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Management of Hepatocellular Carcinoma

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  1. Who Should be Screened
  2. How Should Patients be Screened
  3. What Labs Should be Drawn for Suspicious Lesion
  4. Confirmation of CT/MRI for Suspicious Lesions

I. Who Should be Screened

Practice guidelines recommend that patients who are hepatitis B carriers (HBSAg positive) who have long-standing hepatitis B (hepatitis B acquired neonatallyor in childhood) even without cirrhosis should be screened, as well as other groups detailed in the table below.

Any carrier over 40 years with persistent or intermittent ALT elevation and/or high HBV DNA level >2,000 IU/mL.
(This is per AASLD Hep B guidelines 2009: Ref: 2009 Hep B AASLD Guidelines - Lok AS, McMahon BJ; Chronic hepatitis B: update 2009. Hepatology 2009;50:661-2)
           
            Groups in Whom HCC Screening and Surveillance is Recommended                                                                                                              
Hepatitis B carriers (HSBsAg positive)
Asian males > 40 y*
Asian females > 50 y*
All cirrhotic hepatic B carriers
Family history of HCC
Africans over age 20 y

Non Hepatitis B Cirrhosis
Hepatitis C
Cirrhosis
Alcoholic cirrhosis
Genetic hemochromatosis
Primary biliary cirrhosis
Possibly: α-1 antitrypsin deficiency
nonalcoholic steatohepatitis autoimmune hepatitis

                                                                                                        
*While there are insufficient data in non-Asian HBV carriers,
most providers apply these recommendations to all HBV carriers
regardless of race/ethnicity.

II. How Should Patients be Screened

Patients should be screened with an abdominal ultrasound every six months, with or without a serum AFP measurement. 

Positive findings on the ultrasound should be further evaluated by checking an AFP, and either a multiphase CT of the abdomen or a liver protocol MRI.  If either of these modalities shows an indeterminate lesion, the same modality should be repeated in three months, with a repeat of the AFP.

If an AFP is included in screening, a value >20 ng/mL should prompt further evaluation with either a multiphase CT of the abdomen, or a liver protocol MRI, and indeterminate lesions should be monitored as described above.

III. What Labs Should be Drawn for Suspicious Lesion

A liver panel, additional studies that will permit a MELD score to be calculated (Cr and INR), and a CBC with platelet count should be drawn.  If an AFP has not been previously done, it should be sent.

IV. Confirmation of CT/MRI for Suspicious Lesions

These patients should be referred to Dr. Maggie Shuhart in the Hepatology Clinic.  She will see these patients within two weeks of the referral, and will refer patients to the Liver Tumor Clinic at UWMC, where visits are also typically expedited (within 2-3 weeks). If the patient is potentially an operative candidate, Dr. Shuhart will copy the note to Dr. Grant O’Keefe so that Dr. O’Keefe can see the patient in the Liver Tumor Clinic and discuss the patient at the Liver Tumor Board.  If the recommendation is for surgical resection, the surgery will be done at Harborview, with the assistance of a designated anesthesiologist.  If the recommendation is for either percutaneous RFA or chemoembolization, the interventional radiologist will do this procedure at Harborview.  If the recommendation is for liver transplantation, or for laparoscopic RFA, these procedures will be done at UWMC by their transplant/liver surgeons.

If the patient has portal hypertension and/or decompensated cirrhosis and is clearly not a surgical candidate, Dr. Shuhart will refer the patient to the Liver Tumor Clinic at UWMC.  The physician who sees the patient would then present the patient at the Liver Tumor Board.  If the recommendation is for palliative chemotherapy, this could be done at Harborview.

 

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