Volume 213 - Issue 9
Hepatocellular carcinoma surveillance in Australia: time to improve the diagnosis of cirrhosis and use liver ultrasound
Author: George Larcos
Med J Aust 2020; 213 (9): 431-431.e1. || doi: 10.5694/mja2.50806
Published online: 2 November 2020
Published online: 2 November 2020
To the Editor: The recent discussion on chronic liver disease and ultrasonographic surveillance is welcome.1 Over two decades ago, investigators at Westmead Hospital in Sydney showed that ultrasonographic surveillance of 232 Australian patients with chronic liver disease (most of whom had cirrhosis) was superior to α‐fetoprotein in the detection of hepatocellular carcinoma (HCC).2 In this research, we detected six HCCs with ultrasound for an annual cohort incidence of 1.4%; we calculated that each HCC detected cost $US8472 (in 1998 dollar terms). Further, the superior detection of HCCs with ultrasonography did not translate into improved survival either because of tumour multicentricity, metastases at diagnosis, or patient comorbidity factors precluding surgery.
Since that time, our technical expertise in liver screening with ultrasound has grown. Nevertheless, we remain concerned by the relatively poor sensitivity compared with computed tomography or magnetic resonance imaging. In addition, specialists in diagnostic imaging understand that the distorted liver architecture from cirrhosis and the presence of regenerating nodules pose significant challenges in distinguishing HCC from benign lesions. While published meta‐analyses3,4 offer some promise, they are by their very nature highly selective in the data evaluated and seldom consider the downstream costs of false positive tests. It is perhaps unsurprising that recent appropriateness criteria guidelines from the American College of Radiology sound a note of caution on the role of ultrasound in this context.5
Despite the above, there remains a need to perform a contemporary analysis of the potential benefits and costs of screening in patients with cirrhosis in Australian settings. However, as a recent Australian HCC surveillance study6 has concluded, it is difficult to interpret survival outcomes from selective retrospective studies, and conducting a randomised controlled trial may be nigh on impossible.
Competing interests
No relevant disclosures.
References
- Jeffrey GP, Gordon L, Ramm G. Hepatocellular carcinoma surveillance in Australia: time to improve the diagnosis of cirrhosis and use liver ultrasound. Med J Aust 2020; 212: 297–300. https://www.mja.com.au/journal/2020/212/7/hepatocellular-carcinoma-surveillance-australia-time-improve-diagnosis-cirrhosis
- Larcos G, Sorokopud H, Berry G, Farrell GC. Sonographic screening for hepatocellular carcinoma in patients with chronic hepatitis or cirrhosis: an evaluation. Am J Roentgen 1998; 171: 433–435.
- 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: 1–19.
- Singal A, Volk ML, Waljee A, et al. Meta‐analysis: surveillance with ultrasound for early‐stage hepatocellular carcinoma in patients with cirrhosis. Aliment Pharmacol Ther 2009; 30: 37–47.
- Horowitz JM, Kamel IR, Arif‐Tirwari H, et al. ACR appropriateness criteria: chronic liver disease. J Am Coll Radiol 2017; 14: S103–S117.
- Hong TP, Gow PJ, Fink M, et al. Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population‐based study. Med J Aust 2018; 209: 348–354. https://www.mja.com.au/journal/2018/209/8/surveillance-improves-survival-patients-hepatocellular-carcinoma-prospective