Letter to the Editor Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2024; 30(8): 991-993
Published online Feb 28, 2024. doi: 10.3748/wjg.v30.i8.991
Monitoring of hepatocellular carcinoma
Imen Akkari, Department of Gastroenterology, University Hospital of Hached, University of Sousse, Faculty of Medicine of Sousse, Sousse 4000, Tunisia
Hanen Jaziri, Department of Gastroenterology, University Hospital of Sahloul, University of Sousse, Faculty of Medicine of Sousse, Sousse 4054, Tunisia
ORCID number: Imen Akkari (0000-0002-7953-6873); Hanen Jaziri (0000-0001-5527-3872).
Author contributions: Akkari I designed the report; Jaziri H read and agreed to the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Imen Akkari, MD, Associate Professor, Department of Gastroenterology, University Hospital of Hached, University of Sousse, Faculty of Medicine of Sousse, Rue Mohamed Karoui, Sousse 4000, Tunisia. imenakkaribm@gmail.com
Received: October 3, 2023
Peer-review started: October 3, 2023
First decision: December 6, 2023
Revised: December 12, 2023
Accepted: February 1, 2024
Article in press: February 1, 2024
Published online: February 28, 2024


Screening for hepatocellular carcinoma in patients at risk is an evidence-based approach; however, adherence to the monitoring protocol recommended by international guidelines is difficult. Hence, there is a need to use the best scr-eening options and refine the selection of patients at risk in the future.

Key Words: Hepatocellular carcinoma, Cirrhosis, Risk factors, Surveillance, Imaging, Diagnosis

Core Tip: Hepatocellular carcinoma is a public health problem, and the majority of cases occur in patients with cirrhosis. The screening method for this disease has been the subject of several studies. This Editorial discusses the study titled “Hepatocellular carcinoma surveillance: An evidence-based approach” that was published in World Journal of Gastroenterology in 2019.


We read with great interest the article by Harris et al[1] on the surveillance of hepatocellular carcinoma (HCC). We agree with authors’ insight that surveillance should be performed in cirrhotic and high-risk hepatitis B patients to allow for earlier diagnosis of HCC; however, some issues need to be mentioned.

First, according to that study, the use of alpha-fetoprotein (AFP) in addition to ultrasound is thought to improve the sensitivity of HCC detection. Del Poggio et al[2] also recommend the use of AFP screening, as it guides the choice between the continuation of standard ultrasound or performing second-level imaging. However, this strategy is not recommended by European guidelines. The increased cost of screening is among the arguments against the addition of AFP[3]. On the other hand, it is well known that AFP has variable sensitivity and specificity according to its level, as altered levels can be noted without relationship to HCC and a high value has been reportedly observed in only 10%-20% of HCC cases in the initial stages[3,4]. Harris et al[1] cited another limitation of using this biomarker, namely the need to determine many thresholds depending on the sub-population.

Second, the use of other radiologic modalities for primary screening in obese persons and those with non-alcoholic fatty liver disease[1] seems to be very difficult to apply in real life. In addition to the radiation exposure that occurs with repeated computed tomography examinations, adherence to this screening program is also difficult as these imaging techniques are not easily accessible, particularly in developing countries. Contrast-enhanced ultrasound is a good surveillance option for patients at high risk for HCC[5]. Therefore, Harris et al[1] recommend the use of alternative imaging if the standard ultrasound is limited.

Third, Harris et al[1] reported that screening for HCC is underutilized in some demographics (non-Caucasian race and low socioeconomic status). In another study, < 2% of patients received guideline-concordant biannual HCC surveillance[6]. This deficiency in the screening program was detailed in the study by Del Poggio et al[2]. According to the authors, real-life implementation of screening programs is far from optimal; therefore, a new strategy was proposed to improve the detection of HCC by primary care physicians and involve performing surveillance in a subspecialist setting. The aim of this approach is to improve the results of real-life screening and reduce HCC mortality.

Finally, prediction models of patients at high risk for HCC[7] and artificial intelligence are emerging approaches in medicine that will be an important element in the management of liver diseases. These advances can be useful in screening patients at high risk for HCC development[8]. Refining the selection of patients at risk into sub-groups of very high, moderate, or low risk could improve HCC screening. The use of abdominal computed tomography and magnetic resonance imaging or better contrast-enhanced ultrasound, could serve as alternative methods in the high-risk population.

In summary, rigorous biannual monitoring by standard ultrasound of at-risk patients remains the first-line screening method. Artificial intelligence protocols to predict the development of HCC in at-risk patients could contribute to the selection of patients at high risk requiring a particular monitoring protocol.


Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Tunisia

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Li LQ, China; Xing H, China S-Editor: Li L L-Editor: A P-Editor: Cai YX

1.  Harris PS, Hansen RM, Gray ME, Massoud OI, McGuire BM, Shoreibah MG. Hepatocellular carcinoma surveillance: An evidence-based approach. World J Gastroenterol. 2019;25:1550-1559.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 108]  [Cited by in F6Publishing: 120]  [Article Influence: 24.0]  [Reference Citation Analysis (4)]
2.  Del Poggio P, Mazzoleni M, Lazzaroni S, D'Alessio A. Surveillance for hepatocellular carcinoma at the community level: Easier said than done. World J Gastroenterol. 2021;27:6180-6190.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 2]  [Cited by in F6Publishing: 1]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
3.  European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018;69:182-236.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3934]  [Cited by in F6Publishing: 4885]  [Article Influence: 814.2]  [Reference Citation Analysis (0)]
4.  Pascual S, Miralles C, Bernabé JM, Irurzun J, Planells M. Surveillance and diagnosis of hepatocellular carcinoma: A systematic review. World J Clin Cases. 2019;7:2269-2286.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 16]  [Cited by in F6Publishing: 14]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
5.  Fetzer DT, Rodgers SK, Seow JH, Dawkins AA, Joshi G, Gabriel H, Kamaya A. Ultrasound Evaluation in Patients at Risk for Hepatocellular Carcinoma. Radiol Clin North Am. 2019;57:563-583.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 4]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
6.  Singal AG, Tiro J, Li X, Adams-Huet B, Chubak J. Hepatocellular Carcinoma Surveillance Among Patients With Cirrhosis in a Population-based Integrated Health Care Delivery System. J Clin Gastroenterol. 2017;51:650-655.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 29]  [Cited by in F6Publishing: 29]  [Article Influence: 4.1]  [Reference Citation Analysis (0)]
7.  Guo J, Gao XS. Prediction models for development of hepatocellular carcinoma in chronic hepatitis B patients. World J Clin Cases. 2021;9:3238-3251.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 3]  [Cited by in F6Publishing: 3]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
8.  Masuzaki R, Kanda T, Sasaki R, Matsumoto N, Nirei K, Ogawa M, Moriyama M. Application of artificial intelligence in hepatology: Minireview. Artif Intell Gastroenterol. 2020;1:5-11.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 7]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]