Reply.

Abstract

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. We appreciate the valuable comments by Sultanik et al. on our recently published article.1 They raised some issues. The diagnosis of early cirrhosis without overt clinical manifestations can be missed when using clinical criteria alone. As liver biopsy is ineligible in many cases due to its inherent invasiveness, we investigated whether the liver stiffness (LS) value using transient elastography (TE) could identify chronic hepatitis B patients with early cirrhosis requiring a more careful surveillance program because of an increased risk of developing hepatocellular carcinoma (HCC) among those without clinical evidences of cirrhosis. As Sultanik et al. showed acceptable performance of TE for the prediction of HCC development in their cohort (area under the receiver operating characteristic curve = 0.87), TE might be an acceptable tool for this purpose. However, they also indicated a lower sensitivity (slightly higher than 30%) of TE for the prediction of HCC development using a cutoff of 13 kPa. In our study, we did not mean that patients with an LS value of <13 kPa do not require HCC surveillance based on our concept of “subclinical cirrhosis.” We also acknowledge that patients with a lower LS value (<13 kPa) should not be exempted from HCC surveillance because even patients with a low LS value and well‐controlled viremia are still subject to HCC development. Indeed, in several previous studies proposing TE‐based HCC prediction,2 an increased risk of HCC development in patients with LS values of 8‐12 kPa and 8‐13 kPa was identified with hazard ratios of 5.60, and 3.07, respectively, when compared with a reference LS value of <8 kPa. Two points can be suggested from our study. First, considering the fact that early cirrhosis may be missed by the current ultrasonography‐based surveillance methods,4 a more careful surveillance protocol might be applied in patients with early cirrhosis. Second, although the sensitivity of the LS value is not sufficient by itself, a scoring system using the LS value with other relevant variables may lead to much more improved sensitivity.2 However, because our concept of “subclinical cirrhosis” has not been externally validated, the role of TE and the corresponding optimal cutoff LS value in the surveillance setting in both treated and untreated patients with chronic hepatitis B should be further investigated in future prospective studies.