Alternative Surveillance Improves Outcomes by Detecting Early-Stage Hepatocellular Carcinoma in Chronic Hepatitis B Patients.

Background/Aims: Current guidelines recommend biannual ultrasound for hepatocellular carcinoma (HCC) surveillance in chronic hepatitis B (CHB) patients. However, computed tomography (CT) or magnetic resonance imaging (MRI) may be used when ultrasound is inadequate. The clinical impact of these alternative modalities remains unclear. Methods: CHB patients undergoing regular HCC surveillance were classified into two groups: ultrasound-only and alternative surveillance (CT/MRI). Patients were stratified into high- and low-risk groups using the Risk Estimation for HCC in CHB (REACH-B) score. Outcomes included 10-year overall survival (OS), HCC tumor size, Barcelona Clinic Liver Cancer (BCLC) stage at diagnosis, and OS after HCC diagnosis. Propensity score matching was applied to balance baseline characteristics. Results: A total of 2,024 patients were included after propensity score matching to ensure balanced baseline characteristics, with 1,012 patients in each group. OS was similar (ultrasound-only 96.0% vs alternative 96.8%; p=0.379). HCC occurred in 66 patients in each group. Alternative surveillance detected smaller HCC tumors (1.6 cm vs 2.1 cm; p<0.001) and more BCLC stage 0 cases (alternative 71.2% vs ultrasound-only 42.4%; p=0.003). The OS after HCC diagnosis was higher with alternative surveillance (83.0% vs 67.0%; p=0.025). In high-risk patients (n=970), alternative surveillance increased the OS (97.3% vs 93.6%; p=0.029) and the OS after HCC diagnosis (83.0% vs 60.6%; p=0.010). No significant differences were observed in low-risk patients. Conclusions: CT/MRI-based alternative surveillance led to earlier HCC detection and improved post-diagnosis survival, particularly in high-risk CHB patients, supporting its potential role as an alternative to ultrasound in selected populations.