Page 175 - ebook HCC

172 PROGRAMME AND ABSTRACTS GENEVA, SWITZERLAND EASL HCC SUMMIT 173
FEBRUARY 13 - 16, 2014

SCREENING FOR HCC: WHOM, HOW,
AND HOW OFTEN

Massimo Colombo 1 All societies share the same recommendation for semiannual surveillance with abdominal
1 1st Division of Gastroenterology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore US, as the intervals of screening are not dictated by the level of cancer risk, but rather
Policlinico, University of Milan, Milan, Italy by the growth rate of the tumor, which in fact takes 6 months to double its volume, on
average. While the goal of intensified screening every 3 months is to identify liver cancer
Corresponding author’s e-mail: massimo.colombo@unimi.it at the smallest size in order to optimize treatment, the effectiveness of this policy is in fact
not evidence based. In a randomized controlled study in patients with alcohol and HCV
related cirrhosis in France, the cumulative five-year incidence of HCC nodules detected
with a 3 month US screening was as high as in the arm undergoing 6 month screening
Surveillance of at risk patients is an effective strategy to improve both treatment of (10.0% vs 12.3%), with no differences in the cumulative incidence of small tumors, rates
hepatocellular carcinoma (HCC). The international societies EASL, AASLD and APASL of access to curative treatments (62% vs 58%) and liver-related mortality (85% vs 86%).
concurrently identify patients with cirrhosis as the main target of surveillance whereas the Noticeably, the higher five-year cumulative incidence of liver nodules in the 3 month arm
algorithms slightly differ with respect to targets, modalities of screening and recall policies. (41% vs 28%) clearly heralds a greater economic burden to reach a final diagnosis in this
AASLD and EASL identify non cirrhotic patients with chronic hepatitis B as ideal candidates arm, which might negatively impact on morbidity and cost utility ratio of the strategy of
for screening, AASLD focusing on Asian males older than 40 years of age and Asian intensified screening.
females older than 50 years together with all HBV carriers with a family history of HCC and The diagnostic algorithm of a nodule detected during surveillance is framed by a
African/north American blacks older than 20 years, since these patient categories are at standardized recall policy, which in the West varies according to the size of the nodule
increased risk of liver cancer as a consequence of early exposure to the hepatitis B virus. whereas in the APASL world depends on arterial uptake of the contrast. Owing to the
EASL suggests screening for all patients with clinically active hepatitis B as well for those fact that a less than 10 mm HCC is difficult to diagnose by contrast CT scan or MRI as
with a family history of HCC (understudied in the West compared to EASL). a consequence of immature arterialization of the nodule, an enhanced follow-up with US
AASLD identifies patients with NAFLD as being at risk of developing liver cancer. However, every 3 months to detect any increase in size or change in echo pattern may guide further
CLINICAL SPEAKERS ABSTRACTS with liver mortality, and issues in the recall policy algorithms based on contrast imaging 10 mm in diameter, which represent 80% of tumors detected during surveillance, can be CLINICAL SPEAKERS ABSTRACTS
NAFLD embraces a broad set of patients ranging from those with hepatic steatosis to
investigations with radiology or echo-guided liver biopsy. Conversely, nodules greater than
patients with full-blown cirrhosis, not to speak about the many patients with competing risks
diagnosed by CT or MRI imaging whenever the specific pattern of an intense contrast
techniques thought to be accurate in patients with cirrhosis and chronic active hepatitis
uptake during the arterial phase (wash-in) is seen together with a contrast wash-out during
B, only. EASL recommends screening of chronic hepatitis C patients with bridging fibrosis
the venous/delayed phase. Contrast-enhanced US is not recommended by AASLD and
(Metavir F3), too, given the increased prevalence of HCC in these patients, however,
EASL to diagnose HCC, because it may fail to distinguish intrahepatic cholangiocarcinoma
bridging fibrosis being frequently misdiagnosed with either a percutaneous liver biopsy or
such non invasive approaches, as Fibrotest and Transient elastography.
hepatospecific contrast to diagnose hypovascular tumors.
Abdominal US is the standard of care for surveillance, whereas the serum alpha-fetoprotein
While a typical “wash-in + wash-out” pattern suffices to diagnose an HCC >10 mm using
(AFP) assay is no longer considered for screening (and diagnosis) by the western societies from HCC in cirrhosis. This is not the policy of APASL which suggests US enhanced by
a single imaging technique in a sequential study, a liver biopsy is deemed necessary to
due to its poor accuracy and the lack of a standardized recall policy. A meta-analysis of confirm the diagnosis of nodules which do not display these characteristic features at
studies of surveillance indicated that the semiannual combination of US+AFP has no added contrast imaging. It should be borne in mind, however, that non-invasive diagnosis of a de
value compared to US alone for the early diagnosis of HCC. This notwithstanding, the novo HCC is recommended in cirrhotic patients and patients with chronic hepatitis B, only.
AFP assay still holds a place in the recommendations by APASL, where high risk patients All in all, all societies acknowledge that surveillance is a standard of care for HCC whereas
with chronic viral hepatitis or cirrhosis, will receive the test in combination with serum des- future efforts should be geared toward removing the barriers to universal surveillance of at
gamma-carboxy-prothrombin (DCP), an abnormal prothrombin protein elaborated by the risk patients by concentrating on improving access to testing and consequent treatment.
neoplastic liver cells and AFP-L3, a fucosylated variant of AFP that most hepatologists in
the West are reluctant to adopt for both screening and diagnosis of HCC.