ABSTRACT
BACKGROUND: The aetiological factors of hepatocellular carcinoma may vary over time. AIMS: The study assessed the potential impact of the aetiological factors on the effectiveness of surveillance in real-world patients. METHODS: Multicentre, cross-sectional study enrolling consecutive hepatocellular carcinoma cases during a six month period. RESULTS: 1733 cases (1311 prevalent and 422 incident) were recruited (mean age 68.6 years; 46.1% cases over 70 years; 73.9% males; 95.3% with cirrhosis); 63.0% were hepatitis C virus positive and 23.7% were virus negative. Amongst incident HCCs, 34.5% were single ≤3cm and 54.4% met the Milan criteria; 61.6% were diagnosed during surveillance; virus negative patients showed the lowest rate of surveillance (51.0%). Surveillance was an independent predictor of detecting single HCCs ≤2cm (O.R.=5.4; 95% C.I.=2.4-12.4) or HCCs meeting the Milan criteria (O.R.=3.1; 95% C.I.=1.9-5.2). Compared with an earlier Italian survey, there was a higher proportion of elderly subjects (P<0.01), Child-Pugh class A cases (P<0.01), of virus-negative patients (P<0.01) and with single tumours ≤3cm (P<0.01) and a lower prevalence of hepatitis C virus positive individuals (P<0.01). CONCLUSION: HCC is characterised by a growing prevalence of elderly patients and cases unrelated to hepatitis virus infections. The application of surveillance must be implemented, particularly amongst non-viral patients.
Subject(s)
Carcinoma, Hepatocellular/etiology , Liver Cirrhosis/complications , Liver Neoplasms/etiology , Population Surveillance , Age Distribution , Aged , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/epidemiology , Cross-Sectional Studies , Female , Hepatitis B Surface Antigens/blood , Hepatitis C Antibodies/blood , Humans , Incidence , Italy/epidemiology , Liver Cirrhosis/diagnostic imaging , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/epidemiology , Logistic Models , Male , Middle Aged , Multivariate Analysis , Prevalence , UltrasonographyABSTRACT
PURPOSE: Recommendations of the Barcelona Clinic Liver Cancer (BCLC) therapeutic flow-chart, endorsed by the American Association for the Study of Liver Diseases (AASLD), are the most applied worldwide. Over recent years, however, several referral centers have questioned some of the BCLC treatment allocations and proposed alternative strategies. The present study plans to review and discuss these suggestions, with the aim to evaluate whether there are well-grounded reasons to reconsider some of the BCLC/AASLD recommendations. METHODS: A search was made into the MEDLINE database, focusing on randomized controlled trials, meta-analysis reviews, case-control studies, concordant clinical trials on novel therapies and studies reporting the opinion of respected experts. Their results and conclusions were compared stage by stage with BCLC/AASLD recommendations. RESULTS: In stage 0 (very early, or single <2 cm, or carcinoma in situ, Child A) radiofrequency should replace resection. In stage A (early, or single or three nodules up to 3 cm, Child A-B) radiofrequency and resection should expand their indications. In stage B (intermediate, or multinodular, Child A-B) resection and transplantation should expand their indications, while intra-arterial therapies are changing from conventional to selective treatments. In stage C (advanced, portal invasion or extrahepatic disease, Child A-B) systemic therapies should offer previously unknown promising options. CONCLUSION: In our opinion, so much evidence leads to suggest it is time to reconsider several BCLC/AASLD recommendations. Some treatments are comparable in results but vary in costs, local availability, or complication rates.
