SAN FRANCISCO — Patients with underlying viral hepatitis B are likely to present with hepatocellular carcinoma at a younger age and in better overall health than are patients with hepatitis C, but their tumors tend to be larger and more aggressive.
Important distinctions in the characteristics of liver cancer patients emerged when Dr. Spiros P. Hiotis of the department of surgery at New York University and associates examined the records of 127 patients diagnosed at the university medical center during a 12-year period.
Dr. Hiotis presented the results at a symposium sponsored by the American Society of Clinical Oncology.
Of 89 patients with underlying hepatitis B, 22 presented with hepatocellular cancer before age 40. None of the 38 patients with hepatitis C presented with cancer at such an early age. Among the 119 patients whose cirrhosis status was known, all 35 hepatitis C patients (100%) had cirrhosis at the time of diagnosis, compared with 50 of 84 hepatitis B patients (60%). Serum α-fetoprotein was more than 2,000 ng/mL in nearly half of the hepatitis B patients and in 5 of 35 hepatitis C patients.
Two-thirds of hepatitis B patients had tumors larger than 5 cm at their greatest diameter, compared with 14 of 37 hepatitis C patients (38%). Tumor size determines if a patient meets the Milan criteria, which are used to decide if a patient is a good candidate for a liver transplant. These criteria include having no solitary tumor more than 5 cm in diameter, or, in patients with multiple tumors, having no more than three tumors, none of which is larger than 3 cm.
On one hand, fewer hepatitis B patients met the Milan criteria than did hepatitis C patients (14% vs. 34%). On the other hand, nearly all hepatitis C patients had at least one comorbidity, compared with less than one-fourth of hepatitis B patients.
The typical presentation of advanced disease in hepatitis B patients heightens the need for more aggressive screening, Dr. Hiotis said at the meeting, which was also sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiology and Oncology, and the Society of Surgical Oncology.
He referred to new screening guidelines from the American Association for the Study of Liver Diseases, which were published by Dr. Jordi Bruix of the University of Barcelona and Dr. Morris Sherman of the University of Toronto. (See box.)
Screening for Hepatocellular Carcinoma
Patients at high risk for developing hepatocellular carcinoma (HCC) should be entered into surveillance programs.
The following groups of patients should be screened:
▸ Certain hepatitis B carriers. These carriers will also have either cirrhosis or a family history of HCC, or are Asian males 40 years and older or Asian females 50 years and older.
▸ Other noncirrhotic hepatitis B carriers. The risk of HCC depends on the severity of the underlying liver disease and the current and past hepatic inflammatory activity. Patients with high DNA concentrations of hepatitis B and those with hepatitic inflammatory activity remain at risk for HCC.
▸ Certain patients with nonhepatitis B cirrhosis. Those who should be screened will also have hepatitis C, alcoholic cirrhosis, genetic hemochromatosis, or primary biliary cirrhosis.
▸ Patients with α1-antitrypsin deficiency, nonalcoholic steatohepatitis, and autoimmune hepatitis. These patients are at elevated risk for HCC, but not enough data exist to justify a recommendation for surveillance.
▸ Patients on the transplant waiting list. The development of HCC advances patients on the waiting list. In addition, failure to screen for HCC could mean that the disease progresses beyond listing criteria.
Recommended screening methods and schedules are as follows:
▸ Surveillance for HCC should be performed using ultrasound. AFP levels alone should not be used for screening unless ultrasound is unavailable, because AFP as a screening tool has a high false-positive rate and is much less sensitive than is well-performed ultrasound.
▸ Patients should be screened at 6− to 12-month intervals. Dr. Sherman recommends 6-month intervals. The surveillance interval does not need to be shortened for patients at higher risk of HCC.
Source: American Association for the Study of Liver Diseases Practice Guidelines: Management of Hepatocellular Carcinoma (Hepatology 2005;42:1208–36).