Screening for Hepatocellular Carcinoma

Screening Recommendations

The screening guidelines from three major liver disease organizations can be aggregated as outlined below.

AASLD

• 
  "Patients at high risk for developing hepatocellular carcinoma should be entered in the surveillance programs."
  
• 
  "Patients on the transplant waiting list should be screened for hepatocellular carcinoma because, in the USA, the development of hepatocellular carcinoma gives increased priority for orthotopic liver transplantation and because failure to screen for hepatocellular carcinoma means that patients may develop hepatocellular carcinoma that may progress beyond listing criteria without the physician being aware."
  
• 
  "Surveillance for hepatocellular carcinoma should be performed using ultrasonography."
  
• 
  "Patients should be screened at 6-month intervals."
  

EASL-EORTC

• 
  "A shorter follow-up interval (every 3-4 months) is recommended in the following cases: Where a nodule of less than 1 cm has been detected (see recall policy) and in the follow-up strategy after resection or loco-regional therapies."
  
• 
  Recall policy
  
  • 
    "In cirrhotic patients, nodules less than 1 cm in diameter detected by ultrasound should be followed every 4 months the first year and with regular checking every 6 months thereafter."
    
  • 
    "In cirrhotic patients, diagnosis of hepatocellular carcinoma for nodules of 1-2 cm in diameter should be based on noninvasive criteria or biopsy-proven pathological confirmation."
    
  • 
    "In cirrhotic patients, nodules more than 2 cm in diameter can be diagnosed for hepatocellular carcinoma based on typical features on one imaging technique. In case of uncertainty or atypical radiologic findings, diagnosis should be confirmed by biopsy."
    
  
  
  

APASL. The APASL guideline continues to recommend alpha-fetoprotein screening coupled with hepatic ultrasound every 6 months.

This recommendation is supported by a recent study that found that alpha-fetoprotein combined with hepatic ultrasound has a sensitivity of 99% and a specificity of 68%, compared with a sensitivity of 92% and specificity 74% with ultrasound alone.

Screening Summary

All patients with cirrhosis who are candidates for hepatic resection or liver transplantation, including hepatitis B carriers, should be screened for HCC with hepatic ultrasound every 6 months. If a nodule ≤ 1 cm is detected, additional ultrasound evaluation should be obtained every 4 months for at least 1 year to determine whether there is further growth that necessitates further evaluation. The diagnosis of HCC can be based on nodule histology or typical radiographic findings on dynamic CT or MRI. Until further studies are available, the routine use of alpha-fetoprotein for HCC screening is not recommended.