BACKGROUND While clinical guidelines recommend hepatocellular carcinoma(HCC)surveillance for at-risk individuals,reported surveillance rates in the United States and Europe remain disappointingly low.AIM To quantify H...BACKGROUND While clinical guidelines recommend hepatocellular carcinoma(HCC)surveillance for at-risk individuals,reported surveillance rates in the United States and Europe remain disappointingly low.AIM To quantify HCC surveillance in an Australian cohort,and assess for factors associated with surveillance underutilisation.METHODS All patients undergoing HCC surveillance liver ultrasounds between January 1,2018 to June 30,2018 at a tertiary hospital in Melbourne,Australia,were followed until July 31,2020,or when surveillance was no longer required.The primary outcome was the percentage of time up-to-date with HCC surveillance(PTUDS).Quantile regression was performed to determine the impact of factors associated with HCC surveillance underutilisation.RESULTS Among 775 at-risk patients followed up for a median of 27.5 months,the median PTUDS was 84.2%(IQR:66.3%-96.3%).85.0%of patients were followed up by specialist gastroenterologists.Amongst those receiving specialist care,quantile regression demonstrated differential associations at various quantile levels of PTUDS for several factors.Older age at the 25th quantile(estimate 0.002 per percent,P=0.03),and cirrhotic status at the 75th quantile(estimate 0.021,P=0.017),were significantly associated with greater percentage of time up-to-date.African ethnicity(estimate-0.089,P=0.048)and a culturally and linguistically diverse(CALD)background(estimate-0.063,P=0.01)were significantly associated with lower PTUDS at the 50th quantile,and again for CALD at the 75th quantile(estimate-0.026,P=0.045).CONCLUSION While median PTUDS in this Australian cohort study was 84.2%,awareness of the impact of specific factors across PTUDS quantiles can aid targeted interventions towards improved HCC surveillance.展开更多
Importance:Non-alcoholic fatty liver disease(NAFLD)is a rapidly growing cause of chronic liver disease and is becoming a leading cause of hepatocellular carcinoma(HCC)in many developed countries.This presents major ch...Importance:Non-alcoholic fatty liver disease(NAFLD)is a rapidly growing cause of chronic liver disease and is becoming a leading cause of hepatocellular carcinoma(HCC)in many developed countries.This presents major challenges for the surveillance,diagnosis and treatment of HCC.Objective:To discuss the clinical challenges faced by clinicians in managing the rising number of NAFLD-HCC cases.Evidence Review:MEDLINE,PubMed and Embase databases were searched using the keywords;NAFLD,HCC,surveillance,hepatectomy,liver transplantation,percutaneous ablation,transarterial chemoembolization(TACE),selective internal radiotherapy treatment(SIRT)and sorafenib.Relevant clinical studies were included.Findings:Current HCC surveillance programmes are inadequate because they only screen for HCC in patients with cirrhosis,whereas in NAFLD a significant proportion of HCC develops in the absence of cirrhosis.Consequently NAFLD patients often present with a more advanced stage of HCC,with a poorer prognosis.NAFLD-HCC patients also tend to be older and to have more co-morbidities compared to HCC of other etiologies.This limits the use of curative treatments such as liver resection and orthotopic liver transplantation(OLT).Evidence suggests that although NAFLD-HCC patients who undergo liver resection or OLT have worse perioperative and short-term outcomes,overall long-term survival is comparable to HCC of other etiologies.This highlights the importance of careful patient selection,pre-habilitation and perioperative planning for NAFLD-HCC patients being considered for surgical treatment.Careful consideration is also important for non-surgical treatments,although the evidence supporting treatment selection is frequently lacking,as these patients tend to be poorly represented in clinical trials.Locoregional therapies such as percutaneous ablation and TACE may be less well tolerated and less effective in NAFLD patients with obesity or diabetes.The tyrosine kinase inhibitor sorafenib may also be less effective.Conclusions and Relevance:This review highlights how international guidelines,for which NAFLD traditionally has made up a small part of the evidence base,may not be appropriate for all NAFLD-HCC patients.Future guidelines need to reflect the changing landscape of HCC,by making specific recommendations for the management of NAFLD-HCC.展开更多
文摘BACKGROUND While clinical guidelines recommend hepatocellular carcinoma(HCC)surveillance for at-risk individuals,reported surveillance rates in the United States and Europe remain disappointingly low.AIM To quantify HCC surveillance in an Australian cohort,and assess for factors associated with surveillance underutilisation.METHODS All patients undergoing HCC surveillance liver ultrasounds between January 1,2018 to June 30,2018 at a tertiary hospital in Melbourne,Australia,were followed until July 31,2020,or when surveillance was no longer required.The primary outcome was the percentage of time up-to-date with HCC surveillance(PTUDS).Quantile regression was performed to determine the impact of factors associated with HCC surveillance underutilisation.RESULTS Among 775 at-risk patients followed up for a median of 27.5 months,the median PTUDS was 84.2%(IQR:66.3%-96.3%).85.0%of patients were followed up by specialist gastroenterologists.Amongst those receiving specialist care,quantile regression demonstrated differential associations at various quantile levels of PTUDS for several factors.Older age at the 25th quantile(estimate 0.002 per percent,P=0.03),and cirrhotic status at the 75th quantile(estimate 0.021,P=0.017),were significantly associated with greater percentage of time up-to-date.African ethnicity(estimate-0.089,P=0.048)and a culturally and linguistically diverse(CALD)background(estimate-0.063,P=0.01)were significantly associated with lower PTUDS at the 50th quantile,and again for CALD at the 75th quantile(estimate-0.026,P=0.045).CONCLUSION While median PTUDS in this Australian cohort study was 84.2%,awareness of the impact of specific factors across PTUDS quantiles can aid targeted interventions towards improved HCC surveillance.
文摘Importance:Non-alcoholic fatty liver disease(NAFLD)is a rapidly growing cause of chronic liver disease and is becoming a leading cause of hepatocellular carcinoma(HCC)in many developed countries.This presents major challenges for the surveillance,diagnosis and treatment of HCC.Objective:To discuss the clinical challenges faced by clinicians in managing the rising number of NAFLD-HCC cases.Evidence Review:MEDLINE,PubMed and Embase databases were searched using the keywords;NAFLD,HCC,surveillance,hepatectomy,liver transplantation,percutaneous ablation,transarterial chemoembolization(TACE),selective internal radiotherapy treatment(SIRT)and sorafenib.Relevant clinical studies were included.Findings:Current HCC surveillance programmes are inadequate because they only screen for HCC in patients with cirrhosis,whereas in NAFLD a significant proportion of HCC develops in the absence of cirrhosis.Consequently NAFLD patients often present with a more advanced stage of HCC,with a poorer prognosis.NAFLD-HCC patients also tend to be older and to have more co-morbidities compared to HCC of other etiologies.This limits the use of curative treatments such as liver resection and orthotopic liver transplantation(OLT).Evidence suggests that although NAFLD-HCC patients who undergo liver resection or OLT have worse perioperative and short-term outcomes,overall long-term survival is comparable to HCC of other etiologies.This highlights the importance of careful patient selection,pre-habilitation and perioperative planning for NAFLD-HCC patients being considered for surgical treatment.Careful consideration is also important for non-surgical treatments,although the evidence supporting treatment selection is frequently lacking,as these patients tend to be poorly represented in clinical trials.Locoregional therapies such as percutaneous ablation and TACE may be less well tolerated and less effective in NAFLD patients with obesity or diabetes.The tyrosine kinase inhibitor sorafenib may also be less effective.Conclusions and Relevance:This review highlights how international guidelines,for which NAFLD traditionally has made up a small part of the evidence base,may not be appropriate for all NAFLD-HCC patients.Future guidelines need to reflect the changing landscape of HCC,by making specific recommendations for the management of NAFLD-HCC.
