Hepatocellular carcinoma (HCC) is the 5^th most common cancer worldwide. Its incidence is very high in Asia and Africa and the incidence in Europe and the US is increasing. HCC can grow to a significant size before becoming symptomatic. Consequently, most HCC are diagnosed late and are not amenable to curative treatments, namely surgical resection and liver transplantation. Surgical treatment for patients with early stage HCC provides good long term survival. In patients with good liver function and a single HCC lesion < 5cm in diameter, the 5-year survival rate following surgical resection is 70%. In patients with HCC meeting the Milan criteria, the 5-year survival rate following liver transplantation is about 74%. The median survival of patients with advanced HCC on supportive care is about 14 – 16 weeks. Thus, early detection of HCC leads to a much better prognosis. At present, the only viable option for early detection of HCC is to undergo regular surveillance with blood tests for the tumour marker, alpha feto-protein (AFP), and ultrasound scan of the liver. However, the number, type and interval of tests can vary among physicians, institutions and countries. So what is the best schedule for the at-risk population?

Researchers from the University of Michigan recently performed a meta-analysis on 13 published studies using ultrasound and AFP for early HCC detection in patients with liver cirrhosis (Aliment Pharmacol Ther 2009; 30: 37 – 47). The study showed that the pooled sensitivity and specificity for ultrasound in detecting HCC at any stage is 94%. For detection of early HCC, the pooled sensitivity is 63%. However, surveillance intervals affected ultrasound sensitivity in detecting early HCC. When the surveillance interval was < 6 months, the pooled sensitivity is 70.1%. The pooled sensitivity drops to 50.1% when the surveillance intervals are between 6 and 12 months. (There is no difference in the sensitivity of ultrasound between European and Asian studies and between studies conducted before and after 1992. This suggests technological advances did not play a major role.) When AFP is added to ultrasound surveillance, the pooled sensitivity for early HCC detection increases to 69%.

The current guidelines from the American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver recommend surveillance of cirrhotic patients with ultrasound with or without AFP every 6 – 12 months. The study above demonstrated a significantly higher sensitivity for early HCC detection when ultrasound scanning is performed at or less than 6 monthly intervals. In Japan, some institutions have a policy of screening the at risk population every 3 months and analysis of their data showed earlier detection of HCC which are also smaller in size at diagnosis. Although the above study only dealt with patients with liver cirrhosis, regular surveillance is recommended for all patients who are carriers of the hepatitis B (HBV) and C (HCV) virus, with or without liver cirrhosis. While it is tempting for an HBV and HCV carrier to think that “It will never happen to me so I don’t need surveillance”, I would certainly not take that chance if I were a carrier.

Recently at the delicatessen counter of a supermarket, I heard a mother asked her teenage son “Would you like some salami for lunch?”. After receiving an affirmative reply the mother promptly asked for 20 slices of salami. The teenage boy was shorter than me but he was 3 times as broad and deep as me! In other words, he was overweight, if not obese, with a sizeable belly.

Obesity has reached an epidemic proportion worldwide and the incidence of metabolic syndrome (MetS) seems to be paralleling obesity. Metabolic syndrome is strongly linked to insulin resistance, abdominal obesity, diabetes mellitus and dyslipidaemia. The adipose tissue (or more commonly known as fat) in the body can be divided into subcutaneous adipose tissue and visceral adipose tissue (VAT). Overweight and obese people have increased amount of VAT. One of the many sites for VAT accumulation is the liver and this can give rise to a condition called nonalcoholic fatty liver disease (NAFLD). When inflammation sets in, the condition is called nonalcoholic steatohepatits (NASH). If left unchecked, NASH can lead to progressive liver fibrosis and eventual liver cirrhosis. There is increasing evidence that people with visceral fat accumulation have an increased risk of developing primary liver cancer or hepatocellular carcinoma (HCC). Will visceral fat accumulation cause increased risk of HCC recurrence after curative treatment in patients with suspected NASH?

Researchers from the University of Tokyo studied 62 patients with HCC on a background of suspected NASH (Gut 2009; 58: 839 – 844). The visceral fat area (VFA) was determined by CT images at the time of HCC diagnosis. The patients were divided into two groups based on the VFA:- high VFA group (VFA > 130 sq. cm in males, > 90 sq. cm in females) and control group (VFA < 130 sq. cm in males and < 90 sq. cm in females). Using percutaneous radiofrequency ablation, all patients were treated with a curative intent between 1999 and 2006. These patients were followed up until HCC recurrence. The cumulative recurrence rates at 1, 2 and 3 years in the VFA group were 15.9%, 56.5% and 75.1% , respectively. These are significantly higher values than those found in the controls, being 9.7%, 31.1% and 43.1%, respectively.  The researchers concluded that visceral fat accumulation is an independent risk factor for HCC recurrence after curative treatment in patients with suspected NASH.

While I applaud the mother who wanted to look after her child well, perhaps she has been looking after him far too well for his own good. Saddling an adolescent with excess / excessive weight is equivalent to storing up future health problems for the child. When he / she attains adulthood and starts developing diabetes mellitus, arthritis in the hips and knees, he / she might think differently about the excessive amount of food you have been feeding him / her.