Abstract
Hepatocellular carcinoma (HCC) continues to be a significant cause of mortality in the United States. However, HCC is curable if detected early in its course. Cirrhosis is a well-established risk factor for HCC, but direct evidence demonstrating the benefit of screening for HCC in this population remains under contention today. Ultrasound (US) every 6 months is currently the proposed screening methodology. Serum alpha-feto protein (AFP) has been dropped from screening guidelines, yet recent prospective data reported an added efficacy with the combination of serum AFP and US. Technological advances in cross-sectional imaging have dramatically impacted the field of hepatobiliary imaging, making them attractive alternatives for HCC screening in selected populations. While computed tomography (CT) does not appear to confer any significant advantage to US performed by trained personnel, magnetic resonance imaging (MRI) with hepatobiliary phase (HBP) and diffuse weighted imaging (DWI) offers the best sensitivity and specificity for HCC largely due to its superiority in detecting and characterizing lesions <2 cm. Its cost-effectiveness as a screening tool, however, remains to be seen.
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Jemal A, et al. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69–90.
El-Serag HB, et al. The continuing increase in the incidence of hepatocellular carcinoma in the United States: an update. Ann Intern Med. 2003;139(10):817–23.
El-Serag HB. Hepatocellular carcinoma: recent trends in the United States. Gastroenterology. 2004;127(5 Suppl 1):S27–34.
Kim WR, et al. Mortality and hospital utilization for hepatocellular carcinoma in the United States. Gastroenterology. 2005;129(2):486–93.
Altekruse SF, et al. Changing hepatocellular carcinoma incidence and liver cancer mortality rates in the United States. Am J Gastroenterol. 2014;109(4):542–53.
Rahib L, et al. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res. 2014;74(11):2913–21.
Bruix J, Morris S. Management of hepatocellular carcinoma: an update. AASLD Practice Guidelines 2010 [cited 2014 9/17/14]; Available from: http://www.aasld.org/sites/default/files/guideline_documents/HCCUpdate2010.pdf.
Kansagara D, et al. Screening for hepatocellular carcinoma in chronic liver disease: a systematic review. Ann Intern Med. 2014;161(4):261–9.
Poustchi H, et al. Feasibility of conducting a randomized control trial for liver cancer screening: is a randomized controlled trial for liver cancer screening feasible or still needed? Hepatology. 2011;54(6):1998–2004.
Sarasin FP, Giostra E, Hadengue A. Cost-effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child-Pugh class A cirrhosis. Am J Med. 1996;101(4):422–34.
Andersson KL, et al. Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol. 2008;6(12):1418–24.
Arguedas MR, et al. Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis. Am J Gastroenterol. 2003;98(3):679–90.
Lin OS, et al. Cost-effectiveness of screening for hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C. Aliment Pharmacol Ther. 2004;19(11):1159–72.
Mourad A, et al. Hepatocellular carcinoma screening in patients with compensated hepatitis C virus (HCV)-related cirrhosis aware of their HCV status improves survival: a modeling approach. Hepatology. 2014;59(4):1471–81.
Patel D, et al. Cost-effectiveness of hepatocellular carcinoma surveillance in patients with hepatitis C virus-related cirrhosis. Clin Gastroenterol Hepatol. 2005;3(1):75–84.
European Association For The Study Of The, L, R. European Organisation For, C. Treatment Of. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908–43.
Naimark D, Naglie G, Detsky AS. The meaning of life expectancy: what is a clinically significant gain? J Gen Intern Med. 1994;9(12):702–7.
Laupacis A, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146(4):473–81.
Ascha MS, et al. The incidence and risk factors of hepatocellular carcinoma in patients with nonalcoholic steatohepatitis. Hepatology. 2010;51(6):1972–8.
Kim Y, et al. Temporal trends in population-based death rates associated with chronic liver disease and liver cancer in the United States over the last 30 years. Cancer. 2014;120(19):3058–65.
Chen JG, et al. Screening for liver cancer: results of a randomised controlled trial in Qidong, China. J Med Screen. 2003;10(4):204–9.
Gambarin-Gelwan M, et al. Sensitivity of commonly available screening tests in detecting hepatocellular carcinoma in cirrhotic patients undergoing liver transplantation. Am J Gastroenterol. 2000;95(6):1535–8.
Lok AS, et al. Des-gamma-carboxy prothrombin and alpha-fetoprotein as biomarkers for the early detection of hepatocellular carcinoma. Gastroenterology. 2010;138(2):493–502.
Marrero JA, et al. Alpha-fetoprotein, des-gamma carboxyprothrombin, and lectin-bound alpha-fetoprotein in early hepatocellular carcinoma. Gastroenterology. 2009;137(1):110–8.
Trevisani F, et al. Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HBsAg and anti-HCV status. J Hepatol. 2001;34(4):570–5.
Singal AG, et al. Effectiveness of hepatocellular carcinoma surveillance in patients with cirrhosis. Cancer Epidemiol Biomark Prev. 2012;21(5):793–9.
Snowberger N, et al. Alpha fetoprotein, ultrasound, computerized tomography and magnetic resonance imaging for detection of hepatocellular carcinoma in patients with advanced cirrhosis. Aliment Pharmacol Ther. 2007;26(9):1187–94.
Bruix J, Sherman M, D. American Association for the Study of Liver. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–2.
Lee E, et al. Improving screening for hepatocellular carcinoma by incorporating data on levels of alpha-fetoprotein, over time. Clin Gastroenterol Hepatol. 2013;11(4):437–40.
Takashima T, et al. Diagnosis and screening of small hepatocellular carcinomas. Comparison of radionuclide imaging, ultrasound, computed tomography, hepatic angiography, and alpha 1-fetoprotein assay. Radiology. 1982;145(3):635–8.
Colli A, et al. Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006;101(3):513–23.
Singal A, et al. Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis. Aliment Pharmacol Ther. 2009;30(1):37–47.
Singal AG, Pillai A, Tiro J. Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLoS Med. 2014;11(4):e1001624–e1001624.
Trinchet J-C, et al. Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities. Hepatology. 2011;54(6):1987–97.
Wang J-H, et al. Hepatocellular carcinoma surveillance at 4- vs. 12-month intervals for patients with chronic viral hepatitis: a randomized study in community. Am J Gastroenterol. 2013;108(3):416–24.
Zhang B-H, Yang B-H, Tang Z-Y. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004;130(7):417–22.
Bolondi L, et al. Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost effectiveness analysis. Gut. 2001;48(2):251–9.
Di Martino M, et al. Hepatocellular carcinoma in cirrhotic patients: prospective comparison of US, CT and MR imaging. Eur Radiol. 2013;23(4):887–96.
Henrion J, et al. Surveillance for hepatocellular carcinoma: compliance and results according to the aetiology of cirrhosis in a cohort of 141 patients. Acta Gastroenterol Belg. 2000;63(1):5–9.
Pocha C, et al. Surveillance for hepatocellular cancer with ultrasonography vs. computed tomography – a randomised study. Aliment Pharmacol Ther. 2013;38(3):303–12.
Sangiovanni A, et al. Increased survival of cirrhotic patients with a hepatocellular carcinoma detected during surveillance☆. Gastroenterology. 2004;126(4):1005–14.
Choi BI. The current status of imaging diagnosis of hepatocellular carcinoma. Liver Transpl. 2004;10(2 Suppl 1):S20–5.
Boone JM. Multidetector CT: opportunities, challenges, and concerns associated with scanners with 64 or more detector rows. Radiology. 2006;241(2):334–7.
Luca A, et al. Multidetector-row computed tomography (MDCT) for the diagnosis of hepatocellular carcinoma in cirrhotic candidates for liver transplantation: prevalence of radiological vascular patterns and histological correlation with liver explants. Eur Radiol. 2010;20(4):898–907.
United Network for Organ Sharing. HRSA/OPTN Policy 3.6 organ distribution: allocation of livers. Table 9–3: recommendations for dynamic contrast-enhanced CT of liver. Available at: http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_8.pdf. Accessed on 10 Oct 2014.
Addley HC, et al. Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation. Clin Radiol. 2011;66(4):349–56.
Denecke T, et al. Multislice computed tomography using a triple-phase contrast protocol for preoperative assessment of hepatic tumor load in patients with hepatocellular carcinoma before liver transplantation. Transplant Int. 2009;22(4):395–402.
Ronzoni A, et al. Role of MDCT in the diagnosis of hepatocellular carcinoma in patients with cirrhosis undergoing orthotopic liver transplantation. AJR Am J Roentgenol. 2007;189(4):792–8.
United Network for Organ Sharing. HRSA/OPTN Policy 3.6 organ distribution: allocation of livers. Table 1. Available at: http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_8.pdf. Accessed 10 Oct 2014.
Barr DC, Hussain HK. MR imaging in cirrhosis and hepatocellular carcinoma. Magn Reson Imaging Clin N Am. 2014;22(3):315–35.
Lim KS. Diffusion-weighted MRI of hepatocellular carcinoma in cirrhosis. Clin Radiol. 2014;69(1):1–10.
Liu X, et al. Gadoxetic acid disodium-enhanced magnetic resonance imaging for the detection of hepatocellular carcinoma: a meta-analysis. PLoS ONE. 2013;8(8):e70896–e70896.
Seale MK, et al. Hepatobiliary-specific MR contrast agents: role in imaging the liver and biliary tree. Radiographics. 2009;29(6):1725–48.
Taouli B, Koh D-M. Diffusion-weighted MR imaging of the liver. Radiology. 2010;254(1):47–66.
Bartolozzi C, et al. Contrast-enhanced magnetic resonance imaging of 102 nodules in cirrhosis: correlation with histological findings on explanted livers. Abdom Imaging. 2013;38(2):290–6.
Bolondi L, et al. Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma. Hepatology. 2005;42(1):27–34.
Hanna RF, et al. Cirrhosis-associated hepatocellular nodules: correlation of histopathologic and MR imaging features. Radiographics. 2008;28(3):747–69.
Sun HY, et al. Gadoxetic acid-enhanced magnetic resonance imaging for differentiating small hepatocellular carcinomas (< or =2 cm in diameter) from arterial enhancing pseudolesions: special emphasis on hepatobiliary phase imaging. Investig Radiol. 2010;45(2):96–103.
Vandecaveye V, et al. Diffusion-weighted MRI provides additional value to conventional dynamic contrast-enhanced MRI for detection of hepatocellular carcinoma. Eur Radiol. 2009;19(10):2456–66.
Xu P-J, et al. Added value of breath hold diffusion-weighted MRI in detection of small hepatocellular carcinoma lesions compared with dynamic contrast-enhanced MRI alone using receiver operating characteristic curve analysis. J Magn Reson Imaging. 2009;29(2):341–9.
Hwang J, et al. Pre-transplant diagnosis of hepatocellular carcinoma by gadoxetic acid-enhanced and diffusion-weighted magnetic resonance imaging. Liver Transpl. 2014;20(12):1436–46.
Park MJ, et al. Validation of diagnostic criteria using gadoxetic acid-enhanced and diffusion-weighted MR imaging for small hepatocellular carcinoma (<= 2.0 cm) in patients with hepatitis-induced liver cirrhosis. Acta Radiol. 2013;54(2):127–36.
Park MJ, et al. Small hepatocellular carcinomas: improved sensitivity by combining gadoxetic acid-enhanced and diffusion-weighted MR imaging patterns. Radiology. 2012;264(3):761–70.
Nguyen MH, et al. Racial differences in effectiveness of alpha-fetoprotein for diagnosis of hepatocellular carcinoma in hepatitis C virus cirrhosis. Hepatology. 2002;36(2):410–7.
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Desai, A.P., Te, H.S. (2016). What Is the Best Way to Screen Cirrhotic Patients for Hepatocellular Carcinoma in the United States?. In: Millis, J., Matthews, J. (eds) Difficult Decisions in Hepatobiliary and Pancreatic Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-319-27365-5_9
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DOI: https://doi.org/10.1007/978-3-319-27365-5_9
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