A 45-year-old woman is evaluated during a routine office visit. She was diagnosed with chronic active hepatitis B infection 10 years ago. She has no symptoms and no other medical problems. A liver biopsy performed 3 years ago revealed changes consistent with chronic active inflammation with no cirrhosis. She is taking interferon alfa.
On physical examination, vital signs are normal. No evidence of telangiectasias or other stigmata of chronic liver disease is present. The abdomen is unremarkable without evidence of hepatomegaly, liver tenderness, or ascites. The remainder of the examination findings are normal.
Serum aspartate aminotransferase is 200 U/L and alanine aminotransferase is 100 U/L. (unchanged from 6 months ago). Prothrombin time and activated partial thromboplastin time are normal. Hepatitis C antibody is negative.
The most appropriate screening strategy for hepatocellular carcinoma in this patient is liver ultrasonography. Hepatocellular carcinoma is the most common primary intrahepatic tumor and the fastest growing cause of cancer-related death in men in the United States. The cancer usually develops in patients with cirrhosis. The most common causes of cirrhosis leading to hepatocellular carcinoma are chronic hepatitis B and hepatitis C viral infections and alcoholic liver disease; however, patients with chronic hepatitis B infection in the absence of cirrhosis may develop hepatocellular carcinoma. Patients with a compatible ultrasound imaging study and a subsequent serum α-fetoprotein level greater than 500 ng/mL (500 µg/L) can be diagnosed with hepatocellular carcinoma without a biopsy. The optimal time to initiate a screening program and its ideal frequency are unknown.
Combined use of α-fetoprotein measurement and ultrasonography increases the sensitivity of detection but at the expense of increased false-positive results. α-Fetoprotein is not specific for hepatocellular carcinoma and should not be used alone as a screening test unless ultrasound is not available. Liver CT scanning exposes the patient to unnecessary radiation, particularly if screening is performed frequently.
- Patients with chronic hepatitis B infection in the absence of cirrhosis may develop hepatocellular carcinoma and should undergo periodic screening..