Recent Advances in the Treatment of Hepatocellular Carcinoma

Amit G. Singal; Jorge A. Marrero

Disclosures

Curr Opin Gastroenterol. 2010;26(3):189-195. 

In This Article

Surveillance for Hepatocellular Carcinoma

Surveillance strives to detect HCC at an early stage when it is amenable to curative therapy in order to reduce mortality and is recommended in high-risk populations, most notably patients with cirrhosis.[6] Current guidelines from the American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver (EASL) recommend surveillance of at-risk patients with ultrasound with or without alpha-fetoprotein (AFP) every 6–12 months.[7] Although a randomized controlled trial from China demonstrated a survival benefit using surveillance with ultrasound and AFP in patients with chronic hepatitis B,[8] there are no randomized controlled trials among patients with cirrhosis. Current recommendations for HCC surveillance in this group of patients are based primarily on prospective cohort studies. A recent meta-analysis of these prospective trials demonstrated a sensitivity of only 63% for the detection of early-stage HCC using surveillance ultrasound in patients with cirrhosis.[9••] AFP improved sensitivity to 69% for early HCC, but this was not statistically significant. There was substantial heterogeneity in sensitivity, ranging from 23 to 100% across the included studies, which limits generalizability of the studies. Meta-regression analysis demonstrated a significantly higher sensitivity for early HCC with surveillance every 6 months than with annual surveillance. The prospective studies in this meta-analysis had significant limitations, including verification bias and referral bias.

The accuracy of two biomarkers, AFP and des-y-carboxy prothrombin (DCP) was recently assessed among patients from the Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis (HALT-C) Trial.[10] In a nested case–control study, 39 patients with HCC (24 early stage) were compared to 77 matched control patients. The sensitivities of DCP 40 mU/ml or more and AFP 20 ng/ml or more at the time of diagnosis were 74 and 61%, respectively. Sensitivity increased to 91% when the two markers were used in combination. Among the 39 patients with HCC, a suspicious nodule on ultrasound was detected in 22 (56.4%) cases. When only analyzing the 24 cases of early HCC, ultrasound detected a suspicious nodule in 14 (58.4%). These results suggest that biomarkers can be used in combination with ultrasound to increase the detection of HCC, but currently available biomarkers are not optimal.

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