LIVER PROBLEMS

Consensus-based recommendation for surveillance of liver problems a

This page is part of the PanCare follow-up recommendations for surveillance of late effects. Click here, for more information on these recommendations.

On this page you can find:

Click here, to read this recommendation in PLAIN language.

Who is at risk for liver problems?

CAYA cancer survivors treated with or with a history of

  • radiotherapy to volume exposing the liver, including TBI
  • HSCT (irrespective of GvHD)
  • methotrexate
  • mercaptopurine
  • thioguanine
  • dactinomycin
  • busulfan
  • chronic viral hepatitis b
  • sinusoidal obstruction syndrome
  • chronic GvHD

What liver problems might occur?

  • Liver fibrosis or cirrhosis

  • Hepatocellular liver injury
  • Hepatobiliary dysfunction
  • Biliary tract injury
  • Liver synthetic dysfunction
  • Iron overload

What surveillance modality should be used and at what frequency should it be performed?

All survivors at risk:

  • Physical examination c
  • Measurement of serum liver enzyme concentrations (ALT, AST, gGT, ALP)
    once at entry into long-term follow-up

CAYA cancer survivors treated with radiotherapy to volume exposing the liver and HSCT:

  • Physical examination c
  • Measurement of serum liver enzyme concentrations (ALT, AST, gGT, ALP)
    repeat every 5 years

Survivors who have received ≥ 10 red blood cell transfusions:

  • Serum ferritin
    once at entry into long-term follow-up

What should be done if abnormalities are identified?

  • Refer to a (paediatric) hepatologist or gastroenterologist if persistent liver abnormalities d are identified
  • Avoid alcohol intake and medication that is metabolized via the liver if persistent liver abnormalities d are identified

What advice should be given regarding preventive health behaviours?

  • CAYA cancer survivors should be counselled about limited alcohol intake, immunization against hepatitis A and B, cautious use of drugs and complementary remedies that have a risk of liver injury, and precautions to reduce viral transmission to household and sexual contacts

Disclaimer

While PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication, we acknowledge that the sequence of referral and diagnostic tests might vary according to the local and national healthcare system logistics.

It is recognised that survivors and their healthcare professionals have the final responsibility for making decisions concerning their long-term follow-up care. As such, they may choose to either adopt these recommendations or not to do so after individual informed discussion. It is good practice to document this decision.

In addition to regular surveillance, real-time awareness and prompt reporting of new symptoms and signs is essential to the early detection and timely treatment of late effects.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

a Further recommendations regarding gastro-intestinal problems are specified in the Consensus-based recommendation for gastro-intestinal problems.

b We assume that survivors with chronic hepatitis are followed by an appropriate specialist (e.g. hepatologist or infectious disease specialist)

c Physical examination to check for signs of liver disease, i.e. hepatosplenomegaly and spider naevi.

d In case of increased liver enzyme values (>2x ULN), the test should be repeated after 2 months. If the values remain increased (>2 ULN) without an obvious explanation (alcohol, medication, obesity) then additional investigations should be undertaken in consultation with a hepatologist or gastroenterologist to ascertain a possible underlying cause: virus serology (CMV, EBV, HBV, HCV), ferritin, auto-antibodies, liver ultrasound and functionality of the liver (albumin, bilirubin, coagulation profile) and possibly liver biopsy.

a Further recommendations regarding gastro-intestinal problems are specified in the Consensus-based recommendation for gastro-intestinal
problems.

b We assume that survivors with chronic hepatitis are followed by an appropriate specialist (e.g. hepatologist or infectious disease specialist)

c Physical examination to check for signs of liver disease, i.e. hepatosplenomegaly and spider naevi.

d In case of increased liver enzyme values (>2x ULN), the test should be repeated after 2 months. If the values remain increased (>2 ULN) without an obvious explanation (alcohol, medication, obesity) then additional investigations should be undertaken in consultation with a hepatologist or gastroenterologist to ascertain a possible underlying cause: virus serology (CMV, EBV, HBV, HCV), ferritin, auto-antibodies, liver ultrasound and functionality of the liver (albumin, bilirubin, coagulation profile) and possibly liver biopsy.