慢性HBV感染患者的HCC筛查：没有错误的余地

StephenW

HCC Screening in Patients With Chronic HBV Infection: No Room for Error
       
         

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Steven L. Flamm, MD
Chief, Hepatology Program
Professor of Medicine
Medical Director, Liver Transplantation
Feinberg School of Medicine
Northwestern University
Chicago, Illinois

Patients with chronic HBV infection are at high risk for hepatocellular carcinoma (HCC)─reported incidences are approximately 1% per year in patients without cirrhosis and approximately 3% per year in patients with cirrhosis. As one of the only liver-related illnesses in which patients without cirrhosis can develop HCC, practitioners must be vigilant in screening patients with chronic HBV infection.

Who Should Be Screened?
At minimum, clinicians should adhere to the AASLD guidelines on screening for HCC. According to the 2018 AASLD guidance, the following individuals are at high risk and should be screened:

    All patients with cirrhosis
    Patients with a first-degree family member with history of HCC
    Asian or black men older than 40 years of age
    Asian women older than 50 years of age
    Patients coinfected with hepatitis D virus

The guidance recommends that all patients with chronic HBV infection in these high-risk categories be screened every 6 months via liver ultrasound with or without alpha-fetoprotein (AFP). However, ultrasounds are not onerous, and if patients are willing to get one and have the insurance coverage, I encourage screening in patients who may not fit squarely into one of the high-risk categories outlined in the guidance. This may include younger patients who do not quite meet the age cutoffs or patients with fibrosis but not technically cirrhosis.

Patients who have younger first-degree family members with a history of HCC are at the highest risk. Although I still worry about my patients with first-degree family members who developed HCC at 60 or 70 years of age, I worry less so than if they had a family member who developed HCC at 35 years of age. In my practice, I have also seen my patients develop HCC when there is a strong family history outside of the first-degree family. If a patient tells me that 2 uncles and an aunt all developed HCC, that patient does not technically meet the guidelines—but I would still have heightened concern for this patient compared with a patient with no family history of HCC.

Screening With AFP
Currently, AFP levels are assessed at the discretion of the practitioner. In my practice, I do evaluate AFP in addition to performing a liver ultrasound. It is highly important that practitioners do not miss the development of HCC because if missed, it becomes a terminal disease instead of one that is curable. I find AFP to be helpful because it has been my experience that even mild AFP elevations in patients with chronic HBV infection may indicate HCC development. If the AFP is mildly elevated and the ultrasound is unremarkable, I will request cross-sectional imaging, such as a triphasic CT scan or an MRI, to look for a small lesion that may not be visible on ultrasound.

However, clinicians should keep in mind that if the AFP is normal, that does not rule out HCC. There are many patients with HCC that have a normal AFP—remember that the AFP level is helpful in detecting HCC if it is elevated, but a normal AFP does not provide much useful information.

StephenW

慢性HBV感染患者的HCC筛查：没有错误的余地
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史蒂文·弗拉姆（马里兰州）
肝病学系主任
医学教授
肝移植医学总监
芬伯格医学院
西北大学
伊利诺伊州芝加哥

慢性HBV感染的患者罹患肝细胞癌（HCC）的风险很高-报告的发生率在无肝硬化的患者中约为每年1％，在肝硬化的患者中约为每年3％。作为没有肝硬化的患者可以发展为肝癌的仅有的肝脏相关疾病之一，从业人员必须警惕筛查患有慢性HBV感染的患者。

应该筛选谁？
至少，临床医生应遵守AASLD筛查HCC的指南。根据2018年AASLD指南，以下人员处于高风险中，应进行筛查：

    所有肝硬化患者
    有一级家族成员且具有肝癌病史的患者
    40岁以上的亚裔或黑人男性
    50岁以上的亚裔妇女
    合并感染D型肝炎病毒的患者

该指南建议每6个月通过有或没有甲胎蛋白（AFP）的肝超声检查所有这些高危类别的慢性HBV感染患者。但是，超声检查并不繁琐，如果患者愿意购买超声检查并获得保险，我鼓励对可能不完全属于指南中概述的高风险类别之一的患者进行筛查。这可能包括未达到年龄临界值的年轻患者或患有纤维化但并非技术性肝硬化的患者。

较年轻的一级家庭成员具有HCC病史的患者处于最高风险。尽管我仍然担心我的患有一级家庭成员的患者在60或70岁时发展为HCC，但与他们的家庭成员在35岁时发展为HCC相比，我所担心的要少。在我的实践中，我还看到我的患者在一级家庭之外有很强的家族病史时会发展成肝癌。如果患者告诉我2个叔叔和一个姨妈都患有肝癌，则该患者在技术上不符合指南要求-但与没有HCC家族史的患者相比，我仍然会对此患者更加担忧。

用AFP筛选
当前，AFP水平由从业者决定。在我的实践中，除了进行肝脏超声检查外，我还评估了AFP。从业者千万不要错过肝癌的发展，这是非常重要的，因为如果错过了，它将成为一种绝症而不是可以治愈的疾病。我发现AFP很有帮助，因为根据我的经验，慢性HBV感染患者即使AFP轻度升高也可能预示着肝癌的发展。如果AFP轻度升高且超声检查不明显，我将要求进行断层成像，例如三相CT扫描或MRI，以寻找超声可能看不见的小病变。

但是，临床医生应记住，如果AFP正常，则不能排除HCC。许多肝癌患者的AFP正常-请记住，如果AFP水平升高，AFP水平有助于检测HCC，但是正常AFP并不能提供很多有用的信息。