Liver
Screening
It is recommended that survivors of childhood cancer have yearly re-evaluations with their HCP for chronic health problems. Screening for liver problems should include a history to ascertain if there are any symptoms of:
- Anorexia
- Nausea or vomiting
- Weight loss
- Abdominal pain
Hepatitis C and B are very likely to be asymptomatic
Physical examination should look for signs of:
- Anemia
- Jaundice
- Spider angioma
- Palmar erythema
- Hepato-splenomegaly
- Ascites
Investigations should include:
- Routine blood work
- Including:
- CBC reticulocytes and platelets
- Lytes, creatinine and BUN
- liver enzyme levels:
- Alanine transaminase (ALT)
- Aspartate transaminase (AST)
- Bilirubin
If there are elevated liver enzymes then the albumin and prothrombin times should also be checked.
In addition for patients who have had multiple transfusions and are survivors of HSCT
- Serum ferritin
3–5% of the general population have asymptomatic persistent non-virus non-alcohol related aminotransferase elevation. The incidence of this biochemical abnormality appears to be increased in survivors of childhood cancer.
Testing for hepatitis B, C and A:
A high proportion of survivors and the health care professionals (HCPs) who look after them, are unaware of their transfusion exposure status. The COG Guidelines recommend that all patients treated prior to 1972 should have screening for hepatitis B and all patients treated prior to 1993 should have screening with a serum hepatitis C antibody test. These dates will vary for patients who received transfusions at non-U.S. institutions.
Further testing for the hepatitis C virus should be given to antibody negative patients with abnormal serum transaminases, hyperbilirubinemia, or those who may have a false negative antibody test because of persistent immunosuppression
Immune status against hepatitis A should be checked if the patient has hepatitis B and C - there is the potential for severe hepatitis with liver necrosis in the setting of chronic hepatitis C combined with acute hepatitis A.
Imaging studies:
After abdominal RT it is reasonable to perform an ultrasound scan every year or so to look at the liver parenchyma in detail and surrounding organs. Patients who have had any type of RT are at increased risk of a second malignancy arising within the RT field many years after treatment and this is a reasonable and prudent measure. There is however no evidence to justify this screening approach or to show that this reduces mortality.
In patients with established fibrosis it would be important to perform an ultrasound scan of the liver every year and a serum alpha fetoprotein to exclude hepatocellular carcinoma.
