Looking for trouble

Although cirrhosis is an infrequent problem in pediatric gastroenterology, there are several important management aspects.  One of these is surveillance for hepatocellular carcinoma (HCC).  In this month’s Hepatology, Poustchi et al describe the “feasibility of a randomized control trial for liver cancer screening” (Hepatology 2012; 54: 1998 & editorial 1898).  Not surprisingly, the authors conclude that such a trial is not possible with informed consent.  As such, the effectiveness and cost-effectiveness may not be determined.  Although the consensus is in favor of screening, there are potential disadvantages like discovering non-cancer nodules leading towards unnecessary invasive investigations.

The AASLD considers screening for HCC worthwhile in patients with cirrhosis.  When HCC is discovered early, treatment can be effective.  For example, if HCC meets Milan criteria–either 1 tumor <5cm or 2-3 < 3 cm each– OLT has 91% 1 yr survival.

Most U.S. physicians (74%) report that they screen all of their patients with cirrhosis; however,  population-based studies of Medicare patients show only 6.6% receive regular surveillance (Hepatology 2010; 52: 132-41) & only 12% of veterans with HCV-infected cirrhosis (Ann Intern Med 2011; 154: 85-93).  Better ways of consolidating screening can bridge this gap & perhaps catch cases of HCC amenable to treatment.  This may be another area where an EMR can help with patient/doctor reminders.

Current practice recommendations for cirrhotic patients: Ultrasound every 6 months (with or without AFP).  This recommendation is supported by the AASLD, EASL, and APASL.  The efficacy of HCC surveillance is reviewed further in the January “Education Practice” article: Clin Gastro & Hepatatol 2012: 10: 16-21.

Additional references:

  • Gastroenterology 2011; 141: 1240. Risk of HCC from HBV related to ALT and HBV DNA levels.
  • NEJM 2011; 365: 1118. Review. For cirrhotics/advanced liver dz, recs U/S & AFP q6-12months.
  • Hepatology 2010; 53: 1020. updated guidelines from AASLD. Suggests U/S as screen q6months.
  • J Pediatr 2011; 159: 617. BA associated with HCC.
  • Hepatology 2010; 51: 1972. NASH cirrhosis pts develop HCC. 12.8% over .32 yrs (compared with 20.3 % of pts with HCV cirrhosis). Alcohol & age were independent variables that increased risk.
  • Gastroenterology 2009; 137: 110, editorial page 26. AFP has at best 66% sensitivity for HCC.
  • Gastroenterology 2009; 136: 138, 39(ed). HCC occuring c HCV ~1%/yr in HALT-C study. prolonged Rx -not helpful. n=1005. Best surveillance is US. Only 60% of pts c HCC received surveillance. Hepatolgy 2005; 42 : 1208.
  • Gastroenterologyo 2008; 135: 111. DM & obesity associated with increase risk of HCC in patients with HBV/HCV.
  • Gastroenterology 2008; 134: 1612. Increasing LTx for HCC affects others on Tx list.
  • Gastroenterology 2007; 132: 2557. review
  • Clin Gastro & Hep 2006; 4: 252 Review.
  • Hepatology 2005; 42: 1208. AASLD guidelines for management.
  • Gastroenterology 2004 (November) 127; supplement 1:S1–S323. Review of HCC. S108: screen with alpha-fetoprotein AND U/S every 6-12 months in individuals with cirrhosis or advanced disease (not needed in individuals with mild disease).
  • Clinical Gastro & Hep 2003; 1: 10-18. Review.
  • Gastroenterology 2004; 126: 1005. HCC survival improved when detected as part of surveillance.

2 thoughts on “Looking for trouble

  1. Pingback: How strong is the case for HCC screening? | gutsandgrowth

  2. Pingback: HBV in the Joseon Dynasty | gutsandgrowth

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