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Yilmaz et al. Hepatoma Res 2018;4:46 I http://dx.doi.org/10.20517/2394-5079.2018.49 Page 3 of 10

alpha- fetoprotein (AFP) every 6 months. AASLD does not suggest performing surveillance of patients with
Child-Pugh class C cirrhosis unless they are on the transplant waiting list, given the low anticipated survival
for these patients. They pointed out some technical remarks regarding screening modalities (US alone or
plus AFP), interval (4-8 months) and modification in screening strategy based on etiology of liver diseases or
[26]
risk stratification models . In the previous guideline (AASLD-2011), ultrasound scanning alone was recom-
[27]
mended .
The Canadian Association for the Study of the Liver (CASL 2014): this report is from consensus confer-
ence updated of the existing consensus - CASL 2011. The current statements for cirrhosis are similar with
AASLD except they recommend US alone in every 6 months. The committee does not recommend AFP ei-
ther alone or combined with US due to less sensitivity of AFP (67% sensitivity). They also do not recommend
other biomarkers (AFP) lectin fraction (AFP-L3) and des-gamma-carboxy prothrombin (DCP) due to less
validation [28,29] .

From Asia
The Asian Pacific Association for the Study of the Liver (APASL-2017): their recommendation is using com-
bination of US and serum AFP measurement in every 6 months. The cut-off value of AFP should be set at
200 ng/mL for the cirrhotics. They do not suggest screening to cirrhotics not ineligible for treatments due to
[30]
severe liver disease or other comorbidities which is similar with North America groups .
CHINESE-2017: updated from 2011. Their recommendation for cirrhosis is identical with APASL. The only
[31]
difference is that there is no excluding criteria for severe liver diseases .
The Japan Society of Hepatology (JSH-2015): updated from 2013. Modalities and screening intervals mostly
differ from the other countries and Asia. Besides AFP, a protein induced by vitamin K absence or antagonist-
II (PIVKA-II) and AFP-L3 measurements are also recommended by the JSH to increase sensitivity. The
JSH evidence-based clinical practice guidelines for HCC divided patients into an extremely high-risk group
(hepatitis B or C cirrhosis) and a high-risk group (patients with chronic hepatitis B, chronic hepatitis C, or
non-viral cirrhosis). Their recommendations for extremely high-risk patients are periodic imaging screening
by US every 3-4 months along with three tumour markers (AFP, PIVKA-II and AFP-L3). Additionally, they
recommend multi-detector computed tomography (MDCT) or MRI examinations in every 6-12 months as
the first step of screening (optional) method even there is no evidence of tumour on US, because of poor
visualization capability [32,33] . The recommendations for the high-risk group cirrhosis are more cost effective
and included periodic screening by US along with three tumour markers, every 6 months. MDCT and MRI
are not recommended for high-risk patients [32,33] .

Japan Society of Hepatology- Liver Cancer Study Group (JSH-LCSG 2014): consensus-based guidelines.
The JSH-LCSG practice guidelines use identical definitions for the extremely high-risk group and high-risk
group. However, JSH-LCSG recommends EOB-MRI (gadolinium-ethoxybenzyl-diethylenetriamine penta-
acetic acid-enhanced magnetic resonance imaging) instead of dynamic MDCT which has higher detection
sensitivity than CT, as the first-line modality for surveillance every 6-12 months, even if no tumour is de-
tected on US [33,34] .

From Europe
The European Association for the Study of the Liver (EASL-2018): the guideline is in press, their screen-
ing recommendations for Child-Pugh stage A and B patients are used by abdominal ultrasound every six
months. AFP or other tumour biomarkers (AFP, AFP-L3 and DCP) are not recommended due to less ac-
curacy for early detection of HCC. Stage C cirrhosis is excluded from screening except for transplant candi-
[2]
dates .