Hepatocellular carcinoma
Authors: Alastair D Smith, Arthur A Dunk, Janet E Tuttle-Newhall, James F Trotter
Journal: The Lancet (2004)

Sir—In their Seminar on hepato-cellular carcinoma (HCC), Josep Llovet and colleagues (Dec 6, p 1907)1Llovet JM Burroughs AK Bruix J Hepatocellular carcinoma.Lancet. 2003; 362: 1907-1917Summary Full Text Full Text PDF PubMed Scopus (3850) Google Scholar raise at least two issues that deserve comment. The first is that it is unclear whether the most useful and widely accepted screening policy for detection of early primary HCC among patients with cirrhosis—ie, 6-monthly α fetoprotein estimation and liver ultrasound scan—might be delivered to greatest effect in a transplant centre as opposed to a general hospital setting. In Eastbourne, UK, where the district general hospital serves a local population of just over 200 000, about 120 patients with biopsy-proven cirrhosis were followed up by two of us (ADS, AAD) and required screening for HCC as outlined above. This imaging burden of almost 250 ultrasound scans per year is not inconsiderable for a radiology department that has just two ultrasound machines and is also required to provide timely services for the patients of several other hospital specialists and general practitioners. Furthermore, this figure does not speak to the complexity of image interpretation nor the time required for this; it does not take account of the need for additional computed tomography (CT) or magnetic resonance imaging in instances where ultrasound scans gave equivocal images within a cirrhotic liver; nor does it include the necessary staging CT scans once a diagnosis of HCC has been established. An alternative management strategy would be to have these patients travel to and from the nearest liver transplant centre (in the case of Eastbourne, Kings College Hospital in London: a 200-mile round-trip), to undergo HCC screening there. In the current age of increasingly specialist-provided care demanded by the British government, not least for cancer patients, it could be argued that such a course of action is more appropriate. However, in real terms, it is not an option at present. A small proportion of our patients did travel to London, referred either for liver transplant assessment, or specific HCC appraisal and treatment thereof. The transplant patients had appropriate HCC screening on successive visits. The second issue is that, while Llovet and colleagues' paper was in press, the Liver and Intestinal Organ Transplantation Committee of the United Network for Organ Sharing (UNOS) decreed that additional MELD (model for end-stage liver disease) listing points would no longer be granted to patients with stage T1 HCC only—ie, solitary tumours less than or equal to 1·9 cm in diameter, except in circumstances where such a lesion is associated with an α fetoprotein concentration of more than 500 μg/L.2Organ Procurement and Transplantation Network/United Network for Organ Sharing Liver and Intestinal Organ Transplantation Committee.http://www.optn.org/member/committees.aspGoogle Scholar This decision was reached after a period of public consultation, review of recent evidence,3Yao FY Bass NM Nikolai B et al.A follow-up analysis of the pattern and predictors of dropout from the waiting list for liver transplantation in patients with hepatocellular carcinoma: implications for the current organ allocation policy.Liver Transplant. 2003; 9: 684-692Crossref PubMed Scopus (249) Google Scholar and concern that up to 40% of patients with T1 HCC by imaging criteria do not have this confirmed in their explanted liver. Therefore, only patients with T2 disease will be eligible for additional MELD listing points: the patient can be registered at a MELD score (24) equivalent to a 15% probability of death within 3 months. It will be interesting to see what effect this decision has on patients with T1 HCC who will wait longer for transplantation than has been the case hitherto.