requires a shift in focus from purely theoretical knowledge to competencies that integrate these new domains. Traditional medical education often focuses on content delivery without clear measurable outcomes. The outcome-based education (OBE) framework ensures that students achieve specific competencies, making it necessary to redefine objectives with clearly stated outcomes [9], 10].

Bridging the gap between theory and practice

Surgery students must be able to apply theoretical knowledge in real clinical scenarios, such as diagnosing primary liver cancer, formulating treatment plans, and managing complications. The redefined objectives must emphasize hands-on practice, clinical reasoning, and decision-making. New educational models promote simultaneous learning of theory and clinical practice [2]. Teaching objectives need to reflect this synchronization, ensuring that students gain not only conceptual understanding but also practical application skills.

Addressing advances in liver cancer management

The management of primary liver cancer has evolved significantly with innovations in imaging, molecular diagnostics, and minimally invasive treatments. Objectives must be updated to include these advancements and prepare students for modern clinical practice. Liver cancer treatment often involves a team of specialists [11]. Redefined objectives must focus on equipping students with the ability to collaborate in multidisciplinary settings, understanding the roles of surgery, oncology, radiology, and hepatology [12].

Enhancing professional competence

Traditional objectives often overlook psychomotor skills such as interpreting imaging or conducting preoperative evaluations. The new objectives need to include measurable skill development to ensure clinical competence. In managing liver cancer, ethical considerations, such as patient selection for liver transplantation and equity in treatment allocation, are critical. Updated objectives should address these professional and ethical challenges to prepare students for holistic patient care.

Aligning with student-centered learning

New Medical Education emphasizes active and critical learning over rote memorization. The objectives should encourage problem-solving, decision-making, and reflective practices. Students have diverse interests and career goals [10], 13]. Redefined objectives under the OBE framework allow flexibility for students to achieve core competencies while exploring areas of individual interest.

Building on the above principles and adopting the backward design strategy, we have formulated the learning objectives for the “primary liver cancer” chapter tailored to 8-year clinical medicine undergraduate students. Based on the OBE philosophy and Bloom’s Taxonomy, the teaching objectives for this session are as follows [14]:

1. Understand the pathophysiology and etiology of primary liver cancer, including its relationship with chronic liver diseases such as cirrhosis and hepatitis.

2. Identify the risk factors for liver cancer and understand the epidemiological trends.

3. Gain skills in interpreting diagnostic imaging (CT, MRI, etc.) and understanding biomarkers like alpha-fetoprotein (AFP) in diagnosing liver cancer.

4. Understand and practice preoperative assessment and management strategies for liver cancer patients.

5. Develop an understanding of multidisciplinary management for liver cancer, including surgery, chemotherapy, and liver transplantation.

6. Evaluate and reflect on clinical cases to make informed decisions about treatment options.

Changes in the epidemiology of primary liver cancer in China

Recent studies show a gradual decrease in liver cancer incidence and mortality rates in China. This trend is attributed to better control of risk factors such as hepatitis B virus (HBV) and the implementation of nationwide vaccination programs [15], 16]. Non-alcoholic fatty liver disease (NAFLD) and metabolic syndrome are emerging as significant contributors due to lifestyle changes, including increased prevalence of obesity and diabetes. Liver cancer remains more prevalent in rural areas compared to urban regions, likely due to disparities in healthcare access, education, and environmental factors [17].

The discussion of epidemiological changes and emerging risk factors directly supports this cognitive objective by providing updated, evidence-based insights into liver cancer trends in China. Students can analyze how HBV vaccination and lifestyle changes have reshaped the risk profile of liver cancer, improving their understanding of disease etiology and public health impact. Teaching these changes encourages students to critically evaluate epidemiological data and develop skills in data interpretation and its application in clinical decision-making. Highlighting the role of public health initiatives like HBV vaccination fosters an appreciation of the broader social and systemic efforts required for disease prevention [18].

Treatment overview for intermediate and advanced liver cancer

The main treatment options for middle to late-stage liver cancer include local therapy, systemic therapy, and combined treatment approaches. Transarterial chemoembolization (TACE) is widely regarded as the first-line treatment for intermediate-stage hepatocellular carcinoma (HCC). TACE combines targeted chemotherapy with vascular embolization to reduce tumor size and progression. Molecular targeted drugs such as sorafenib and lenvatinib remain standard first-line treatments for advanced-stage HCC. Immune checkpoint inhibitors (ICIs) such as atezolizumab (anti-PD-L1 monoclonal antibody) combined with bevacizumab (anti-VEGF monoclonal antibody) represent a breakthrough, offering superior efficacy compared to sorafenib as a first-line treatment in advanced cases [19], 20]. The main challenges in treating middle to late-stage liver cancer are the heterogeneity of the disease, the accessibility of treatment options, and the management of adverse drug reactions.

Discussing the updated treatment modalities enhances students’ knowledge of contemporary therapeutic approaches, their indications, and mechanisms. Explaining how ICIs like atezolizumab improve survival rates for advanced HCC demonstrates cutting-edge advancements, fostering a deeper understanding of treatment strategies. Incorporating treatment algorithms and case studies enables students to practice clinical decision-making and treatment planning. Highlighting challenges such as treatment accessibility or balancing efficacy with quality of life helps students develop empathy and ethical sensitivity. Discussions on disparities in access to therapies like ICIs in rural China can encourage students to reflect on their roles as advocates for equitable healthcare. This approach ensures students are equipped not only with up-to-date knowledge and practical skills but also with the ethical and empathetic perspectives necessary for managing complex cancer cases effectively.

Advances in early diagnosis of liver cancer

Early-stage HCC often lacks specific symptoms, leading to delayed detection. In addition to AFP, significant progress has been made in the early diagnosis of liver cancer. AFP-L3 is a specific isoform of AFP associated with malignant tumors, offering better specificity compared to total AFP [21], 22]. Using AFP with markers like des-γ-carboxyprothrombin (DCP) and glypican-3 enhances diagnostic accuracy [23]. Contrast-enhanced ultrasound (CEUS), dynamic CT, and MRI have improved sensitivity for detecting small liver lesions. Circulating tumor DNA (ctDNA), exosomal RNA, and microRNA are promising areas of research for non-invasive early detection [24]. Artificial intelligence applications in imaging and data analysis are enhancing early detection capabilities.

Teaching AFP’s discovery, limitations, and its integration with advanced methods enhances students’ foundational knowledge of diagnostic principles and practices. Students learn to assess AFP levels and imaging findings within a diagnostic framework, building critical analytical skills. By incorporating the history, current application, and advancements of AFP and other diagnostic tools into teaching, educators can comprehensively address the cognitive, psychomotor, and affective domains. This ensures students gain updated knowledge, practical diagnostic skills, and a deeper understanding of the broader social and economic context of liver cancer diagnosis.

Milestones in the development of liver surgery in China

Dr. Mengchao Wu was known as the “father of Chinese hepatobiliary surgery.” He pioneered techniques for precise liver segmentation, which revolutionized surgical precision and safety in hepatectomy. The “anatomical hepatectomy” technique based on liver blood supply significantly reducing intraoperative blood loss [25]. Dr. Zhaoyou Tang was a leader in combining clinical practice with basic research. He proposed the “elimination plus transformation theory” of liver cancer, emphasizing the importance of Chinese and Western Medicine integration [26]. He advocated for integrating chemotherapy and immunotherapy with surgery, contributing to long-term survival improvements [27]. Dr. Xiaoping Chen advanced laparoscopic and minimally invasive techniques in liver surgery. His work on laparoscopic liver resections has set international benchmarks for minimally invasive surgery [28]. These pioneers have collectively transformed liver surgery in China, improving surgical outcomes, long-term survival rates, and global recognition.

Incorporating the history and contributions of Chinese pioneers in liver surgery into teaching not only provides medical knowledge but also inspires students to connect scientific advancements with clinical practice. Discussing the personal journeys and challenges faced by these surgeons fosters respect for the medical profession and inspires students to pursue excellence. Teaching the contributions of Chinese liver surgery pioneers not only aligns with the OBE framework but also provides a well-rounded educational experience. Students gain technical knowledge, practical insights, and ethical perspectives, preparing them to contribute to the future development of clinical medicine and patient care. By showcasing the evolution of liver surgery in China, educators can inspire a sense of national pride and professional responsibility in medical students.

Cutting-edge teaching content

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an innovative surgical approach designed for patients with liver tumors who have insufficient future liver remnant (FLR) to undergo traditional hepatectomy [29]. It offers faster liver hypertrophy compared to conventional portal vein embolization. However, this approach is associated with high morbidity and mortality rates, particularly in patients with compromised liver function. This also requires careful patient selection and expertise. Conversion therapy involves the use of systemic therapies or locoregional treatments to shrink unresectable liver tumors, making them resectable. Targeted agents such as lenvatinib and immunotherapies like atezolizumab + bevacizumab are increasingly used for conversion. TACE or hepatic artery infusion chemotherapy (HAIC) can reduce tumor size, facilitating subsequent resection. Conversion therapy has significantly improved resection rates and survival in patients with advanced liver cancer, bridging the gap between systemic and surgical treatments [30].

Integrating ALPPS, conversion therapy, and other innovations into teaching equips students with a thorough understanding of cutting-edge techniques in liver surgery, aligning with multiple learning objectives. Students can learn to evaluate tumor burden, liver volume, and response to conversion therapy to decide on treatment pathways. Hands-on activities, such as interpreting CT images of patients undergoing ALPPS, encourage application of theoretical knowledge in practical scenarios.

Clinical manifestations and diagnosis of primary liver cancer

The early detection and accurate diagnosis of primary liver cancer are pivotal for determining treatment strategies and patient prognosis. The non-specific nature of early clinical symptoms (e.g., fatigue and weight loss) makes timely diagnosis challenging. Understanding clinical manifestations and diagnostic tools is essential for clinicians to make informed decisions on appropriate interventions. Early diagnosis is closely associated with better survival rates, as early-stage liver cancer can be treated effectively through surgery or locoregional therapies. Teaching students how to recognize early signs and use diagnostic tools is crucial in improving patient outcomes and ensuring effective treatment.

Using CBL, interactive lectures and hands-on methods such as simulation-based learning and flipped classrooms, students will be equipped with the necessary skills to recognize symptoms and utilize diagnostic tools effectively in clinical practice. We introduced real clinical cases where students must identify the symptoms of liver cancer and suggest appropriate diagnostic methods. Interactive lectures and discussions presenting key clinical signs and diagnostic procedures will engage students interactively. Case studies and diagnostic images are used to demonstrate how clinicians identify HCC in practice. Visual representation of clinical and imaging findings helps students understand the differences between benign and malignant lesions in the liver, which is critical for accurate diagnosis. Integration of laboratory tests and biomarkers help students understand the utility of biomarkers in clinical practice, particularly in the early detection of liver cancer. Assigning preparatory readings or videos on liver cancer symptoms and diagnostic tools, followed by in-class discussions and interactive quizzes, encourages active learning and reinforces key concepts about clinical manifestations and diagnostic methods through peer discussions and teacher feedback. Organizing small group discussions where students analyze real-life case scenarios of HCC and present their diagnostic strategies, encourages collaborative learning and allows students to practice clinical reasoning, helping them consolidate their knowledge on liver cancer diagnosis.

Treatment options and surgical indications for primary liver cancer

Primary liver cancer has a diverse range of treatment options, including liver resection, liver transplantation, and locoregional therapies (such as TACE and ablation). These options are highly dependent on the stage of the disease, liver function, and patient comorbidities, making treatment decisions complex and nuanced. Students must understand how to integrate multiple factors, such as tumor size, location, liver reserve, and vascular invasion, into a comprehensive treatment plan. New technologies such as liver transplantation protocols are continuously evolving, and their indications, benefits, and risks are not universally standardized. Understanding when and how to apply these advanced techniques requires advanced clinical knowledge, making it a challenging area for students.

The complexity of treatment choices and surgical indications for primary liver cancer makes this topic a challenging area of teaching. However, using strategies such as CBL, a multidisciplinary approach, interactive decision-making models, and structured decision-making frameworks can help students navigate these difficulties. By providing real-life scenarios, engaging with up-to-date evidence, and utilizing innovative teaching methods like flipped classrooms, we can equip students with the skills and knowledge necessary to make informed decisions about HCC treatment.

Case description

Patient: A 35-year-old male, with a long history of chronic HBV infection, presents with complaints of right upper abdominal discomfort for the past 2 months. The discomfort is described as a dull ache with occasional bloating but no overt pain. The patient denies fever, weight loss, or jaundice. He has no history of alcohol consumption or smoking, and there is no family history of liver cancer.

Medical history: The patient was diagnosed with HBV at the age of 25 and has been on anti-viral therapy intermittently. Liver function tests have been periodically monitored, but he has never had a liver biopsy or imaging studies beyond routine follow-up. He reports occasional fatigue but is otherwise active.

Current symptoms: Right upper quadrant discomfort, occasional nausea, no vomiting, no significant weight loss.

Physical examination

General appearance: The patient appears well-nourished and in no acute distress.

Vital signs:

• Blood pressure: 120/78 mmHg;

• Heart rate: 78 bpm;

• Respiratory rate: 16/min;

• Temperature: 36.7 °C.

Abdominal examination:

• Inspection: No visible distention or jaundice;

• Palpation: Mild tenderness in the right upper quadrant, no rebound tenderness or guarding;

• Percussion: Liver dullness is noted below the costal margin, suggesting hepatomegaly;

• Auscultation: Normal bowel sounds, no bruit over the liver.

Other systems: No signs of edema, ascites, or encephalopathy.

Laboratory diagnosis

Liver function tests:

• Alanine aminotransferase (ALT): 120 U/L (elevated);

• Aspartate aminotransferase (AST): 110 U/L (elevated);

• Total bilirubin: 1.2 mg/dL (within normal range);

• Albumin: 4.0 g/dL (normal).

International normalized ratio (INR): 1.1 (normal)

HBV serology:

• Hepatitis B surface antigen (HBsAg): Positive;

• HBV DNA: 8.0 × 10⁵ IU/mL (elevated);

• Anti-hepatitis B core antibody (HBc): Positive.

AFP: 50 ng/mL (mildly elevated)

Other tests:

• Complete blood count (CBC): Normal;

• Renal function: Normal;

• Coagulation profile: Normal.

Radiologic examination

Abdominal ultrasound: Hepatomegaly noted with a hypoechoic lesion in the right lobe of the liver measuring 9.5 cm × 14.0 cm (Figure 3); no ascites or portal vein thrombosis observed.

Contrast-enhanced CT: A 14 cm mass in the right liver lobe with early arterial phase enhancement and washout in the portal venous phase, suggesting a malignant lesion. The mass appears well-circumscribed, with no major vascular invasion (Figure 3).

MRI: A lesion with characteristics consistent with HCC, exhibiting arterial phase hyperenhancement and washout in the venous phase (Figure 3).

Questions for students

1. What is your most likely diagnosis for this patient? Why?

2. How would you stage this patient’s liver cancer? Which staging systems are commonly used for HCC, and how do they influence treatment decisions?

3. Based on the clinical presentation and radiologic findings, would you consider this patient a candidate for surgery? What are the criteria for surgical resection or liver transplantation in HCC patients?

4. What other treatment options would you consider for this patient, and why?

5. Given the patient’s age and medical history, what ethical considerations should be taken into account when deciding on treatment options?

Pre-class

This section is designed to prepare students for active engagement during theory-based lessons and clinical practice, ensuring a seamless integration of knowledge and skills. The primary goal of the pre-class preparation is to provide students with foundational knowledge about HCC and its clinical relevance, ensuring they come to class with the necessary background to engage with the theoretical content and clinical discussions.

Assigned readings: Prior to the class, students are assigned specific reading materials, such as recent literature on HCC epidemiology, risk factors, clinical presentation, diagnostic methods, and current treatment guidelines. This provides students with up-to-date, evidence-based knowledge.

Pre-class video or lecture: A brief recorded video or online lecture is provided, summarizing key concepts related to HCC, including its pathophysiology, diagnostic methods, staging, and treatment options.

Questions: What are the main risk factors for primary liver cancer, and how do they contribute to its development? How is HCC diagnosed, and what role does imaging play in its detection? What are the most recent advancements in the treatment of HCC, and how do they impact patient outcomes?

Pedagogical considerations: These pre-class activities ensure that students have a solid understanding of the basic concepts of primary liver cancer before the theoretical class, allowing them to come prepared for deeper discussion and critical thinking. The questions aim to stimulate curiosity and prompt students to begin thinking about the clinical implications of HCC.

Theoretical-class

The primary goal of this section is to provide students with an in-depth understanding of primary liver cancer, including its pathophysiology, clinical presentation, diagnostic strategies, and current treatment options. By the end of this part, students should be able to recognize the signs and symptoms of HCC, understand the principles of diagnosis and staging, and evaluate treatment modalities based on evidence-based guidelines.

Lecture topics:

1. Understanding the molecular mechanisms of hepatocellular carcinoma, including genetic mutations, the role of cirrhosis, and the impact of chronic HBV and hepatitis C virus (HCV) infections;

2. Exploring the global burden of HCC, with a focus on the risk factors specific to the Chinese population, such as HBV infection and alcohol consumption;

3. Discussing the common symptoms, signs, and complications associated with primary liver cancer, such as jaundice, ascites, and portal hypertension;

4. Detailing the use of imaging modalities (ultrasound, CT, and MRI) and laboratory tests (AFP and liver function tests) in diagnosing HCC, as well as the role of biopsy and staging systems (e.g., TNM staging);

5. Analyzing current treatment options for HCC, including surgical resection, liver transplantation, locoregional therapies (TACE, ablation), and systemic treatments (targeted therapy, immunotherapy).

Interactive discussions: Presenting hypothetical or real-life patient cases to discuss differential diagnosis, treatment planning, and management strategies.

Questions: How would you differentiate between hepatocellular carcinoma and other liver diseases (e.g., cirrhosis or cholangiocarcinoma) based on clinical presentation and diagnostic tests? What role does AFP play in the diagnosis of HCC, and what are its limitations? What are the indications and contraindications for surgical resection of primary liver cancer?

Pedagogical considerations: The primary purpose of this theoretical teaching phase is to ensure students grasp the essential medical knowledge needed to understand the complexities of primary liver cancer. Through interactive discussions and case-based scenarios, students are encouraged to apply theoretical knowledge to clinical situations. The guiding questions are designed to challenge students to think critically, analyze clinical data, and make informed decisions based on current medical guidelines. By exploring both diagnostic and therapeutic strategies, this section aims to integrate theory with clinical practice, preparing students for real-world decision-making in the treatment of primary liver cancer. The concepts discussed in this part will directly feed into the clinical clerkship-class, where students will observe and participate in patient care.

Clerkship-class

The primary goal of the clinical practice phase is to allow students to directly observe and engage in the management of patients with primary liver cancer. This includes the process of diagnosing HCC, interpreting diagnostic imaging, formulating treatment plans, and understanding patient management strategies in the clinical setting. Students will apply the knowledge from the theoretical-class to real clinical situations and gain insight into the decision-making processes that clinicians use.

Clinical observation: Students will observe patients in a liver surgery or hepatology ward, where they can interact with patients diagnosed with primary liver cancer. This may include observing medical history taking, physical examinations, diagnostic procedures (e.g., ultrasound and CT scans), and discussions of treatment options (e.g., surgical resection, liver transplantation, and locoregional therapies).

Case discussions: Students will participate in multidisciplinary team (MDT) meetings, where they will review patient cases of primary liver cancer with senior clinicians. This provides an opportunity for students to witness clinical decision-making and the integration of various diagnostic and treatment modalities.

Clinical skill training: Students will practice clinical skills relevant to liver cancer diagnosis and management, such as conducting liver physical exams, interpreting liver function tests, and performing imaging-guided procedures (e.g., biopsy or ablation) under supervision. Students will also be trained to assess liver function and identify common complications of HCC, such as portal hypertension or ascites.

Patient interaction: Students will interact with patients in a supervised setting to gather clinical histories, ask relevant questions about risk factors (e.g., chronic hepatitis B/C virus infection and alcohol use), and engage in basic patient education about HCC management. They will also observe the impact of the disease on patients’ quality of life and psychosocial aspects.

Pedagogical considerations: Clinical practice in the “primary liver cancer” chapter focuses on bridging the gap between classroom learning and real-world clinical practice. It allows students to observe, engage with, and manage patients diagnosed with primary liver cancer in a supervised environment. Through hands-on experience and direct patient care, students will develop essential clinical skills, improve their diagnostic and decision-making abilities, and understand the multidisciplinary approach to managing HCC. This phase is essential in preparing students for the complexities of clinical practice, fostering professionalism, empathy, and teamwork, all critical components of the New Medicine educational framework.

Post-class

The post-class activities are designed to reinforce and extend the learning experience from the theory lesson, helping students apply what they’ve learned to real-world scenarios and prepare for the clinical practice phase.

Post-class case study: After the class, students are provided with a case study of a patient with primary liver cancer. They are asked to apply diagnostic and treatment approaches discussed in class to the case.

Reflection essay: Students write a reflection essay where they discuss their understanding of HCC, its treatment options, and how they would manage the case based on current clinical guidelines.

Questions: Based on the case study, how would you approach the diagnosis and staging of primary liver cancer? What treatment options would you consider for this patient, and why? Reflecting on the class, what is the most challenging aspect of diagnosing and treating HCC, and how would you overcome it in clinical practice?

Pedagogical considerations: The post-class activities are intended to help students synthesize and apply the knowledge gained during the lecture. The case study encourages critical thinking and decision-making, while the reflection essay allows students to consolidate their learning and self-assess their understanding of the topic.

CBL teaching

In the CBL teaching process, methods such as discussion and flipped classroom have been employed. The utilization of online real-time interactive systems, including the Ruijin Hospital Teaching Center App and Chaoxing Learning Platform, can enhance the classroom teaching atmosphere, increase student engagement, and make the entire learning process more dynamic. Students are divided into groups of 5–6, and they will proceed step by step to complete discussions and interactions based on the designed case and the structured questions, until the entire case-based teaching is concluded.