- The incidence of hepatocellular carcinoma (HCC) is rising in many countries.
- Care of the patient with HCC involves physicians from different disciplines including hepatologists, surgeons, liver transplant teams, oncologists, interventional radiologists, and to some extent radiation oncologists.
- Assessing the degree of liver function impairment prior to, during and after therapy is important since HCC usually appears in the setting of underlying liver disease.
Surveillance and Assessment
- Patients at high risk for developing HCC should be entered into surveillance programs (I).
The at-risk groups for whom surveillance is recommended are identified in Table 1.
- Patients on the transplant waiting list should be screened for HCC because in the USA the development of HCC gives increased priority for orthotopic liver transplantation, and because failure to screen means that HCC may progress beyond listing criteria without the physician being aware (III).
- Surveillance for HCC should be performed using ultrasonography (II).
- Patients should be screened at 6 month intervals (II).
- The surveillance interval does not need to be shortened for patients at higher risk of HCC (III).
- Nodules found on ultrasound surveillance that are < 1 cm should be followed with ultrasound at intervals from 3-6 months (III). If there has been no growth over a period of up to 2 years, resume routine surveillance (III).
- Nodules > 1 cm found on ultrasound screening of a cirrhotic liver should be investigated further with either a 4-phase multidetector computed tomography (MDCT) scan or dynamic contrast enhanced magnetic resonance imaging (MRI). If the appearances are typical of HCC (ie, hypervascular in the arterial phase with washout in the portal venous or delayed phase), the lesion should be treated as HCC. If the findings are not characteristic or the vascular profile is not typical, a second contrast enhanced study with the other imaging modality should be performed, or the lesion should be biopsied (II).
- Biopsies of small lesions should be evaluated by expert pathologists. Tissue that is not clearly HCC should be stained with all the available markers including CD34, CK7, glypican 3, HSP-70, and glutamine synthetase to improve diagnostic accuracy (III).
- If the biopsy is negative for patients with HCC, the lesion should be followed by imaging at 3-6 month intervals until the nodule either disappears, enlarges, or displays diagnostic characteristics of HCC. If the lesion enlarges but remains atypical for HCC a repeat biopsy is recommended (III).
Table 1. Groups for Whom HCC Surveillance is Recommended or in Whom the Risk of HCC is Increased, but in Whom Efficacy of Surveillance Has Not Been Demonstrated
|Population Group||Threshold Incidence for Efficacy of Surveillance (> 0.25 LYG) (%/year)||Incidence of HCC|
|Cirrhotic hepatitis B carriers||0.2-1.5||3-8%/year|
|Hepatitis C cirrhosis||1.5||3-5%/year|
|Stage 4 primary biliary cirrhosis||1.5||3-5%/year|
|Genetic hemachromatosis and cirrhosis||1.5||Unknown, but probably > 1.5%/year|
|Alpha 1-antitrypsin deficiency and cirrhosis||1.5||Unknown, but probably > 1.5%/year|
|Asian male hepatitis B carriers > age 40||0.2||0.4-0.6%/year|
|Asian female hepatitis B carriers > age 50||0.2||0.3-0.6%/year|
|Hepatitis B carrier with family history of HCC||0.2||Incidence higher than without family history|
|African/North American Blacks with hepatitis B||0.2||HCC occurs at a younger age|
|Surveillance benefit uncertain|
|Hepatitis C and stage 3 fibrosis||1.5||< 1.5%/year|
|Non-cirrhotic NAFLD||1.5||< 1.5%/year|
|Hepatitis B carriers < 40 (males) or < 50 (females)||0.2||< 0.2%/year|
Figure 1. Algorithm for Investigation of Small Nodules Found on Screening in Patients at Risk for HCC
To best assess the prognosis of HCC patients it is recommended that the staging system take into account tumor stage, liver function and physical status. The impact of treatment should also be considered when estimating life expectancy. Currently, the Barcelona Clinic Liver Cancer (BCLC) system is the only staging system that accomplishes these aims (II).