LATE LIVER INJURY

Evidence-based recommendation for surveillance of late liver injury (IGHG a ) b

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 late liver injury?

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 c
  • sinusoidal obstruction syndrome
  • chronic GvHD

What late liver injury might occur?

  • Liver fibrosis or cirrhosis

  • Hepatocellular liver injury
  • Hepatobiliary dysfunction
  • Biliary tract injury
  • Liver synthetic dysfunction
  • Iron overload
  • Focal nodular hyperplasia (FNH) and nodular regenerative hyperplasia (NRH) d

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

All survivors at risk:

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

What should be done if abnormalities are identified?

  • In case of increased liver enzyme values between 1-2 x ULN the test should be repeated within 1 year
  • In case of increased liver enzyme values >2x ULN the test should be repeated within 2 months
  • If persistent liver abnormalities (> ULN) are identified:

    Refer to a hepatologist or gastroenterologist for further examination if there is no obvious explanation (alcohol, medication, obesity)
    Avoid or prescribe with caution potentially hepatotoxic medications and supplements
    Evaluate body mass index and discuss healthy weight goals, especially in those with evidence of metabolic syndrome
    Consider immunization against hepatitis A and B if not already immune
    Counsel about importance of measures to maintain liver health:

    Cautious use or avoidance of alcohol intake
    Maintain a healthy weight and lifestyle
    Precautions to reduce viral transmission to household and sexual contacts in survivors with chronic HBV/HCV infection

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 This recommendation reflects the recommendations of the evidence-based IGHG Late hepatic toxicity guideline (Late hepatic toxicity surveillance for survivors of childhood, adolescent and young adult cancer: Recommendations from the international late effects of childhood PanCareFollowUp Recommendations for long-term follow-up care 2024 47 cancer guideline harmonization group, Cancer Treatment Reviews, 2021, accessible through https://www.ighg.org/guidelines/topics/hepatic-toxicity/).

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

c We assume that survivors with chronic viral hepatitis are followed by an appropriate specialist (e.g. hepatologist or infectious diseases specialist). Follow-up should be performed in all survivors with a history of chronic viral hepatitis according to the hepatitis clinical practice guidelines in each country (expert opinion).

d We did not formulate surveillance recommendations for FNH and NRH due to the benign nature of FNH and because these are rare entities that are typically detected incidentally. These outcomes are written in this recommendation to increase awareness and to avoid unnecessary investigations.

e Physical examination to evaluate height, weight, and body mass index and check for signs of liver disease or bile duct injury, i.e. hepatosplenomegaly, jaundice/icterus, spider naevi, pruritus.