Hepatocellular Carcinoma Screening Program Research Articles

Combined Hepatitis B Virus and Hepatocellular Carcinoma Screening Using Point-of-Care Testing and Ultrasound in a Tanzanian Emergency Department.

The WHO aims to detect 90% of global cases of hepatitis B virus (HBV) by 2030. Sub-Saharan Africa carries a disproportionate burden of HBV and hepatocellular carcinoma (HCC). In this study, we sought to assess the utility of a combined HBV and HCC screening program in Tanzania. We conducted a prospective, serial cross-sectional study of patients who participated in a combined HBV and HCC screening program at a regional referral hospital emergency department (ED) in Arusha, Tanzania, between April 19, 2022 and June 3, 2022. All patients completed a study questionnaire and were tested for HBV surface antigen. Patients who were HBV positive were screened for HCC via point-of-care ultrasound (POCUS). The primary outcome was the number of new HBV diagnoses. Data were analyzed with descriptive statistics. A total of 846 patients were tested for HBV (primary ED: 761, clinic referral: 85). The median age of patients was 44 ± 15 years, and 66% were female. Only 15% of patients reported having a primary care doctor. Thirteen percent of patients had been previously vaccinated for HBV. There were 17 new HBV diagnoses (primary ED: 16, clinic referral: 1), which corresponds to a seroprevalence of 2.0% (95% CI: 1.2%, 3.2%). No patients had liver masses detected on POCUS. An ED-based, combined HBV and HCC screening protocol can be feasibly implemented. This study could serve as a model for HBV/HCC screening in regions with high HBV endemicity and low rates of community screening.

209EMF Combined Hepatitis B Virus and Hepatocellular Carcinoma Screening Using Point-of-Care Testing and Ultrasound in a Tanzanian Emergency Department: A Preliminary Report

Sub-Saharan Africa has a disproportionate burden of hepatitis B virus (HBV) and hepatocellular carcinoma (HCC). The World Health Organization aims to detect 90% of global cases of HBV by 2030 -- novel screening strategies will be needed to achieve this goal. In this study, we sought to assess the utility of an emergency department (ED)-based, combined HBV and HCC screening program in Arusha, Tanzania.

Implementation of a Hepatocellular Carcinoma Screening Program for At-risk Patients Safety-Net Hospital: A Model for National Dissemination.

This study aimed to enhance hepatocellular carcinoma (HCC) screening to achieve earlier diagnosis of patients with hepatitis C (HCV) cirrhosis in our Safety-Net population. Adherence to HCC screening guidelines at Safety-Net hospitals is poor. Only 23% of patients with HCC at our health system had a screening exam within 1-year of diagnosis and 46% presented with stage IV disease. HCV-induced cirrhosis remains the most common etiology of HCC (75%) in our patients. In the setting of an established HCV treatment clinic, an HCC screening quality improvement initiative was initiated for patients with stage 3 fibrosis or cirrhosis by transient elastography. The program consisted of semiannual imaging. Navigators scheduled imaging appointments and tracked compliance. From April 2018 to April 2021, 318 patients were enrolled (mean age 61 years, 81% Black race, 38% uninsured). Adherence to screening was higher than previously reported: 94%, 75%, and 74% of patients completed their first, second, and third imaging tests. Twenty-two patients (7%) were diagnosed with HCC; 55% stage I and 14% stage IV. All patients were referred and 13 (59%) received treatment. Median time to receipt of treatment was 77 days (range, 32-282). Median overall survival for treated patients was 32 months. Implementation of an HCC screening program at a safety-net hospital is feasible and facilitated earlier diagnosis in this study. Patient navigation and tracking completion of imaging tests were key components of the program's success. Next steps include expanding the program to additional at-risk populations.

Hepatocellular carcinoma (HCC) in patients with Non-Alcoholic Fatty Liver Disease (NAFLD): screening, treatment and survival analysis in a Brazilian series

ObjectiveThe aim of the present study was to evaluate the clinical features, Hepatocellular Carcinoma (HCC) screening, treatment modalities, and Overall Survival (OS) in a series of Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma (NAFLD-HCC) Brazilian patients. MethodsThis was a cross-sectional study at the Instituto do Cancer do Estado de São Paulo, at the Faculdade de Medicina da Universidade de São Paulo with the approval of the local research ethics committee. NAFLD patients with HCC diagnosed, from May 2010 to May 2019, were included. ResultsA total of 131 patients were included. Risk factors for NAFLD were present in 94.7% of the patients. Only 29% of patients were in the HCC screening program before diagnosis. HCC treatment was performed in 84.7% of patients. Cumulative survival at the end of the first year was 72%, second-year 52%, and fifth-year 32%. HCC screening before diagnosis was not significantly associated with higher cumulative survival. The independent factors associated with shorter general survival were BCLC C-D, p < 0.001, and the size of the largest nodule > 42 mm, p = 0.039. ConclusionsAlthough the efficacy of screening in our population regarding overall survival was hampered due to the sample size (29% had screening), BCLC stages C‒D and the size of the largest nodule larger than 42 mm were identified as independent factors of worse prognosis.

Influence of Metabolic Syndrome on Cancer Risk in HBV Carriers: A Nationwide Population Based Study Using the National Health Insurance Service Database.

Purpose: Hepatitis B virus (HBV) infection and metabolic syndrome (MS) are known independent risk factors for hepatocellular carcinoma (HCC) and other extrahepatic organ malignancies. The purpose of this study was to investigate whether MS and HBV have synergistic effects on cancers and to examine whether increasing the number of MS components could lead to higher risk of cancer development. Materials and Methods: We evaluated data from 1,504,880 HBV-infected adults who underwent a regular HCC screening program provided by the Korean National Health Insurance Service between 2009 and 2016. Results: The prevalence of MS in Korean HBV patients was 38.7% (582,449/1,504,880). Among individuals with HBV infection, the presence of MS was associated with an increased risk for the majority of malignancies except for HCC (HR = 0.862, p-value < 0.05). The presence of a higher number of MS components was associated with a significantly increased risk of developing cancers in most organs; only HCC was negatively associated with an increasing number of MS components (p < 0.01). Conclusions: Our data show that the presence of MS increases the risk for most malignancies, excluding HCC. Moreover, we found that as the number of MS components increased, the risk for most cancers also increased; this trend was reversed in HCC.

Epidemiological projections of viral-induced hepatocellular carcinoma in the perspective of WHO global hepatitis elimination.

Hepatitis B is an eminent risk factor for hepatocellular carcinoma (HCC) in Southeast Asia and sub-Saharan Africa, whereas hepatitis C is a key risk factor for HCC in Western Europe and North America. Increased awareness of the global burden of viral hepatitis resulted, in May 2016, in the adoption of the first global health sector strategy on viral hepatitis by the World Health Assembly, which calls for the elimination of viral hepatitis as a public health threat by 2030. Although the incidence of liver cancer resulting from viral infections has increased since the 1990s, the implementation of public health interventions, such as hepatitis B vaccination and antiviral therapies might have reduced the global burdens of HCC. Hepatitis B immunization in infancy has been associated with a reduction in the risk of infant fulminant hepatitis, chronic liver disease, and HCC in Taiwan. Achieving viral hepatitis elimination by 2030 can be accelerated by improving the access to HCC screening programs. HCC surveillance programs in developed countries must be refined to increase an access to personalized surveillance program, whereas the limited access to surveillance and treatment of HCC in developing countries remains a significant public health issue.

Surgical resection of early stage hepatocellular carcinoma: balancing tumor biology with the host liver.

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. In early stage HCC, current practice guidelines recommend surgical resection with 5-year overall survival (OS) rates approaching 60%. Due to heterogeneity of the patient population and underutilization of HCC screening, in the past only 10-37% of patients were eligible for surgical resection at the time of initial HCC diagnosis. With recent implementation of HCC screening programs resulting in earlier diagnosis, the number of patients that might be candidates for curative surgical resection has increased. Factors determining outcome following HCC diagnosis are complex and heterogenous in nature and treatment decisions should be based on both tumor- and patient-related factors. Tumor characteristics including tumor size, macrovascular invasion (MVI), and multifocality must be balanced against measures of liver dysfunction including portal hypertension, liver function, and future liver remnant (FLR) to assess the applicability of hepatic resection in patients newly diagnosed with HCC. The aim of this article is to review the indications for curative HCC surgical resection as it pertains to underlying tumor- and patient-related factors. We also discuss adjunctive therapies that may allow for an increased role for hepatic resection in HCC patients with early stage disease who are ineligible for upfront resection due to small liver remnant size.

Long-Term Evaluation of Outcomes for Abdominal Ultrasound Screening for Hepatocellular Carcinoma

Background: Mass screening for hepatocellular carcinoma (HCC) with abdominal ultrasound (AUS) has been demonstrated in short-term follow-up in Taiwan, but long-term effectiveness and cost-effectiveness of AUS have not been well studied particularly when the recently emerging antiviral therapy has been introduced. The aim of this study is therefore to evaluate long-term outcomes of population-based organized service screening program without control group. Methods: AUS screening based on a risk score–guided invitation has been launched since October 2008 in Changhua. A total of 85,147 subjects aged 40-74 years attended the Changhua community-based integrated screening (CHCIS) program were targeted. Those with high score based on hepatitis virus infection, ALT, AST, type 2 diabetes, platelet count were invited to receive ultrasonography screening performed by board-certified gastroenterologists in town-based health center to identify liver cirrhosis, and suspected HCC cases. We developed a pseudo-control group by building up the disease natural history for HCC embedded with the risk prediction model and the survival by detection modes. The pseudo-control model was further used to the development of health economic decision model for cost-effectiveness of various preventive strategies. Results: We observed a 61% (RR = 0.39, 95% CI: 0.32-0.46) HCC mortality reduction with AUS by risk groups together with ∼30% coverage rate of antiviral therapy in an 8-year period. The simulated results indicates the additional contribution of 30% compliance rate of antiviral therapy (empirical estimate) to HCC mortality reduction was ∼22%. The corresponding figures were raised to 30% and 35% when the compliance rate of antiviral therapy was enhanced to 50% and 70%, respectively. The results of cost-effectiveness analysis shows the incremental cost-effectiveness ratio was $22,849 for the administration of AUS, and $101,849 for the administration of AUS plus 30% compliance to antiviral therapy. The corresponding figures for 50% and 70% compliance rate to antiviral therapy were $141,805 and $181,919, respectively. Conclusion: The population-based screening program for HCC together with antiviral therapy achieved HCC mortality reduction by 60%. The computer study design with a pseudo-control group on the basis of disease natural history of HCC embedded with the predictive model, and the survival part of HCC enables us to quantify the attributable proportion from different preventive regimes, and to estimate long-term effectiveness of the overall and marginal effectiveness and cost-effectiveness of AUS and antiviral therapy under different scenarios. Such approach provides the health policy-makers a reference for resource allocation.

PCN117 - HEALTHCARE EXPENDITURES FOR THE TREATMENT OF PATIENTS WITH HEPATOCELLULAR CARCINOMA IN JAPAN

Hepatocellular carcinoma (HCC) has a low survival rate, and accounts for approximately 30,000 mortalities each year in Japan. This study aimed to estimate the healthcare expenditures of HCC patients. Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), we randomly extracted a sample comprising 25% of all Japanese citizens who had been hospitalized at least once from April 2009 to December 2016. Patients with a recorded diagnosis of HCC were identified, and the month of the initial diagnosis was designated the index month. Patients with other cancers during the study period or without data for one year before the index month were excluded from analysis. The index month and the three preceding months were designated the initial phase, the six-month period preceding death was designated the terminal phase, and the period between these phases was designated the continuing phase. Healthcare expenditures were estimated according to the following treatment types: (1) hepatectomy; (2) locoregional therapy (LRT), including percutaneous ethanol injection, percutaneous microwave coagulation therapy, and radiofrequency ablation; (3) transcatheter arterial chemoembolization (TACE); (4) transcatheter arterial embokization (TAE); and (5) molecular targeted drugs (MTD). The mean monthly expenditures were calculated for each phase and treatment type. We identified 7782 HCC patients during the study period. There were 3105, 1882, 2142, 396 and 251 patients who received monotherapy of hepatectomy, LRT, TACE, TAE, and MTD, respectively. The monthly healthcare expenditures during the initial/continuing/terminal phases for hepatectomy, LRT, TACE, TAE and MTD were $4931/$911/$6416, $2269/$1435/$3687, $2793/$1577/$4300, $2886/$1304/$5170 and $1914/$1295/$4428, respectively. We estimated the healthcare expenditures of HCC patients for various phases and treatment types using the NDB. These estimates may have downstream applications in cost-effectiveness analyses of HCC screening programs and treatment approaches.

The portal hypertension syndrome: etiology, classification, relevance, and animal models.

Portal hypertension is a key complication of portal hypertension, which is responsible for the development of varices, ascites, bleeding, and hepatic encephalopathy, which, in turn, cause a high mortality and requirement for liver transplantation. This review deals with the present day state-of-the-art preventative treatments of portal hypertension in cirrhosis according to disease stage. Two main disease stages are considered, compensated and decompensated cirrhosis, the first having good prognosis and being mostly asymptomatic, and the second being heralded by the appearance of bleeding or non-bleeding complications of portal hypertension. The aim of treatment in compensated cirrhosis is preventing clinical decompensation, the more frequent event being ascites, followed by variceal bleeding and hepatic encephalopathy. Complications are mainly driven by an increase of hepatic vein pressure gradient (HVPG) to values ≥10 mmHg (defining the presence of Clinically Significant Portal Hypertension, CSPH). Before CSPH, the treatment is limited to etiologic treatment of cirrhosis and healthy life style (abstain from alcohol, avoid/correct obesity…). When CSPH is present, association of a non-selective beta-blocker (NSBB), including carvedilol should be considered. NSBBs are mandatory if moderate/large varices are present. Patients should also enter a screening program for hepatocellular carcinoma. In decompensated patients, the goal is to prevent further bleeding if the only manifestation of decompensation was a bleeding episode, but to prevent liver transplantation and death in the common scenario where patients have manifested first non-bleeding complications. Treatment is based on the same principles (healthy life style..) associated with administration of NSBBs in combination if possible with endoscopic band ligation if there has been variceal bleeding, and complemented with simvastatin administration (20-40 mg per day in Child-Pugh A/B, 10-20 mg in Child C). Recurrence shall be treated with TIPS. TIPS might be indicated earlier in patients with: 1) Difficult/refractory ascites, who are not the best candidates for NSBBs, 2) patients having bleed under NSBBs or showing no HVPG response (decrease in HVPG of at least 20% of baseline or to values equal or below 12 mmHg). Decompensated patients shall all be considered as potential candidates for liver transplantation. Treatment of portal hypertension has markedly improved in recent years. The present day therapy is based on accurate risk stratification according to disease stage.

Radiation burden of hepatocellularcarcinoma screening program inhepatitis B virus patients should werecommend magnetic resonanceimaging instead

Background: Current Hepatocellular Carcinoma (HCC) surveillance guidelines in high risk patients recommends characterization of a lesion detected on ultrasound with CT. Despite the superior diagnostic utility of MRI compared to CT, MRI is used as a problem solving tool after CT. Our aim was to assess the radiation burden of CT in a HCC screening program and assess the risk/benefit compared with MRI as the second step after ultrasound in a HCC screening program. Methods: We conducted a retrospective cohort study of chronic hepatitis B (CHB) patients in a tertiary centre screening program from 2004 to 2014. Imaging modality, number of scans and radiation dose were calculated. Findings: 382 CHB patients were engaged in an average 5 years of HCC surveillance. Those with 1-3 year follow up received a total dose per patient of 5 mSv, 4-6 years follow up received 11 mSv, >7 years follow up received 18 mSv of radiation. In the patients with over 7 years follow up the risk of radiation induced cancer was 1 in 850. Some patients had over 100 mSv resulting in radiation induced cancer risk of 1 in 146. 3 patients out of all 382 (0.79%) patients were diagnosed with HCC during surveillance. 99% of CTs were for false positive findings on ultrasound. Review of literature demonstrated better sensitivity and specificity for small HCC using MRI in addition to improved cost effectiveness of MRI in a screening program. Conclusion: A significant number of CHB patients received multiple CT scans for false positive findings on ultrasound. Utilizing MRI instead of CT to further characterize US lesions has no radiation exposure and therefore no associated radiation induced cancer risk. Utilizing MRI instead of CT to further characterize US lesions has greater sensitivity and no radiation exposure compared to the current surveillance model.

An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis.

Over one fourth of patients with cirrhosis experience physical harm for false-positive or indeterminate surveillance tests-more often related to ultrasound than AFP. Interventions are needed to reduce surveillance-related harm to increase the value of HCC screening programs in clinical practice. (Hepatology 2017;65:1196-1205).

Hepatology Clinical.

Hepatology Clinical.

PWE-040 Natural History of Cirrhosis in A Cohort of Patients Undergoing Structured Surveillance for Hepatocellular Carcinoma: Results from The Aberdeen Surveillance Cohort

Introduction Cirrhosis is the end-stage of chronic liver disease due to a variety of different aetiologies with the natural history of this condition characterised by a variable asymptomatic phase of compensation followed by a rapid ‘decompensated’ phase marked by ascites, jaundice, variceal bleeding, encephalopathy and development of hepatocellular carcinoma (HCC). The cornerstone of management for cirrhotic subjects includes 6 monthly surveillance to detect development of HCC. Aberdeen Royal Infirmary is one of the few centres in the UK to have a structured HCC screening program where patients are followed up in a nurse led clinic. The aim of this study was to determine rates of decompensation and development of HCC in a cohort of cirrhotic patients undergoing structured surveillance. Methods The electronic records of 231 patients who were initiated on surveillance between the years 2010–2015 were reviewed. Only patients who attended the clinic on at least 2 occasions were included. Those with a prior history of HCC or had an HCC discovered at their first ultrasound were excluded. Primary end-points studied were the time to develop ascites, variceal haemorrhage, hepatic encephalopathy, jaundice, HCC and mortality. Data analyses were conducted using SPSS version 23. Statistical methods used include Cox regression and Kaplan Meier survival analyses. Results The 231 patients included in the study were mostly male (61.5%) with alcohol being the predominant aetiological factor (33.3%). The mean age at entry into the cohort was 58.1± 11.2 years, with a mean MELD of 8.6±2.9 and UKELD of 48.2± 3.1. The median follow-up duration was 26 months (range 6–60) giving a total cohort follow up of 522 patient years. Most patients had compensated and Childs-Pugh A cirrhosis at the time of entry (62.8% and 60.2% respectively). Of the 145 patients with compensated cirrhosis at entry, 26 (19.9%) developed jaundice or other signs of decompensation during follow up. Mean time to first decompensation episode was 49 (95% CI; 45–52) months, giving a rate of 8.7 /100 patient years. During follow-up, 7 patients developed HCC giving a detection rate of 1.36/100 patient-years. Mean age at detection of HCC was 71.6 ± 7.3 years. Mortality rate in the entire cohort was 3.6/100 patient years. Conclusion The results from our surveillance cohort outline the natural history of a large group of cirrhotic patients systematically followed up in a structured nurse-led clinic. The rates of decompensation and HCC highlight the importance of pursuing the strategy of active surveillance. Disclosure of Interest None Declared

Utility and cost-effectiveness of screening for hepatocellular carcinoma in a resource-limited setting.

The utility, efficacy and cost-effectiveness of establishing a prospective screening program for hepatocellular carcinoma (HCC) in a low-cost setting as Egypt has not been previously studied. Eligible patients in this observational study were screened by ultrasound and alpha-fetoprotein (AFP) every 6months. A focal lesion on ultrasound or AFP >200ng/ml or significant increase in 6months indicated a recall. Characteristics of cases detected on screening were compared to patients diagnosed outside the screening program. Of 1,920 eligible patients, 1,286 patients participated and 102 patients (7.9%) developed HCC, with an annual incidence of 5.3%. Ninety-one (89.2%) were BCLC stage 0 or A and 11 (10.8%) stage D. Ultrasound detected a hepatic focal lesion in 99 patients, of which 74 were confirmed to be HCC, and AFP added another 28 HCC cases. The annual cost of detecting a treatable HCC case by ultrasound was 3,980 EGP (<euro> 400) and by both ultrasound and AFP 4,645 EGP (<euro> 500). Adding the cost of treatment, the cost/quality-adjusted life year (QALY) gained was 7,907 EGP (<euro> 800)/QALY for screening with ultrasound only, and 8,430 EGP (<euro> 850)/QALY for using both ultrasound and AFP, which in both cases is <50% of the per capita GDP and <20% of the accepted cost/QALY for Egypt. Screening for HCC is feasible and is highly cost-effective in a resource-limited setting. Adding AFP to ultrasound increased detection with a trivial addition to cost/QALY.

Causes and Stages of Hepatocellular Carcinoma at Patient Presentation at a Tertiary Medical Center in Western Saudi Arabia

Background: With 748,300 new cases diagnosed every year, hepatocellular carcinoma (HCC) is the 5th and the 7th most common cancer among males and females, respectively, and causes 7% of all cancer-related deaths. HCC represents more than 90% of primary liver cancers. Objective: The aim of the present study was to recognize the stages of HCC at presentation in patients who were diagnosed at King Abdul Aziz University Hospital (KAUH) and to identify the associated laboratory features of advance HCC. Materials and Methods: A retrospective analysis of 57 HCC patients admitted to KAUH between January 2008 and December 2012 was conducted. The diagnosis was established using ultrasound (U/S), computed tomography (CT) and/or magnetic resonance imaging (MRI), with or without a liver biopsy, as well as blood testing for alpha-fetoprotein. The following data were extracted from the medical records at KAUH: patient demographics (age, sex and nationality), laboratory results (CBC, LFT, PT, INR and alpha-fetoprotein), radiological results, biopsy results for those patients who underwent biopsy, outcomes (living, deceased or lost from the follow-up), and mortality and survival rates. Results: A total of 57 HCC patients were admitted during the study period, and 3 patients were excluded from the analysis. Of the remaining 54 patients, 44 (81.5%) were males and 10 (18.5%) were females. The mean age was 64.54 years (SD, 11.2 years; range, 31 - 86 years). The majority of patients were Saudis (19, 35.2%), non-Saudis (35, 64.8%), Egyptians (9, 16.6%) and Yemenis (7, 13%). The remaining 19 (35.2%) patients comprised other nationalities. Chronic hepatitis C virus was the most common cause for liver cirrhosis (35 patients, 64.8%). CT was the primary diagnostic method (37 patients 68.5%), while 9 (16.7%) cases were confirmed by adnominal MRI. Six patients (11.1%) were diagnosed with abdominal ultrasound examination and elevated alpha-fetoprotein levels. In 2 (3.7%) patients, HCC was confirmed by liver biopsy. The majority of the patients (37, 68.5%) had advanced disease. Only 21 (39%) patients underwent radio frequency appellation (RFA). The mean survival time from diagnosis to death was 5.9 months (SD, 5.7 months), and the longest survival time to death was 20 months. Conclusion: The majority of our patients presented at an advanced disease stage, and CHC was the most common underlying cause for liver cirrhosis in our cohort of HCC patients. The proper implementation of HCC screening programs for cirrhotic patients is expected to help detect the treatable stages of HCC in a timely manner.

Detection of Non-Liver Incidentalomas on Sonogram in an Urban Veteran Hepatocellular Carcinoma Screening Program

Purpose: Concern regarding the burden of unnecessary evaluations of non-liver findings on screening sonograms for hepatocellular carcinoma (HCC) is currently an area of debate. The purpose of this study was to evaluate the incidence of incidental findings on screening sonograms, as well as subsequent workup performed, in an electronic medical record (EMR)-based HCC screening program with automated clinical reminders in an urban VA Medical Center. Methods: A retrospective database of cirrhotic patients previously created by a search of the VA New York Harbor Health System electronic medical software (VistA) from 2008 until 2011 was utilized. Rates of radiological and AFP screening tests were calculated from February 8, 2012 through February 7, 2013. Rates of HCC detection and incidental findings leading to further work-up were calculated. Results: Three hundred eighty live, cirrhotic patients actively pursuing health care at the VA within the past 2 years were included in the study. Non-GI physicians were the primary directors of screening for 59.3% of the patients, and gastroenterologists were responsible for 40.7%. During the year of follow-up, 63.4% of patients had at least one imaging test or AFP level performed, 52.4% had at least one imaging study performed, 23.2% had two imaging studies performed, and 14.5% of patients had two imaging studies and two serum AFPs. There was a statistically significant difference in screening rates when comparing patients with ICD-9 codes for cirrhosis to those without. There were 210 screening sonograms performed. There were an additional 6 CTs and 1 MRI ordered for follow-up of non-liver pathology identified during these sonograms (2.9% and 0.5% respectively), including four complex renal cysts, two suspected portal venous thromboses, and one case of hydronephrosis. On these follow-up exams, three of these findings were confirmed; however, no non-liver malignancies were biopsy proven, due to concerns regarding the patient's suitability to tolerate invasive procedures given the severity their underlying liver disease. The follow-up MRI detected an HCC, which had not been previously visualized on the prior sonogram. Overall, 16 new cases of HCC were diagnosed, five of which were initially visualized on sonogram. Conclusion: An EMR based HCC surveillance program at a VA hospital provides an important avenue to detect HCC in high-risk patients that may otherwise be missed. Fear of surveillance sonograms leading to excessive expense and radiation exposure due to further work-up of incidental findings appears to be unfounded, as in our study rates; further studies were low, and many of the incidental findings were ultimately corroborated on follow-up imaging.

HIV and Hepatitis C Virus: Special Concerns for Patients With Cirrhosis

Since the advent of highly active antiretroviral therapy, liver disease has been a major cause of morbidity and mortality in patients with human immunodeficiency virus (HIV) infection. Chronic viral hepatitis accounts for >80% of liver-related mortality. Liver-related morbidity is due to acceleration of hepatitis C virus (HCV) disease, drug-induced hepatotoxicity, and, possibly, direct damage from HIV infection itself. As a consequence of this complex interaction, end-stage liver disease and hepatocellular carcinoma are frequent complications in patients with HIV infection. Infectious diseases physicians who care for HIV-infected patients with advanced HCV-related liver disease need to know how to assess for advanced fibrosis, to know when to refer a patient for endoscopic screening for varices, and to enroll patients in a screening program for hepatocellular carcinoma.

Hepatocellular carcinoma: cost-effectiveness of screening. A systematic review

Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide. HCC is a potential target for cancer surveillance (or screening) as it occurs in well-defined, at-risk populations. Curative therapy is possible only for small tumors and screening strategy has been recommended by the US, Italian, and other international liver societies and is practiced widely, but its benefits are not clearly established. The objective of this study was to review the available evidence with respect to the cost-effectiveness of key technologies in the prevention HCC. The literature search was conducted with the support of PubMed. Firstly we selected articles by reading the abstracts. Secondly, we read the articles and the revision was further restricted, with the following as inclusion criteria: (1) full economic evaluation of HCC screening programs; (2) comparison between HCC techniques; (3) outcome measures expressed in terms of quality adjusted life years (QALY); (4) full text availability. The initial review of the literature yielded 346 articles. Of those, 288 were excluded at the first stage. Of those excluded, 108 did not meet the target, 106 did not present the cost analysis, 33 did not analyze the treatment of the disease, and in 41 the abstract was not available. Of the 58 included in the first step, seven examined the cost-effectiveness of different HCC screening techniques, seven investigated the cost-effectiveness of HCC screening versus no screening, and one looked at the cost-effectiveness of timing for HCC surveillance and monitoring, while 43 were about HBV vaccination and screening. We included only the seven articles examining the cost-effectiveness of different HCC screening techniques. In general, incidence is the key parameter which determines the cost-effectiveness of HCC screening. Discrepancies in the results exist when determining the type of technology to be used. Ultrasound (US) alone or in association with alpha fetoprotein (AFP) technology is likely to be the most cost effective and the use of computed tomography (CT) gives controversial results.

Hospital- and Community-Based Screenings for Hepatocellular Carcinoma in Taiwan

In Taiwan, hepatocellular carcinoma (HCC) has been the leading cause of cancer incidence and mortality in recent decades. The majority of patients have hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. The HBV carrier rate and incidence of HCC in children have declined with the implementation of a hepatitis B vaccination program for newborns since 1984. A combination of α-fetoprotein and ultrasonography (US) has been used for surveillance in patients with chronic HBV and HCV infection in intervals of 3–6 and 6–12 months for cirrhosis and chronic liver disease, respectively. A secular survival improvement in HCC patients has been demonstrated. A reasonable screening protocol should include two stages. The first stage is identification of high-risk subjects and the second stage is US screening of high-risk subjects. Community-based HCC screening programs have been conducted for more than two decades in Taiwan. The commonly used first-stage markers are HBsAg and anti-HCV, while the platelet count should be a useful marker in HCV-endemic communities. The benefit of HCC screening was shown by a prolonged overall survival. However, this was limited to the early curable stage in elderly subjects. Prevention and control of HCC have multiple modalities. Identification of a high-risk group for active surveillance, effective antiviral treatment for chronic HBV and HCV infection, and early detection and prompt treatment of HCC should decrease the sequelae of HCC in Taiwan.