title: Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis.
abstract: OBJECTIVE
  Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.
  
  
  METHODS
  A Markov decision model was developed that compared three management strategies - immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression - for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model's strength was assessed with sensitivity analyses.
  
  
  RESULTS
  In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.
  
  
  CONCLUSIONS
  The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.
authors: Toronto General Research Institute, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. kbremner@uhnresearch.ca
authors: Karen E
authors: KE
authors: Bremner
authors: Ahmed M
authors: AM
authors: Bayoumi
authors: Morris
authors: M
authors: Sherman
authors: Murray D
authors: MD
authors: Krahn
mesh_terms: D001706:Biopsy; D002170:Canada; D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D003661:Decision Support Techniques; D006498:Hepatectomy; D006801:Humans; D008017:Life Expectancy; D008099:Liver / Q000473:pathology*; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008390:Markov Chains; D009364:Neoplasm Recurrence, Local; D017410:Practice Guidelines as Topic; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D016019:Survival Analysis
references: Ann Surg. 2002 Mar;235(3):373-82
references: 11882759
references: J Clin Oncol. 2002 Mar 15;20(6):1527-36
references: 11896101
references: Ann Surg. 2002 Apr;235(4):604; author reply 604-5
references: 11923620
references: Hepatology. 2004 Dec;40(6):1352-60
references: 15565564
references: J Gastrointest Surg. 2005 Jan;9(1):62-7; discussion 67-8
references: 15623446
references: Radiology. 2005 Feb;234(2):460-7
references: 15671002
references: Liver Transpl. 2000 Jan;6(1):67-72
references: 10648580
references: Hepatology. 2000 Apr;31(4):899-906
references: 10733546
references: Radiology. 2000 May;215(2):373-80
references: 10796910
references: Abdom Imaging. 2000 May-Jun;25(3):246-50
references: 10823443
references: Med Care. 2000 Jun;38(6):583-637
references: 10843310
references: Am J Gastroenterol. 2000 Jun;95(6):1535-8
references: 10894592
references: Ann Intern Med. 2000 Nov 7;133(9):665-75
references: 11074899
references: Gut. 2001 Feb;48(2):251-9
references: 11156649
references: N Engl J Med. 2001 Feb 15;344(7):495-500
references: 11172192
references: Am J Gastroenterol. 2001 Feb;96(2):579-83
references: 11232711
references: Cancer. 2001 Apr 15;91(8):1479-86
references: 11301395
references: Hepatology. 2001 May;33(5):1073-9
references: 11343234
references: Clin Liver Dis. 2001 May;5(2):479-507
references: 11385973
references: Ann Surg. 2001 Jul;234(1):63-70
references: 11420484
references: Ann Surg. 2001 Jul;234(1):71-8
references: 11420485
references: Transplantation. 2001 Sep 15;72(5):861-8
references: 11571451
references: J Hepatol. 2001 Aug;35(2):254-8
references: 11580148
references: J Hepatol. 2001 Sep;35(3):421-30
references: 11592607
references: Semin Oncol. 2001 Oct;28(5):450-9
references: 11685738
references: Hepatology. 2001 Dec;34(6):1109-12
references: 11731999
references: Gut. 2002 Jan;50(1):123-8
references: 11772979
references: Hepatology. 2002 Mar;35(3):519-24
references: 11870363
references: AJR Am J Roentgenol. 2002 Jul;179(1):67-73
references: 12076907
references: AJR Am J Roentgenol. 2002 Jul;179(1):75-80
references: 12076908
references: J Comput Assist Tomogr. 2002 Sep-Oct;26(5):691-8
references: 12439300
references: J Hepatol. 2003 Feb;38(2):237-9
references: 12547414
references: Radiology. 2003 Feb;226(2):543-9
references: 12563152
references: J Hepatol. 2003;38 Suppl 1:S136-49
references: 12591191
references: Am J Gastroenterol. 2003 Mar;98(3):630-8
references: 12650799
references: J Hepatol. 2003 Aug;39(2):269-71
references: 12873825
references: Cancer Invest. 2003 Jun;21(3):418-28
references: 12901288
references: J Surg Oncol. 2003 Sep;84(1):36-44; discussion 44
references: 12949989
references: Arch Surg. 2003 Nov;138(11):1207-13
references: 14609868
references: Lancet. 2003 Dec 6;362(9399):1907-17
references: 14667750
references: Hepatogastroenterology. 2003 Nov-Dec;50(54):2022-7
references: 14696457
references: Br J Surg. 2004 Feb;91(2):131-3
references: 14760656
references: Liver Transpl. 2004 Feb;10(2 Suppl 1):S26-9
references: 14762835
references: Liver Transpl. 2004 Feb;10(2 Suppl 1):S39-45
references: 14762838
references: Liver Transpl. 2004 Feb;10(2 Suppl 1):S58-63
references: 14762841
references: Liver Transpl. 2004 Feb;10(2 Suppl 1):S115-20
references: 14762851
references: Arch Surg. 2004 Feb;139(2):193-200
references: 14769580
references: Ann Surg Oncol. 2004 Mar;11(3):298-303
references: 14993025
references: J Am Coll Surg. 2004 Mar;198(3):356-65
references: 14992736
references: Med Decis Making. 2004 Jan-Feb;24(1):20-9
references: 15005951
references: Dig Dis Sci. 2004 Mar;49(3):453-8
references: 15139497
references: Aliment Pharmacol Ther. 2004 Jun 1;19(11):1159-72
references: 15153169
references: Clin Liver Dis. 2004 May;8(2):419-43, viii
references: 15481348
references: Gastroenterology. 2004 Nov;127(5 Suppl 1):S133-43
references: 15508077
references: Gastroenterology. 2004 Nov;127(5 Suppl 1):S248-60
references: 15508091
references: Med Decis Making. 1983;3(4):419-458
references: 6668990
references: Gastroenterology. 1985 Aug;89(2):259-66
references: 2408960
references: Gastroenterology. 1986 Feb;90(2):289-98
references: 2416627
references: J Hepatol. 1986;2(2):165-73
references: 3958472
references: Med Decis Making. 1985 Summer;5(2):157-77
references: 3831638
references: Gastroenterology. 1989 Jun;96(6):1566-71
references: 2469617
references: Cancer. 1989 Jun 1;63(11):2207-10
references: 2541886
references: N Engl J Med. 1991 Sep 5;325(10):675-80
references: 1651452
references: Hepatology. 1992 Jul;16(1):132-7
references: 1352268
references: HPB Surg. 1993;6(3):199-203; discussion 203-4
references: 8387809
references: Med Decis Making. 1993 Oct-Dec;13(4):322-38
references: 8246705
references: J Hepatol. 1994 Jan;20(1):117-21
references: 8201212
references: J Hepatol. 1994 Jan;20(1):65-71
references: 7515408
references: JAMA. 1995 May 24-31;273(20):1610-3
references: 7745775
references: Hepatology. 1995 Aug;22(2):432-8
references: 7543434
references: Hepatology. 1995 Dec;22(6):1863-73
references: 7489999
references: N Engl J Med. 1996 Mar 14;334(11):693-9
references: 8594428
references: Radiology. 1996 Oct;201(1):1-14
references: 8816509
references: Am J Med. 1996 Oct;101(4):422-34
references: 8873514
references: Med Decis Making. 1997 Apr-Jun;17(2):123-5
references: 9107606
references: Med Decis Making. 1997 Apr-Jun;17(2):142-51
references: 9107609
references: Med Decis Making. 1997 Apr-Jun;17(2):152-9
references: 9107610
references: Ann Intern Med. 1997 Nov 15;127(10):855-65
references: 9382363
references: Ann Intern Med. 1997 Nov 15;127(10):866-74
references: 9382364
references: Hepatology. 1998 Jan;27(1):273-8
references: 9425947
references: Hepatology. 1998 Aug;28(2):436-42
references: 9696009
references: Liver. 1998 Aug;18(4):251-4
references: 9766820
references: Hepatology. 1999 Jan;29(1):62-7
references: 9862851
references: JAMA. 1998 Dec 23-30;280(24):2088-93
references: 9875876
references: Surgery. 1999 Mar;125(3):332-8
references: 10076619
references: Lancet. 1999 Apr 10;353(9160):1253-7
references: 10217098
references: Gastroenterol Clin Biol. 1999 May;23(5):552-6
references: 10429862
references: Hepatology. 1999 Oct;30(4):889-93
references: 10498639
references: Semin Liver Dis. 1999;19(3):271-85
references: 10518307
references: J Clin Gastroenterol. 2005 Feb;39(2):152-9
references: 15681913
references: Am J Gastroenterol. 2005 Mar;100(3):643-51
references: 15743364
references: Am J Gastroenterol. 2003 Mar;98(3):679-90
references: 12650806
references: Dig Dis Sci. 2003 Mar;48(3):581-6
references: 12757173
references: Liver Transpl. 2003 Jul;9(7):672-81
references: 12827551
references: JAMA. 2003 Jul 9;290(2):228-37
references: 12851278
references: Crit Rev Oncol Hematol. 2003 Jul;47(1):13-27
references: 12853096
references: Hepatology. 2005 Nov;42(5):1208-36
references: 16250051
references: Ann Surg. 2006 Mar;243(3):321-8
references: 16495695