In whom, how and how often is surveillance for hepatocellular carcinoma cost-effective, by AL Ruelas-Villavicencio et al.
Hepatocellular carcinoma (HCC) is an increasingly frequent diagnosis, particularly after the introduction of US routine screening in patients with chronic liver disease. Data collected in series originating from different regions of the world showed a yearly incidence rate of about 3-5% in cirrhotic patients pointing to the need of a cost-effective screening protocol for early diagnosis and more effective treatment. This paper addresses this still controversial issue and namely which is the best time frame to perform screening protocols in subjects with chronic liver disease at risk for the development of HCC. A rather large cohort of histologically proven HCCs was examined, and the diagnostic efficacy of US and α-Fetoprotein (αFP) in detecting HCC assessed when performed either every 6 or 12 months. Data support the conclusion that screening every 12 months is better, both in terms of accuracy of diagnosis and obviously cost. However, this important conclusion must be taken with some caveats. The first is that the clinical characteristics of the patients were those of an advanced, symptomatic disease leaving unanswered the key issue of the best timing for early diagnosis of HCC in fully compensated cirrhosis. The second caveat stands on the clinical series per se where the male:female ratio was almost 1, while male sex has been consistently showed to be a clear risk factor for HCC. The 3rd is the real meaning of αFP in detecting HCC; in this series, as well as in many others, the value was ranging from normal to clearly elevated in spite of a similar clinical situation. The unpredictably of this tests recently suggested the removal of this so called “tumor marker” from the diagnostic roster of the hepatologist. Collectively, the key question of the best protocol for the follow-up of patients with cirrhosis and early diagnosis of HCC is unfortunately still to come.
Clinical and epidemiological features of 147 Chilean patients with chronic hepatitis C, by A Soza et al.
Hepatitis C Virus (HCV) infection is 5 times higher that HIV, involves more that 150 million subjects and must be regarded as a major health problem worldwide. Geographical differences has been reported with a rather clear North-to-South gradient above the equator and most probably, a mirror image below. The paper by Soza et al. somehow fills the gap in the geographical patchwork of HCV infection providing data on the characteristics of HCV-infected patients in Chile, a long Country stretching almost from the Equator to the Southern pole. Chile may be therefore the ideal place to investigate whether geographical and climatic differences may account for the higher HCV infection observed in the Southern hemisphere. Although the geographical provenience is not reported for the patients, the clinical appearance looks rather similar to that observed in European and US series. In particular, it was confirmed that the natural history of the HCV-related liver disease is rather benign, stressing once again the need for evidence-based criteria in the selection of patients to be treated. Interesting was also the observation, again confirmatory, that the liver disease was rather advanced in more that half of patients at the time of the diagnosis (10% had HCC) pointing to the need for an effective screening program. However, effective screening must reside on sound epidemiological evidence similar to those collected in Europe and US in the last 15 years. Due to the geographical considerations listed above, Chile may be a rather unique place to address the possible role of the latitude and the environment in the clinical aspects and natural history of HCV-related liver disease.
