The most common primary malignancy arising within the liver is hepatocellular carcinoma (HCC) and almost always in the setting of cirrhosis. HCC is the fifth most common solid tumor in the world and accounts for ϳ500,000 deaths each year.1-3 Data on the epidemiology and natural history of chronic hepatitis C virus infection show that its frequency has increased over the past [20][21][22][23][24][25][26][27][28][29][30] including liver transplantation (LT). 7,8 This clinical scenario has important implications for diagnosing HCC at an early stage. Although surveillance is practiced in many units, there is only one randomized controlled trial concerning surveillance for HCC in cirrhosis. All others are cohort studies. Two well-designed studies show a higher chance of receiving treatment at an earlier stage, 9,10 strongly supporting current practice. A theoretical cohort of patients with Child class A cirrhosis was studied, and researchers found that with incidence of HCC of 1.5% a year, surveillance resulted in an increase in longevity of approximately 3 months. 11 However, if the incidence of HCC was 6%, the increase in survival was approximately 9 months. However, this study did not include transplantation as a treatment option. One study that used a similar analysis that did include LT suggested that surveillance became cost-effective when the incidence of HCC exceeded 1.4% per year. These data suggest that in patients with cirrhosis of varying causes, surveillance may be effective when the risk of HCC exceeds 1.5% per year. 6,[10][11][12] The single randomized controlled trial of surveillance surveillance every 6 months has shown a survival benefit of 6-monthly surveillance of ultrasound with alfafetoprotein (AFP). This study included 18,816 people aged 35-59 years with hepatitis B virus infection or a history of chronic hepatitis in urban Shanghai, China. Participants were randomly allocated to surveillance (9,373) or no surveillance (9,443). Participants were invited to have an AFP test and undergo ultrasound examination every 6 months. When the surveillance group was compared with the control group, the number of HCC cases was 86 vs. 67; subclinical HCC was 52 (60.5%) vs. 0, and small HCC was 39 (45.3%) vs. 0 respectively. Resection was achieved in 40 (46.5%) vs. 5 (7.5%) in whom it was not achieved. The 1-, 3-, and 5-year survival rates were 65.9%, 52.6%, and 46.4% vs. 31.2%, 7.2%, and 0, respectively. Thirty-two people died from HCC in the surveillance group vs. 54 in the control group, and the HCC mortality rate was statistically significantly lower in the surveillance group than in controls, being 83.2 of 100,000 and 131.5 of 100,000, respectively, with a mortality rate ratio of 0.63 (95% confidence interval, 0.41-0.98).
13The knowledge that all treatments yield better results when used for smaller and unifocal HCC 6 drives current diagnostic practice. Staging of patients with HCC has prognostic significance and determines therapy, including surgery. For both LT and resection, survival is higher for pa...
