Screening and Surveillance

Owing to the increased risk of HCC in certain populations (ie, HCC risk > 1.5% per year for non-HBV cirrhosis,> 0.2% for HBV carriers), surveillance measures have been implemented, often using a combination of serologic and radiologic tests.

In the one large-scale study performed to date, from China, 18,816 patients were randomized to either surveillance with ultrasound and a-fetoprotein every 6 months or no monitoring. A 37% decrease in HCC-related mortality was noted in those who were screened compared with the unscreened cohort. The 1-, 3-, and 5-year mortality rates in the screened group were 66%, 53%, and 46% compared with rates of 31%, 7%, and 0%, respectively, in the control group. These data need further confirmatory studies. However, based on the premise that early diagnosis of HCC will lead to early treatment and reduction in mortality, surveillance measures are widely implemented in the patients groups identified in Table 49-1.

1.  Serologic screening—A persistently elevated a-fetoprotein level is a risk factor for subsequent HCC. Absolute a-fetoprotein levels have inadequate sensitivity and specificity to detect HCC. However, very high (> 500 ng/mL) levels are generally associated with the presence of HCC, and if a mass is identified on subsequent imaging, biopsy is not necessarily needed to confirm the diagnosis. Other serologic studies such as des-y-carboxy prothrombin (an abnormal prothrombin induced in patients deficient in vitamin K), glycosylated a-fetoprotein ratio, a-fucosidase, and glypican 3 need further investigation before being considered for HCC screening.

2.  Radiographic imaging—Ultrasound is widely used for HCC surveillance. On ultrasonography either a hyperechoic or a hypoechoic lesion can be seen. Ultrasound has low sensitivity (~65%) but excellent specificity for the detection of liver lesions (> 90%). However, there is concern that its accuracy may be limited in obese individuals and in those with multiple cirrhotic nodules.

HCC surveillance is recommended in at-risk populations, with ultrasonography performed every 6-12 months. Most hepatologists, however, use a combination of ultrasonography and a-fetoprotein every 6 months for surveillance. If a lesion greater than 1 cm is identified or a previously known nodule enlarges, further diagnostic evaluation with either contrast-enhanced CT or MRI should be performed.

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