1. Prof. Massimo Colombo Co-Chairman Department of Medicine, Head Division of Gastroenterology Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena Università degli Studi di Milano Milano Paris Hepatitis Conference Paris, 19th-20th January 2009 Screening and diagnosis of hepatocellular carcinoma

2. Increasing Incidence of Early Stage HCC in the Referral Centers The Experience in Japan Diagnostic periodStage I (n=274)Stage II (n=448)CTP A (n=726) 1968-1980 (n=151) 2 (1.3%) 6 (4.0%) 37 (24.5%) 1981-1990 (n=409)32 (7.8%) 85 (20.8%)138 (33.8%) 1991-2000 (n=757)155 (20.5%)249 (32.9%)351 (46.4%) 2001-2004 (n=324) 85 (26.3%)108 (33.3%)200 (61.7%) Toyoda H et al, Clin Gastroenterol Hepatol 2006;4:1170-1176 Ogaki Municipal Hospital, Japan. Data-base: 1968-2004. 1641 patients with a HCC Curative treatments in 1067 (65%)

3. Groups of Patients for whom Surveillance Is Recommended 1 EASL Conference, Bruix et al J Hepatol 2001;35:421-430 ; 2 AASLD Practice Guidelines, Bruix & Sherman Hepatology 2005;42:1208-1236 3 JSH Clinical Practice Guidelines for HCC, Makuuchi et al Hepatol Res 2008;38:37-51 TARGET POPULATION GuidelinesChronic hepatitis B or C Cirrhosis 1 EASL HBV: not specified HCV: histological transition to cirrhosis Child-Pugh A & B Child-Pugh C if LT available 2 AASLD HBV: ALT + DNA + Age cut-offs for ethnic groups All etiologies 3 JSHIncreasing risk: sex, age, alcoholVery high risk: HBV/HCV

4. Are Surveillance Programs Improved by Patients Stratification by Clinical and Histological Scores? StudyPatientsPredictorsHigh risk groupLow risk group Ganne-Carrié 1996 1 Cirrhosis, mixedAge > 50 yrHCC = 24% at 3 yrHCC = 0 at 3 yr (France)etiologyMale sex(LLCD+ = 72%) (151 training,Large varices Screening spared in 44% patients 0 HCC missed 49 validation)Pro-time < 70% AFP ≥ 15 ng HCV-Ab Velasquez 2003 2 Cirrhosis, mixedAge ≥ 55 yrHCC = 30.1% at 4 yrHCC = 2.3% at 4 yr (Spain)etiology (n=463)HCV-Ab Pro-time ≤ 75% Screening spared in 58% patients 10% HCC missed Platelets ≤ 75,000 1 Hepatology 1996;23:1112-1118; 2 Hepatology 2003;37:520-527

5. Studies Comparing the Diagnostic Accuracy and Outcome of Surveillance with Different Screening Intervals Study DesignIntervals mo. Screening outcome Santagostino 2002 1 (Milan, Italy) Multicenter comparative 559 hemophiliacs HCV+ 6 vs 12 No differences in detection of early cancer Jan 2006 2 (Taipei, TW) Community-based RCT 4,180 with mixed risks 6 vs 12 No differences in early cancer detection and mortality rates Trinchet 2007 3 (Bondi, F) Multicenter RCT 1,190 cirrhotics HCV/Etoh 3 vs 6No differences in detection. More false positives in the 3 month arm 1 Blood 2003;102:78-82; 2 J Hepatol 2006;44 Suppl 2:S4; 3 ILCA Proceedings Barcelona 5-7 October 2007, 11

6. Radiological Diagnosis of Hepatocellular Carcinoma in Patients With Cirrhosis EASL/AASLD Guidelines Imaging techniques contrast-enhanced US, contrast-enhanced spiral CT and gadolinium-enhanced MRI 1-2 cm nodetwo imaging techniques showing hyperenhanced node in the arterial phase and hypoenhanced node in the portal phase (wash-out) > 2 cm nodeone imaging technique EASL, AASLD & JSH Conference, Barcelona 2005; AASLD Practice Guidelines 2007; *Forner et al 2008 Prospective validation* 89 patients with a 5-20 mm nodule Sensitivity 33% CE – US + MRI Specificity 100%

7. The Diagnosis of HCC at Two Coincidental Imaging Techniques in 55 1-2 cm Liver Nodules in 54 Cirrhotic Patients CE-US and CTCE-US and MRICT and MRI Sensitivity(%)5056 Specificity (%)899086 Early arterial hypervascularization CE-US and CTCE-US and MRICT and MRI Sensitivity(%)262841 Specificity (%)100 Portal/venous wash-out CE-US and CTCE-US and MRICT and MRI Sensitivity(%)211826 Specificity (%)100 Combined Sangiovanni et al 2009 submitted

8. Number and Estimated Cost of the Stepwise Investigations for the Assessment of 55 1-2 cm  Nodules in 54 Cirrhotic Patients 1st step2nd step3rd stepNo. FNBAggreg. Cost (€) HCC diagnosis by at least 1 single imaging CE-USCTMRI3328,667 MRICT3330,215 CTCE-USMRI3328,909 RMCE-US3329,346 MRICTCE-US3330,970 CE-USCT3330,607 AASLD criteria CE-US and CTMRI4326,440 CE-US and MRICT4330,922 CT and MRICE-US4333,898 Sangiovanni et al 2009 submitted p=0.031

9. The Importance of Liver Biopsy To Discriminate Dysplastic Nodes (DN) from Early Hepatocellular Carcinoma (HCC) Diagnostic ApproachEtiologyDN HCCReference Histology Reticulin HBV/HCVStromal invasion (  )Stromal invasion (+)Kojiro et al 2005 Immunostain GPC-3 HBV/HCV HCV 83-100% negative 72-100% positiveCapurro et al 2003 Llovet et al 2006 PCR 13 genes GPC-3, survivin, LYVE-1 Mixed HCV 98% discriminative accuracy 94% discriminative accuracy Paradis et al 2003 Llovet et al 2006 Microarray assays 120 genes 93 genes HBV HCV 100% discriminative accuracyNam et al 2005 Wurmbach et al 2007

10. The Importance of Liver Biopsy To Identify a Very Early HCC Nakashima O et al, Hepatology 1995;22:101-105; Kojiro M et al, Sem Liver Dis 2005;25:133-142 Distinctly nodular, earlyVaguely nodular, very early Hypervascular on contrast imagingHypovascular on contrast imaging Very early HCC:17% of all HCCs 1-2 cm in size (Bolondi et al 2005) 5-yr survival after resection: 93% vs 54% early (Takayama et al 1998) cm

11. A RCT of Population-based Screening for HCC: The Importance of Early Diagnosis for Improving Liver-Related Mortality Findings Screened group Control group (pp x yr = 38,444) (pp x yr = 41,077) HCC occurrence Cases 86 67 Early cancer 39 0 Total incidence (per 100,000)223.7163.1 Rate ratio (95% CI)1.37 (0.99, 1.89)reference Deaths from HCC Deaths 32 54 Total mortality (per 100,000) 83.2131.5 Rate ratio (95% CI)0.63 (0.41, 0.98)reference RCT in urban Shanghai, abdominal US+AFP every 6 months, HBV / chronic hepatitis Limitations: patients with cirrhosis unknown, suboptimal compliance (58%), no transplant Zhang BH, J Cancer Res Clin Oncol 2004;130:417-422

12. Clinic-based Surveillance for HCC in Cirrhotics: The Importance of Treatment Refinement for Improving Liver-Related Mortality Sangiovanni A, et al Gastroenterology 2004;126:1005-1014 52 3.7 (1.5-8) 28% 34% 69% 45% 37 3.0 (1.5-6.0) 38% 28% 100% 37% 23 2.2 (1.4-3.1) 43% 5% 92% 10% HCC, No. HCC size, cm Radical treatments Mortality in treated Mortality in untreated Overall mortality 1987-911992-961997-2001Outcomes = 0.02 = 0.024 n.s. = 0.0009 A prospective cohort study of 447 patients with compensated cirrhosis of mixed etiology in Milan under surveillance with abdominal US and AFP. p-value

13. Improved Survival of HCC Patients Is More Influenced by Early Detection Than by Improvement of Medical Care Chie WC, et al J Evaluat Clin Pract 2007;13:79-85 NH Taiwan University Hospital. Data-base: 1988-1998: A=1989-1993, B=1994-1998 3,445 patients with HCC. 5-yr survival: 29% (A) vs 35% (B), p=0.01. Cancer type (B/A) Attributable proportion of advance in medical care 1 - (B/A) Attributable proportion of early detection Breast cancer0.230.77 Cervical cancer0.50 Colorectal cancer0.480.52 Gastric cancer0.240.76 Liver cancer0.340.66 Prostate cancer0.700.30

14. Markov Decision Models to Simulate Cost-utility Ratio of Surveillance According to AASLD/EASL Guidelines StudyEtiology of cirrhosis Incremental cost utility ratio (US$/QALY) Assumptions Everson et al 2000Mixed 35,0002.5% HCC x year Arguedas et al 2003HCV 26,68950-yr old eligible to OLT Patel et al 2005HCV 26,100 46,700 50,400 Hepatic resection Cadaveric liver transplant Living donor liver transplant Anderson et al 2008Mixed 30,700US alone Sarasin et al 1996Mixed 48,29360 % survival 3-yr after resection Saab at al 2003Mixed (Wait list) 74,000 Lin et al 2004HCV 73,789 Thompson Coon 2007Mixed£ 31,900Most alcohol-related

15. Conclusions 1.According to EASL/AASLD recommendations, patients at high risk for developing HCC should be entered into surveillance programs (Level 1). 2.In most industrialized countries > 50% of the patients with a diagnosis of HCC have been treated with screening and found eligible to radical treatments. 3.The disparity in outcomes between patients diagnosed with an early HCC compared to those with a more advanced tumor, strongly supports screening for HCC. 4.Though surveillance is appropriate when the risk of developing HCC is 1.5% or greater, the cost-effectiveness and the cost-benefit ratios of surveillance vary considerably depending on screening strategies and therapeutic options available.

16. Clinic-based Surveillance Programmes: The Compliance of Patients with Compensated Cirrhosis Authors CountryEtiologyNo.IntervalsFollow-upComplete drop-outs (months) (annual rate) Henrion 2003 BelgiumAlcohol1726 6015.3% Oka 1990 JapanMixed1402-3 36 6.6% Colombo 1991 ItalyMixed4473-12 33 4.7% Sangiovanni 2004 ItalyMixed4176-12148 4.0% Henrion 2003 BelgiumHCV 646 60 3.7% Velazquez 2003 SpainMixed4633-6 39 2.4% Pateron 1994 FranceMixed1186 36 1.1% Thompson Coon J et al Health Technol Assess 2007;11:No. 34