Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis.
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.
Bremner
Karen E
KE
Toronto General Research Institute, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. kbremner@uhnresearch.ca
Bayoumi
Ahmed M
AM
Sherman
Morris
M
Krahn
Murray D
MD
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
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