Page 488 - Read Online

Page 2 of 10 Yilmaz et al. Hepatoma Res 2018;4:46 I http://dx.doi.org/10.20517/2394-5079.2018.49

covery of alpha-fetoprotein (AFP) in HCC by the Russian scientist, screening HCC is widely recommended
[7,8]
for patients who are under risk for more than 40 years .

Over the time, the underlying etiologies, incidence, and HCC outcomes are changed according to the coun-
tries. While the incidence of HCC is rising in the west, attributed to the past HCV epidemia (baby-boomers)
and trends of metabolic disorders, it is decreasing in the East [9-11] . In despite of receiving regular HCC sur-
veillance, nearly 40% of patients still died in 5 years [12,13] . These changes are accommodating the new research
on and development of new guidelines for HCC management.

[14]
Guidelines mean “rules or instructions about the best way to do something” . They assist health care pro-
viders in the decision-making process according to evidence-based data, with guiding clinical practice in
[15]
circumstances where all possible resources and therapies are available . International scientific societies
have issued recommendations for establishing a common standardized approach in the management of
HCC.

Although these organizations are international, the recommendation-guidelines mostly directed to their
own cases. It is essential for gastroenterologist to be familiar with these organizations and their proposed
guidelines. As recommended in the guidelines, it is more appropriate to follow the guidelines but to adapt
on the patient basis. In this article, you will find a summary of the current screening guidelines for HCC of
three different continents.

CURRENT GUIDELINES
The success of the screening is influenced by the availability of effective treatment with the identification of
the target population and the selection of appropriate screening tests. The cost-effectiveness should also be
taken into consideration. In this review, the target group is divided into cirrhotic and non-cirrhotic patient
group.

Screening recommendations for cirrhotic adults
Cirrhosis is the strongest predisposing factor for HCC formation. Nearly 85%-95% of HCC is developed on
the cirrhotic liver [16-18] . These patients have a lifetime risk of developing HCC by 30% with leading cause of
liver related death in compensated cirrhosis [2,19,20] . The risk varies with the underlying condition; the high-
est 5-year cumulative risks are reported in HCV cirrhosis (17% in the west, 30% in Japan), hemochromatosis
(21%), HBV cirrhosis (10% in high endemic areas, 15% in the west), alcoholic cirrhosis (8%-12%), and biliary
cirrhosis (4%). Also, the presence of co-infection (HCV/HBV or HBV/HCV) or alcohol abuse increases the
[21]
risk by at least 200% . In addition to underlying etiology, other patient-related factors influence the risk of
9
HCC. In general, low platelet count of less than 100 × 10 /L, presence of esophageal varices in addition to
older age and male gender correlate with development of HCC among patients with cirrhosis [22-24] . However,
current guidelines do not incorporate with the risk of stratification models (RSM) for cirrhotic that may be
useful in the future for excluding some patients from screening.

Screening modalities consist of the periodic application of diagnostic tools with cost effectiveness which is
generally taken into consideration based on the gain of life expectancy and guidelines indicating that an
incidence of ≥ 1.5% year would warrant surveillance of HCC in cirrhosis [25,26] . Guidelines including the last
updated screening section with data-supported recommendations were selected for the review; recommen-
dations are as follows.

From North America
The American Association for the Study of Liver Diseases (AASLD-2017): routine screening is recommended
for HCC in adults with cirrhosis. The initial screening is performed with ultrasound (US) with or without