Monitoring for Potential Hepatocellular Carcinoma (HCC)

Best Practice 4

Surveillance for hepatocellular carcinoma with liver imaging +/- serum AFP should be pursued twice annually for an indefinite duration in all patients with stage 3 fibrosis or liver cirrhosis post-SVR.

Best Practice 5

Surveillance for HCC is not recommended for patients with stages 0–2 fibrosis post-SVR.

Best Practice 6

Intensification of HCC screening frequency in the immediate post-SVR context is not presently recommended.

In general, the risk of de novo HCC decreases after the attainment of SVR with interferon-based regimens. However, established cirrhosis is a risk factor for the development of HCC and there is no “finite point beyond which the risk of HCC in patients with a history of HCV-associated cirrhosis is reduced to the level of persons without a history of liver disease,” the authors point out. Available evidence as well as clinical experience suggest that surveillance is associated with decreased mortality from HCC and should be conducted at six-month intervals in all patients with cirrhosis, regardless of whether they have achieved SVR.  Since HCC also occurs in patients with bridging fibrosis, the surveillance recommendations for patients with cirrhosis also apply to this population. Ultrasound is the recommended imaging modality for hepatoma surveillance.

Currently available evidence does not support routine screening after SVR for HCC in patients with F0–2 fibrosis, although clinicians may choose to obtain a final ultrasound during the year after SVR that follows DAA therapy.

Variceal Bleeding Prophylaxis

Best Practice 7

Initial endoscopic screening for esophagogastric varices is recommended for all patients with liver cirrhosis, independent of SVR.

Best Practice 8

Repeat endoscopic screening should be pursued for cirrhotic patients post-SVR at 2 to 3 years if no varices or small varices were identified on initial screening exam.

Best Practice 9

If no varices are identified on endoscopy 2 to 3 years post-SVR, cessation of further endoscopic screening may be considered on an individual patient basis, if there are no risk factors for progressive cirrhosis.

The authors write, “Increasing evidence points to the capacity for SVR to result in resolution or reduction of portal hypertension, especially in patients with Child-Pugh A cirrhosis, laying a foundation for a favorable change in the natural history of esophageal varices after SVR.” The risk of variceal bleeding is low after SVR is attained via interferon-based therapy.

The authors propose that if no varices are found on prior screening examination, a follow-up endoscopy after 2 to 3 years should be conducted and if no varices are found, and there is no evidence of another progressive liver disease, no further screening is necessary.

In the event of small varices on prior screening examination, no treatment is necessary; a follow-up endoscopy should be conducted after 2 to 3 years and if the varices are unchanged or smaller, no further screening is necessary. Otherwise, treatment and further follow-up are necessary.

If varices on prior screening have been treated with primary prophylaxis with beta-blockers and/or band ligation, endoscopy should be repeated after 6 to 12 months, treatment continued if varices are unchanged, and endoscopy should be repeated after 1 to 2 years. Treatment may be discontinued if varices are reproducibly considered sufficiently small to be low-risk.

Surveillance and/or treatment already instituted should be continued in decompensated patients or patients with a prior history of variceal bleeding.