Sensitivity of Ultrasound and Alpha Fetoprotein for Detection of Hepatocellular Carcinoma in Patients with Cirrhosis

BACKGROUND: Hepatocellular carcinoma (HCC) is the fastest growing cause of cancer related mortality in the United States. Prognosis is strongly tied to early detection, which facilitates curative treatment and long-term survival. Therefore, HCC screening is recommended in at risk patients, i.e. those with cirrhosis. Although ultrasonography is routinely used to screen at-risk patients for HCC, it is operator dependent and its sensitivity outside of prospective cohort studies is poorly described. Further, the benefit of adding serum biomarkers, such as alpha fetoprotein, has also been poorly studied. The aim of our study was to quantify the effectiveness of ultrasound and AFP for HCC detection in patients with cirrhosis. METHODS: We performed a retrospective chart review of patients newly diagnosed with HCC at UT Southwestern and Parkland Health and Hospital System between January 2009 and December 2015. We excluded patients who did not have at least one ultrasound within 12 months prior to HCC diagnosis. Ultrasounds were categorized as positive if there was a suspicious mass > 1 cm and AFP as positive if ≥20 ng/mL, the most common cut-off in clinical practice. Sensitivity was compared between ultrasound alone and combination of ultrasound + AFP using the chi-square test, with statistical significance defined as p<0.05. RESULTS: Of the 925 patients diagnosed with HCC between January 2009 and December 2015, 521 patients had an ultrasound within 12 months prior to HCC diagnosis. The overall sensitivity of ultrasound for HCC detection was 77.5% n=404/521). Of the 521 included patients, 400 had at least one AFP within 12 months of HCC diagnosis. There were 154 patients who had both positive ultrasound and AFP, 143 with positive ultrasound alone, 59 with positive AFP alone, and 44 with negative ultrasound and AFP. The sensitivity of ultrasound alone was 74.3% compared to 89.0% with ultrasound and AFP p<0.001). CONCLUSION: Ultrasound alone has suboptimal sensitivity for HCC detection in clinical practice, highlighting the need for better screening tools. Adding serum biomarkers, such as AFP, can significantly improve HCC detection in clinical practice.