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

Table 1. Recommendations for cirrhotic adults
Time interval
Continent Guidelines Modality Exceptions
(months)
North America AASLD-2017 US with or without AFP 6 Child-Pugh stage C unless awaiting
liver transplantation
CASL-2014 US 6 Same as AASLD
Asia APASL-2017 US and AFP 6 Severe liver diseases/other co-
morbidities (ineligible for curative
therapy)
CHINESE-2017 US and AFP 6 NS
JSH-2015* Extremely-high risk patients: (HBV/HCV
cirrhosis)
- US and three Tm markers (AFP/PIVKA-II/ 3-4
AFP-L3)
- CT or MRI (optional) 6-12 NS
High risk patients: (cirrhosis of another
etiology)
US and three tumor markers (AFP/PIVKA- 6
II, AFP-L3)
JSH-LCSG-2014 Recommend EOB-MRI instead of CT or MR Same as JSH NS
Europe EASL-2018** US 6 Same as AASLD
SPANISH-2016 (AEEH, US 6 NS
SEOM, SERAM,
SERVEI and SETH)
SEOM-2015 US 6 Same as AASLD
ESMO-ESDO-2012 US 6 NS
*3rd JSH-HCC guidelines, 2013 update; **in press. HBV: hepatitis B virus; HCV: hepatitis C virus; AFP: alpha-fetoprotein; NS: not specified;
US: ultrasound; PIVKA-II: proteins induced by vitamin K absence; CT: computed tomography; MRI: magnetic resonance imaging; EOP-
MRI: gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOBDTPA)-enhanced magnetic resonance imaging

Selected guidelines from Spain (consensus document from The Spanish Association for the Study of the
Liver (AEEH), Spanish Society of Medical Oncology (SEOM), The Spanish Society of Medical Radiology
(SERAM), The Spanish Society of Vascular and International Radiology (SERVEI), The Spanish Society of
Liver Transplantation (SETH)-2016 and European Society for Medical Oncology (ESMO)/European Society
of Digestive Oncology (ESDO)-2012 recommend every 6 months US examination to patients with or without
cirrhosis, and specify the theory behind this recommendation [35,36] . However; SEOM-2015 guideline excluded
[37]
Child C patients from screening (unless awaiting for liver transplantation) like EASL .

This section was summarized in Table 1.

Recommendations for non-cirrhotic adults
A small proportion of patients with HCC is diagnosed in the non-cirrhotic liver (NCL) with the risk of be-
ing less than 1% annually in patients with chronic hepatitis without significant fibrosis, in contrast to 3%-7%
annually when the patient develops cirrhosis [26,35,38] . HCC in NCL ranges widely from 7% to 54% according
[39]
to the etiology of the liver disease and varies of the geographic areas . While viral hepatitis is pre-screened
with decrease in the east as known, metabolic causes predominate in the west.

As compared to cirrhotic HCC, it has lower prevalence of the three main risk factors (hepatitis B and C virus
infections and alcohol abuse), with an increased prevalence of other etiological factors, such as non-alcoholic
fatty liver diseases, obesity and type 2 diabetes mellitus, exposure to genotoxic substances-aflatoxin, tobacco,
sex hormones, inherited diseases and genetic mutations [2,3,11,26,30,36,38-40] .

In contrast to cirrhotic, NCL-HCC are more suitable for surgical treatments even in more advanced tumour
stage at the time of diagnosis, since it is generally detected at a symptomatic stage due to unsettled scheduled
screening program in these groups [2,38,39] .