Challenges and Controversies

The patient meets criteria for HCC screening post-SVR due to the presence of cirrhosis. The recommended HCC surveillance modality is ultrasound and AFP every 6 months. However, in this case, the patient's body habitus significantly worsens the qualty of ultrasound. Therefore, continuing abdominal ultrasound and AFP is a suboptimal approach. Screening with AFP alone lacks sufficient sensitivity for detecting HCC. Other HCC biomarkers, including AFP-L3% and des gamma carboxy prothrombin (DCP) have been studied in combination with AFP (e.g., GALAD score with also incorporates gender and age), showing improved sensitivity and specificity. However, these are still investigational for the purposes of HCC surveillence. Multi-phase abdominal CT or multi-phase abdominal MRI and alpha fetoprotein for HCC surveillance woud each be acceptible alternatives to ultrasound in this case. MRI is preferrable to CT due to the lack of radiation and iodinated contrast. On the other hand, MRI is more expensive, may be less tolerable to the patient, and may be limited by motion artifact and body habitus. Therefore, my recommendation is that while multi-phase abdominal MRI and serum AFP for all future screenings would be the ideal option, the modality would depend on a discussion with the patient regarding feasibility and preference for CT vs MRI (or alternating between these).

Ultrasound reports should ideally include a LI-RADS visualization score (A for adequate, B for moderate limitation, C for severe limitation). Poor visualization (scores B or C) can occur in up to 20% of patients with liver cirrhosis and unfortunately, this means the ultrasound has lower sensitivity in detecting liver lesions (particularly early stage HCC). In this patient's case, I would obtain either a multi-phase abdominal CT or an MRI with serum alpha-fetoprotein (AFP) for HCC screening in 3-6 months. If the CT or MRI and AFP are normal, I would alternate between ultrasound with AFP (as visualization score may be improved next time) vs. CT or MRI with AFP every 6 months. The optimal recall strategy for this patient group is not clear, so having an informed discussion with the patient about the potential risks/benefits of each imaging modality would be helpful. Emerging screening modalities (e.g., biomarkers, abbreviated MRI, etc) may allow for a more streamlined approach in the future.