Hepatocellular Carcinoma Surveillance in Cirrhosis
A 58-year-old man with compensated cirrhosis from chronic hepatitis C, cured with direct-acting antivirals two years ago, attends the hepatology clinic. He is asymptomatic, with a firm liver edge, no ascites and no encephalopathy. His Child-Pugh score is A, platelet count 96 x 10⁹/L, albumin 38 g/L, and the international normalised ratio is 1.1. Which of the following is the most appropriate strategy for hepatocellular carcinoma surveillance?
- A.Abdominal ultrasound every 6 monthsCorrect
- B.Serum alpha-fetoprotein every 6 months alone
- C.Triphasic computed tomography of the liver annually
- D.Liver function tests every 3 months
Explanation
All patients with established cirrhosis, regardless of aetiology and including those whose hepatitis C has been cured, remain at risk of hepatocellular carcinoma and require lifelong surveillance. The recommended modality is abdominal ultrasound every six months, with or without serum alpha-fetoprotein, an interval chosen because it approximates the doubling time of small hepatocellular carcinomas and allows detection while lesions remain within curative criteria for resection, ablation, or transplantation. Ultrasound is inexpensive, radiation free, widely available, and has a sensitivity of roughly 60% to 80% for early hepatocellular carcinoma, which rises when combined with alpha-fetoprotein. Alpha-fetoprotein used alone is inadequate because up to a third of small tumours do not secrete it and levels are also raised by active hepatitis, cirrhosis flares, and pregnancy, giving both poor sensitivity and poor specificity. Triphasic computed tomography or magnetic resonance imaging is the diagnostic test used when ultrasound detects a nodule of 1 cm or larger, where arterial phase hyperenhancement with portal venous washout is diagnostic without biopsy, but repeated computed tomography as a screening tool exposes patients to cumulative radiation and contrast nephrotoxicity. Liver function tests reflect synthetic and excretory function and are entirely insensitive to a small focal tumour. Surveillance should also be offered to patients with chronic hepatitis B who meet age and ethnicity criteria even without cirrhosis. Ultrasound quality is reduced in obesity and marked steatosis, in which case abbreviated magnetic resonance imaging is a reasonable alternative.
Why each option
- A.
- Correct. Six-monthly abdominal ultrasound, with or without alpha-fetoprotein, is the standard surveillance strategy in cirrhosis.
- B.
- Alpha-fetoprotein alone misses up to a third of small tumours and is falsely elevated by hepatitis flares, so it is not used as a sole test.
- C.
- Cross-sectional imaging is the diagnostic step after a nodule is found, not a screening tool, given radiation and contrast exposure.
- D.
- Liver function tests measure synthetic and excretory capacity and cannot detect a small focal malignancy.
Reference: AASLD Practice Guidance on Prevention, Diagnosis, and Treatment of Hepatocellular Carcinoma, 2023
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