2021 年 9 月 16 日 肝硬化患者进行 HCC 监测的利弊

StephenW

发表于胃肠病学期刊扫描/研究 · 2021 年 9 月 16 日肝硬化患者进行 HCC 监测的利弊临床胃肠病学和肝病学 1 条专家评论带回家的消息    这是一项为期 18 个月的有趣研究，研究了 614 名肝硬化患者的前瞻性队列中 HCC 监测的益处和危害。好处的特点是早期 HCC 检测和治愈性治疗，而危害则是对错误或不确定结果的诊断程序。在研究过程中发生的 HCC 病例中，61.5% 是在监督检查中发现的。在监测期间几乎没有对患者造成伤害。    有趣的是，监测组和非监测组之间的治愈性治疗和诊断阶段没有显着差异。需要在更长的随访期内在大型队列中进行进一步的几项多中心研究，以确认有利的风险收益比。– Natasha VonRoenn，医学博士    撰稿人        Daniel Geh MBChB、BMedSci、MRCP    撰稿人        海伦·里夫斯 BMBS, PhD, FRCP肝细胞癌 (HCC) 是肝硬化常见且可怕的并发症，对高危人群进行监测的价值经常受到争论。 1 虽然监测有可能增加早期/无症状 HCC 的检出率，这些 HCC 可以根治性治疗，这需要具有成本效益并与假阳性结果的潜在危害相平衡。 Singal 等人报告说，在精心挑选的、在安全网医疗保健环境中接受监测的健康肝硬化患者队列中，HCC 发生率为 2.8%（18 个月内 614 名患者中有 26 例 HCC）。令人鼓舞的是，62.5% 的患者在早期被检测到（BCLC 0/A），44% 的患者提供了治愈性治疗。尽管大多数是通过监测发现的（16；61.5%），但通过监测发现的那些或偶然/有症状的（62.5% 对 50%）在早期检测中没有显着差异——可能反映缺乏一致的研究期间的正式监测，以及进行研究的环境，初级保健提供者的就诊次数相对较多。报告的“身体伤害”最小，54 名患者 (8.8%) 需要因监测结果为假阳性而进行额外扫描。这些主要归因于腹部超声扫描 (USS) 的假阳性结果——众所周知，其敏感性大于特异性。2 但值得注意的是，该系列中 4/16 的 HCC 仅通过甲胎蛋白 (AFP) 检测到，进一步推动了关于单独使用 USS 与 USS+AFP 作为监视工具的作用的辩论。作者以积极的方式强调了“身体伤害”的缺乏，尽管这些当然没有考虑成本效益或患者的心理和成本负担。也许这里的积极信息是：(1) 接受初级保健或肝病医生定期随访的健康肝硬化患者更有可能在早期发现他们的 HCC——尽管他们的表现相对令人失望正式的 HCC 监测计划——将身体伤害降到最低； (2)有较大改进空间。参考    Geh D、Rana FA、Reeves HL。权衡肝细胞癌监测对潜在危害的好处。 J肝细胞癌。 2019；6:23-30。 https://doi.org/10.2147/JHC.S159581    EASL 临床实践指南：肝细胞癌的管理。 J肝素。 2018 年； 69（1）：182-236。 https://doi.org/10.1016/j.jhep.2018.03.019

StephenW

Published in Gastroenterology

Journal Scan / Research · September 16, 2021
Benefits and Harms of HCC Surveillance in Patients With Cirrhosis

Clinical Gastroenterology and Hepatology

1 Expert Comment
TAKE-HOME MESSAGE

    This is an interesting study conducted over an 18-month period looking at both the benefits and harms of HCC surveillance in a prospective cohort of 614 patients with cirrhosis. The benefits were characterized as early HCC detection and curative treatment, whereas harms were diagnostic procedures for false or indeterminate results. Of cases of HCC that developed over the course of the study, 61.5% were found during a surveillance examination. Virtually no harm occurred to patients during surveillance.

    Interestingly, curative treatment and stage at diagnosis did not differ significantly between the surveillance group and those without. Further several multicenter studies need to be conducted in large cohorts over longer follow-up to confirm the favorable risk-benefit ratio.

–  Natasha VonRoenn, MD

    Written by
        Daniel Geh MBChB, BMedSci, MRCP
    Written by
        Helen Reeves BMBS, PhD, FRCP

Hepatocellular carcinoma (HCC) is a common and dreaded complication of liver cirrhosis, with the value of surveillance in at-risk populations frequently debated.1 While surveillance has the potential to increase the detection of early-stage/ asymptomatic HCCs that can be treated curatively, this needs to be cost-effective and balanced against the potential harms of false-positive results. Singal et al., report an HCC incidence of 2.8% (26 HCCs in 614 patients over 18 months) in a carefully selected cohort of fit cirrhotic patients undergoing surveillance in a safety-net healthcare setting. Encouragingly, 62.5% were detected at an early stage (BCLC 0/A), with 44% offered curative therapy.  Although the majority were detected by surveillance (16; 61.5%), there was no significant difference in early-stage detection between those detected by surveillance or those detected incidentally/presenting symptomatically (62.5% vs 50%) – possibly reflecting the lack of consistent formal surveillance during the study period, but also the setting in which the study was conducted, with relatively high numbers of visits to primary care providers.

Minimal ‘physical harms’ were reported, with 54 patients (8.8%) requiring additional scans consequent to a false positive surveillance result. These were largely attributed to false-positive findings on abdominal ultrasound scans (USS) – known to have greater sensitivity than specificity.2 Notably though, 4/16 HCCs in this series were detected by alpha-fetoprotein (AFP) alone, fueling further the debate of the role of USS alone versus USS+AFP as surveillance tools.  The lack of ‘physical harms’ is highlighted in a positive fashion by the authors, although of course, these do not consider cost-effectiveness or the psychological and cost burdens to patients.

Perhaps the positive take-home messages here are: (1) fit patients with cirrhosis who are under regular follow-up by primary care or hepatology physicians, are more likely to have their HCC detected at an early stage - despite the relatively disappointing performance of formal HCC surveillance programs - coming to minimal physical harm; (2) there is room for major improvement.

References

    Geh D, Rana FA, Reeves HL. Weighing the benefits of hepatocellular carcinoma surveillance against potential harms. J Hepatocell Carcinoma. 2019;6:23-30. https://doi.org/10.2147/JHC.S159581
    EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018; 69(1):182-236. https://doi.org/10.1016/j.jhep.2018.03.019

StephenW

https://www.practiceupdate.com/c ... S0&lid=20849513

zuihouyiji

就是说定期检查与不检查结果是一样的。

StephenW

回复 zuihouyiji 的帖子

是的，这项研究表明定期监测对早期发现 HCC 的影响小.研究人员建议需要更好的 hcc 检测 .