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El-Serag HB, Jin Q, Tayob N, Salem E, Luster M, Alsarraj A, Khaderi S, Singal AG, Marrero JA, Asrani SK, Kanwal F. HES V2.0 outperforms GALAD for detection of HCC: A phase 3 biomarker study in the United States. Hepatology 2024:01515467-990000000-00920. [PMID: 38899967 DOI: 10.1097/hep.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND AIMS The original hepatocellular carcinoma early detection screening (HES) score, which combines alpha-fetoprotein (AFP) with age, alanine aminotransferase, and platelets, has better performance than AFP alone for early HCC detection. We have developed HES V2.0 by adding AFP-L3 and des-gamma-carboxy prothrombin to the score and compared its performance to GALAD and ASAP scores among patients with cirrhosis. APPROACH AND RESULTS We conducted a prospective-specimen collection, retrospective-blinded-evaluation phase 3 biomarker cohort study in patients with cirrhosis enrolled in imaging and AFP surveillance. True-positive rate (TPR)/sensitivity and false-positive rate for any or early HCC were calculated for GALAD, ASAP, and HES V2.0 scores within 6, 12, and 24 months of HCC diagnosis. We calculated the AUROC curve and estimated TPR based on an optimal threshold at a fixed false-positive rate of 10%. We analyzed 2331 patients, of whom 125 developed HCC (71% in the early stages). For any HCC, HES V2.0 had higher TPR than GALAD overall (+7.2%), at 6 months (+3.6%), at 12 months (+7.2%), and 24 months (+13.0%) before HCC diagnosis. HES V2.0 had higher TPR than ASAP for all time points (+5.9% to +12.0%). For early HCC, HES V2.0 had higher sensitivity/TPR than GALAD overall (+6.7%), at 12 months (+6.3%), and 24 months (+14.6%) but not at 6 months (+0.0%) and higher than ASAP for all time points (+13.4% to +18.0%). CONCLUSIONS In a prospective cohort study, HES V2.0 had a significantly higher performance for identifying new HCC, including early stage, than GALAD or ASAP.
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Affiliation(s)
- Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
- Section of Health Services Research, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Qingchun Jin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nabihah Tayob
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emad Salem
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Michelle Luster
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Abeer Alsarraj
- Section of Health Services Research, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Saira Khaderi
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Amit G Singal
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jorge A Marrero
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sumeet K Asrani
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
- Section of Health Services Research, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Koo E, Singal AG. Hepatocellular Carcinoma Surveillance: Evidence-Based Tailored Approach. Surg Oncol Clin N Am 2024; 33:13-28. [PMID: 37945138 DOI: 10.1016/j.soc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Hepatocellular carcinoma (HCC) surveillance is recommended by professional society guidelines given a consistent association with reduced HCC-related mortality. HCC surveillance should be performed using semiannual abdominal ultrasound and alpha-fetoprotein, although this combination has suboptimal sensitivity and can miss more than one-third of HCC at an early stage. There are promising emerging blood-based and imaging-based strategies, including abbreviated MRI and biomarker panels; however, these require further validation before routine use in clinical practice. HCC surveillance is underused in clinical practice due to patient-related and provider-related barriers, highlighting a need for interventions to improve surveillance utilization in clinical practice.
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Affiliation(s)
- Eden Koo
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, POB 1, Suite 420, Dallas, TX 75390-8887, USA.
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Roldan GA, Blomker J, Aby ES. Hepatocellular Carcinoma from a Hepatologist's Perspective. Semin Intervent Radiol 2023; 40:524-535. [PMID: 38274218 PMCID: PMC10807972 DOI: 10.1055/s-0043-1777846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, represents a growing health challenge worldwide. The incidence of HCC is rising, which, in turn, has led to a corresponding increase in the associated number of deaths. HCC will become the third leading cause of cancer-related deaths in the United States by 2030. HCC usually develops in the setting of chronic liver disease. Individuals at increased risk of HCC are recommended to undergo surveillance with ultrasound every 6 months along with serum α-fetoprotein testing. Computed tomography (CT) and magnetic resonance imaging (MRI) are considered alternatives based on specific patient factors. Lesions suspicious for HCC are recommended to undergo a diagnostic testing, which includes contrast-enhanced multiphase CT or MRI and liver biopsy when findings are indeterminate. The Barcelona Clinic Liver Cancer prognosis and treatment strategy is the most used assessment for patients with HCC ( Fig. 2 ). Curative therapies include resection, liver transplantation, and ablation. Locoregional therapies, such as transarterial chemoembolization and radioembolization, can be used for patients with intermediate-stage HCC. For patients with advanced-stage HCC, systemic therapy is often used. This review aims to provide an overview of HCC from a hepatologist's perspective, including epidemiology, screening, surveillance, diagnosis, and management.
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Affiliation(s)
- Giovanni A. Roldan
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, Minnesota
| | - Jacquelin Blomker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Elizabeth S. Aby
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, Minnesota
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Rich NE, Chernyak V. Standardizing liver imaging reporting and interpretation: LI-RADS and beyond. Hepatol Commun 2023; 7:e00186. [PMID: 37314738 PMCID: PMC10270536 DOI: 10.1097/hc9.0000000000000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/02/2023] [Indexed: 06/15/2023] Open
Abstract
Imaging plays a crucial role in diagnosis and post-treatment monitoring of primary liver cancers. Clear, consistent, and actionable communication of imaging results is crucial to avoid miscommunication and potential detrimental impact on patient care. In this review, we discuss the importance, advantages, and potential impact of universal adoption of standardized terminology and interpretive criteria for liver imaging, from the point of view of radiologists and clinicians.
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Affiliation(s)
- Nicole E. Rich
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern, Dallas, Texas, USA
| | - Victoria Chernyak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
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McMahon B, Cohen C, Brown Jr RS, El-Serag H, Ioannou GN, Lok AS, Roberts LR, Singal AG, Block T. Opportunities to address gaps in early detection and improve outcomes of liver cancer. JNCI Cancer Spectr 2023; 7:pkad034. [PMID: 37144952 PMCID: PMC10212536 DOI: 10.1093/jncics/pkad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023] Open
Abstract
Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.
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Affiliation(s)
- Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | | | - Robert S Brown Jr
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George N Ioannou
- Department of Medicine, Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Anna S Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lewis R Roberts
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amit G Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, TX, USA
| | - Timothy Block
- Baruch S. Blumberg Institute and Hepatitis B Foundation, Doylestown, PA, USA
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Curran C, Priest M, Datta S, Forrest EH, Stanley AJ, Barclay ST. Hepatocellular Carcinoma Risk Scores Predict Patients Under Surveillance at Low Risk of Benefit and High Risk of Harm. Dig Dis Sci 2023; 68:770-777. [PMID: 36376575 DOI: 10.1007/s10620-022-07731-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/11/2022] [Indexed: 02/08/2023]
Abstract
AIMS Surveillance for hepatocellular carcinoma (HCC) is recommended for patients with cirrhosis. Multiple risk scores aim to stratify HCC risk, potentially allowing individualized surveillance strategies. We sought to validate four risk scores and quantify the consequences of surveillance via the calculation of numbers needed to benefit (NNB) and harm (NNH) according to classification by risk score strata. METHODS Data were collected on 482 patients with cirrhosis during 2013-2014, with follow-up until 31/12/2019. Risk scores (aMAP, Toronto risk index, ADRESS HCC, HCC risk score) were derived from index clinic results. The area under the receiving operating characteristic curve (AUC) was calculated for each. Additionally, per-risk strata, NNB was calculated as total surveillance ultrasounds per surveillance diagnosed early HCC (stage 0/A) and NNH as total ultrasounds performed per false positive (abnormal surveillance with normal follow-up imaging). RESULTS 22 (4.6%) patients developed HCC. 77% (17/22) were diagnosed through surveillance, of which 13/17 (76%) were early stage. There were 88 false positives and no false negatives (normal surveillance result however subsequent HCC detection). Overall NNB and NNH were 241 and 36, respectively. No score was significantly superior using AUC. Patients classified as low risk demonstrated no surveillance benefit (AMAP, THRI) or had a high NNB of > 300/900 (ADRESS HCC, HCC risk score), with low NNH (24-38). CONCLUSION Given the lack of benefit and increased harm through false positives in low-risk groups, a risk-based surveillance strategy may have the potential to reduce patient harm and increase benefit from HCC surveillance. CLINICAL TRIALS REGISTRATION This was not a clinical trial and the study was not pre-registered.
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Affiliation(s)
- Chris Curran
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK.
- , Flat 2/2, 53 Dalnair Street, Glasgow, G3 8SQ, UK.
| | - Matthew Priest
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK
| | - Shouren Datta
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G12 8QQ, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G12 8QQ, UK
| | - Stephen T Barclay
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
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7
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Singal AG, Ghaziani TT, Mehta N, Zhou K, Grinspan LT, Benhammou JN, Moon AM, Yang JD, Salgia R, Pillai A, Zheng E, Rich NE, Gopal P, Jalal P, Verna E, Yekkaluri S, Phen S, Melendez-Torres J, Alshuwaykh O, Choi H, Junus K, Grady J, Song M, Leven EA, Yum J, Gowda V, Alsudaney M, Hernandez P, Desai N, Parikh ND. Recall patterns and risk of primary liver cancer for subcentimeter ultrasound liver observations: a multicenter study. Hepatol Commun 2023; 7:e0073. [PMID: 36881615 PMCID: PMC9995094 DOI: 10.1097/hc9.0000000000000073] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Patients with cirrhosis and subcentimeter lesions on liver ultrasound are recommended to undergo short-interval follow-up ultrasound because of the presumed low risk of primary liver cancer (PLC). AIMS The aim of this study is to characterize recall patterns and risk of PLC in patients with subcentimeter liver lesions on ultrasound. METHODS We conducted a multicenter retrospective cohort study among patients with cirrhosis or chronic hepatitis B infection who had subcentimeter ultrasound lesions between January 2017 and December 2019. We excluded patients with a history of PLC or concomitant lesions ≥1 cm in diameter. We used Kaplan Meier and multivariable Cox regression analyses to characterize time-to-PLC and factors associated with PLC, respectively. RESULTS Of 746 eligible patients, most (66.0%) had a single observation, and the median diameter was 0.7 cm (interquartile range: 0.5-0.8 cm). Recall strategies varied, with only 27.8% of patients undergoing guideline-concordant ultrasound within 3-6 months. Over a median follow-up of 26 months, 42 patients developed PLC (39 HCC and 3 cholangiocarcinoma), yielding an incidence of 25.7 cases (95% CI, 6.2-47.0) per 1000 person-years, with 3.9% and 6.7% developing PLC at 2 and 3 years, respectively. Factors associated with time-to-PLC were baseline alpha-fetoprotein >10 ng/mL (HR: 4.01, 95% CI, 1.85-8.71), platelet count ≤150 (HR: 4.90, 95% CI, 1.95-12.28), and Child-Pugh B cirrhosis (vs. Child-Pugh A: HR: 2.54, 95% CI, 1.27-5.08). CONCLUSIONS Recall patterns for patients with subcentimeter liver lesions on ultrasound varied widely. The low risk of PLC in these patients supports short-interval ultrasound in 3-6 months, although diagnostic CT/MRI may be warranted for high-risk subgroups such as those with elevated alpha-fetoprotein levels.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - T. Tara Ghaziani
- Department of Internal Medicine, Stanford University, Palo Alto, California, USA
| | - Neil Mehta
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kali Zhou
- Department of Internal Medicine, University of Southern California, Los Angeles, California, USA
| | - Lauren T. Grinspan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jihane N. Benhammou
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Andrew M. Moon
- Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ju Dong Yang
- Department of Internal Medicine, Cedar Sinai Medical Center, Los Angeles, California, USA
| | - Reena Salgia
- Department of Internal Medicine, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Elizabeth Zheng
- Department of Internal Medicine, Columbia University, New York, New York, USA
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Prasun Jalal
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Verna
- Department of Internal Medicine, Columbia University, New York, New York, USA
| | - Sruthi Yekkaluri
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel Phen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Omar Alshuwaykh
- Department of Internal Medicine, Stanford University, Palo Alto, California, USA
| | - Hailey Choi
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kevin Junus
- Department of Internal Medicine, University of Southern California, Los Angeles, California, USA
| | - John Grady
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Song
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily A. Leven
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jung Yum
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Vrushab Gowda
- Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Manaf Alsudaney
- Department of Internal Medicine, Cedar Sinai Medical Center, Los Angeles, California, USA
| | - Perla Hernandez
- Department of Internal Medicine, Cedar Sinai Medical Center, Los Angeles, California, USA
| | - Nirmal Desai
- Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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8
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Tayob N, Kanwal F, Alsarraj A, Hernaez R, El-Serag HB. The Performance of AFP, AFP-3, DCP as Biomarkers for Detection of Hepatocellular Carcinoma (HCC): A Phase 3 Biomarker Study in the United States. Clin Gastroenterol Hepatol 2023; 21:415-423.e4. [PMID: 35124267 PMCID: PMC9346092 DOI: 10.1016/j.cgh.2022.01.047] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/05/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS α-fetoprotein (AFP), AFP Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3), and des-gamma-carboxy prothrombin (DCP) in combination or in GALAD (Gender, Age, AFP-L3, AFP, and DCP) were tested for hepatocellular carcinoma (HCC) surveillance in retrospective cohort and case-control studies. However, there is a paucity of prospective data and no phase III biomarker studies from North American populations. METHODS We conducted a prospective specimen collection, retrospective blinded evaluation (PRoBE) cohort study in patients with cirrhosis enrolled in a 6-monthly surveillance with liver imaging and AFP. Blood samples were prospectively collected every 6 months and analyzed in a retrospective blinded fashion. True positive rate (TPR) and false positive rate (FPR) for any or early HCC were calculated within 6, 12, and 24 months of HCC diagnosis based on published thresholds for biomarkers individually, in combination and in GALAD and Hepatocellular Carcinoma Early Detection Screening (HES) scores. We calculated the area under the receiver operating curve and estimated TPR based on an optimal threshold at a fixed FPR of 10%. RESULTS The analysis was conducted in a cohort of 534 patients; 50 developed HCC (68% early) and 484 controls with negative imaging. GALAD had the highest TPR (63.6%, 73.8%, and 71.4% for all HCC, and 53.8%, 63.3%, and 61.8 % for early HCC within 6, 12, and 24 months, respectively) but an FPR of 21.5% to 22.9%. However, there were no differences in the area under the receiver operating curve among GALAD, HES, AFP-L3, or DCP. At a fixed 10% FPR, TPR for GALAD dropped (42.4%, 45.2%, and 46.9%) and was not different from HES (36.4%, 40.5%, and 40.8%) or AFP-L3 alone (39.4%, 45.2%, and 44.9%). CONCLUSIONS In a prospective cohort phase III biomarker study, GALAD was associated with a considerable improvement in sensitivity for HCC detection but an increase in false-positive results. GALAD performance was modest and not different from AFP-L3 alone or HES.
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Affiliation(s)
- Nabihah Tayob
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Service Center of Excellence, Houston, Texas; Section of Health Services Research, Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Abeer Alsarraj
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Service Center of Excellence, Houston, Texas; Section of Health Services Research, Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Service Center of Excellence, Houston, Texas; Section of Health Services Research, Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Service Center of Excellence, Houston, Texas; Section of Health Services Research, Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas.
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9
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Lee J, Park SB, Byun S, Kim HI. Impact of ultrasonographic blind spots for early-stage hepatocellular carcinoma during surveillance. PLoS One 2022; 17:e0274747. [PMID: 36112645 PMCID: PMC9481035 DOI: 10.1371/journal.pone.0274747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Abdominal ultrasonography (US) is the backbone of hepatocellular carcinoma (HCC) surveillance. Although previous studies have evaluated clinical factors related to surveillance failure, none have focused specifically on US blind spots.
Methods
This study included 1,289 patients who underwent 6 months intervals surveillance using US and serum alpha-fetoprotein (AFP) and were eventually diagnosed with single-nodular HCC. Patients were divided into US-detected group (n = 1,062) and US-missed group (HCC detected only by AFP ≥ 20ng/mL; n = 227). Blind spots consisted of four locations: hepatic dome, caudate lobe or around the inferior vena cava, <1 cm beneath the ribs, and the surface of the left lateral segment. Both groups were compared by HCC location, proportional distribution, treatment method, and overall survival.
Results
A higher proportion of HCCs were located within blind spots in the US-missed group than in the US-detected group (64.3% vs. 44.6%, P < 0.001). HCC ≥ 2 cm detected in blind spots was higher than in non-blind areas (60.3% vs. 47.1%, P = 0.001). Blind spot HCCs were more treated with surgery, whereas those located in a non-blind area were more treated with local ablation. Patients with an HCC located within a blind spot in the US-detected group had better overall survival than the same in the US-missed group (P = 0.008).
Conclusions
Using the current surveillance test, blind spots affected the initially detected HCC tumor size, applicability of the treatment modality, and overall survival. Physicians should pay attention to US blind spots when performing US-based HCC surveillance.
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Affiliation(s)
- Junghwan Lee
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Su Bee Park
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Soyoung Byun
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Ha Il Kim
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
- * E-mail:
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10
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Rich NE, Singal AG. Overdiagnosis of hepatocellular carcinoma: Prevented by guidelines? Hepatology 2022; 75:740-753. [PMID: 34923659 PMCID: PMC8844206 DOI: 10.1002/hep.32284] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/27/2021] [Accepted: 12/04/2021] [Indexed: 12/13/2022]
Abstract
Overdiagnosis refers to detection of disease that would not otherwise become clinically apparent during a patient's lifetime. Overdiagnosis is common and has been reported for several cancer types, although there are few studies describing its prevalence in HCC surveillance programs. Overdiagnosis can have serious negative consequences including overtreatment and associated complications, financial toxicity, and psychological harms related to being labeled with a cancer diagnosis. Overdiagnosis can occur for several different reasons including inaccurate diagnostic criteria, detection of premalignant or very early malignant lesions, detection of indolent tumors, and competing risks of mortality. The risk of overdiagnosis is partly mitigated, albeit not eliminated, by several guideline recommendations, including definitions for the at-risk population in whom surveillance should be performed, surveillance modalities, surveillance interval, recall procedures, and HCC diagnostic criteria. Continued research is needed to further characterize the burden and trends of overdiagnosis as well as identify strategies to reduce overdiagnosis in the future.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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Park HJ, Seo N, Kim SY. Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance. Korean J Radiol 2022; 23:598-614. [PMID: 35434979 PMCID: PMC9174497 DOI: 10.3348/kjr.2021.0896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 11/15/2022] Open
Abstract
While ultrasound (US) is considered an important tool for hepatocellular carcinoma (HCC) surveillance, it has limited sensitivity for detecting early-stage HCC. Abbreviated MRI (AMRI) has recently gained popularity owing to better sensitivity in its detection of early-stage HCC than US, while also minimizing the time and cost in comparison to complete contrast-enhanced MRI, as AMRI includes only a few essential sequences tailored for detecting HCC. Currently, three AMRI protocols exist, namely gadoxetic acid-enhanced hepatobiliary-phase AMRI, dynamic contrast-enhanced AMRI, and non-enhanced AMRI. In this study, we discussed the rationale and technical details of AMRI techniques for achieving optimal surveillance performance. The strengths, weaknesses, and current issues of each AMRI protocol were also elucidated. Moreover, we scrutinized previously performed AMRI studies regarding clinical and technical factors. Reporting and recall strategies were discussed while considering the differences in AMRI protocols. A risk-stratified approach for the target population should be taken to maximize the benefits of AMRI and the cost-effectiveness should be considered. In the era of multiple HCC surveillance tools, patients need to be fully informed about their choices for better adherence to a surveillance program.
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Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Nieun Seo
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Nathani P, Gopal P, Rich NE, Yopp A, Yokoo T, John B, Marrero JA, Parikh ND, Singal AG. Hepatocellular carcinoma tumour volume doubling time: a systematic review and meta-analysis. Gut 2021; 70:401-407. [PMID: 32398224 PMCID: PMC7657990 DOI: 10.1136/gutjnl-2020-321040] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tumour growth patterns have important implications for surveillance intervals, prognostication and treatment decisions but have not been well described for hepatocellular carcinoma (HCC). The aim of our study was to characterise HCC doubling time and identify correlates for indolent and rapid growth patterns. METHODS We performed a systematic literature review of Medline and EMBASE databases from inception to December 2019 and national meeting abstracts from 2010 to 2018. We identified studies reporting HCC tumour growth or tumour volume doubling time (TVDT), without intervening treatment, and abstracted data to calculate TVDT and correlates of growth patterns (rapid defined as TVDT <3 months and indolent as TVDT >9 months). Pooled TVDT was calculated using a random-effects model. RESULTS We identified 20 studies, including 1374 HCC lesions in 1334 patients. The pooled TVDT was 4.6 months (95% CI 3.9 to 5.3 months I2=94%), with 35% classified as rapid, 27.4% intermediate and 37.6% indolent growth. In subgroup analysis, studies from Asia reported shorter TVDT than studies elsewhere (4.1 vs 5.8 months). The most consistent correlates of rapid tumour growth included hepatitis B aetiology, smaller tumour size (continuous), alpha fetoprotein doubling time and poor tumour differentiation. Studies were limited by small sample sizes, measurement bias and selection bias. CONCLUSION TVDT of HCC is approximately 4-5 months; however, there is heterogeneity in tumour growth patterns, including more aggressive patterns in Asian hepatitis B-predominant populations. Identifying correlates of tumour growth patterns is important to better individualise HCC prognostication and treatment decisions.
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Affiliation(s)
- Piyush Nathani
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas TX
| | - Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
| | - Adam Yopp
- Department of Surgery, UT Southwestern Medical Center, Dallas TX
| | - Takeshi Yokoo
- Department of Radiology, UT Southwestern Medical Center, Dallas TX
| | - Binu John
- Department of Internal Medicine, University of Miami, Miami FL
| | - Jorge A Marrero
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor MI
| | - Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
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