Abbreviated MRI for hepatocellular carcinoma screening: A systematic review and meta-analysis

Abbreviated MRI with second shot arterial phase for HCC evaluation: modified version of LI-RADS and recall reduction strategy

OBJECTIVES

To evaluate the feasibility of simulated abbreviated MRI (AMRI) with second shot arterial phase (SSAP) for HCC surveillance and diagnosis.

METHODS

A total of 129 consecutive patients (age, 58.8 ± 11.4 years; male, 71.3%) underwent gadoxetic acid-enhanced MRI using a modified injection protocol for HCC evaluation from July 2017 to February 2018. The modified injection protocol consisted of routine dynamic imaging (6 mL) and SSAP imaging (4 mL). Two radiologists independently reviewed two AMRI sets: AMRI without SSAP (surveillance set) and AMRI with SSAP (diagnosis set). A modified version of the Liver Imaging Reporting and Data System (LI-RADS) for the diagnosis set was devised by referring to contrast-enhanced ultrasound LI-RADS.

RESULTS

Sixty-seven patients with HCC and 62 patients without HCC were included. In the surveillance set, sensitivity and specificity for the detection of patients with HCC were 95.5% and 96.8%, and 94.0% and 96.8% in reviewers 1 and 2, respectively. In the diagnosis set, the scores of most HCCs (76/78, 97.4%) were consistent between LI-RADS of full-protocol and modified LI-RADS of AMRI with SSAP protocol. When the HCC surveillance and diagnosis strategy was changed from strategy 1 (AMRI without SSAP) to strategy 2 (AMRI with SSAP), the recall rate significantly decreased from 52.7 to 3.9% (p < 0.001).

CONCLUSIONS

The modified LI-RADS score of the AMRI with SSAP protocol showed high agreement with the LI-RADS score of the full protocol. The HCC surveillance and diagnosis strategy using the AMRI with SSAP protocol reduced the recall rate. These results may enable to diagnose HCC simultaneously with surveillance.

KEY POINTS

• A modified version of LI-RADS was devised for the diagnostic algorithm using AMRI with the second shot arterial phase (SSAP) by referring to CEUS LI-RADS. • The modified LI-RADS scores using AMRI with SSAP showed a high concordance rate with the conventional LI-RADS score using full-protocol MRI. • The recall rate significantly decreased when the HCC surveillance and diagnosis strategy was changed from strategy 1 (AMRI without SSAP; surveillance then recall test) to strategy 2 (AMRI with SSAP; simultaneous surveillance and diagnosis).

Hepatitis delta virus: Disease assessment and stratification

Hepatitis D virus (HDV) causes one of the most severe forms of hepatitis in people with chronic hepatitis B (CHB) infection. Timely and accurate assessment of hepatitis delta virus (HDV) and disease stratification is mandatory for thorough pre-therapeutic evaluation for prioritizing treatment and outcome prediction. Viral biomarkers associated with HDV and hepatitis B virus (HBV) are crucial to aid in diagnosis, and monitoring of serum viral nucleic acids for both viruses is recommended. Liver biopsy remains the gold standard for staging of liver fibrosis and grading of histological activity and should remain central for diagnostic purposes, but is also of importance for research to enhance our understanding of HDV. The emergence of novel non-invasive tests for the assessment of liver fibrosis in HDV patients coupled with the well-recognized potential complications of liver biopsy has resulted in reduced utility of liver biopsy in clinical practice. Preliminary data suggest that these emerging non-invasive modalities appear to be reliable, and their use is supported, similar to other viral hepatitis. Nevertheless, further validation is required before their widespread adoption into clinical practice.

Emerging Tools for Hepatocellular Carcinoma Surveillance

Abdominal ultrasound, with or without alpha-fetoprotein, is the recommended strategy for hepatocellular carcinoma (HCC) surveillance but misses over one-third of HCC at an early stage. Emerging imaging modalities, including computed tomography and magnetic resonance imaging, have early data showing high sensitivity for early-stage HCC, but potential issues such as radiologic capacity, patient acceptance, cost-effectiveness, and need for validation in Western non-hepatitis B virus populations still need to be evaluated. Similarly, blood-based biomarker panels, including GALAD and liquid biopsy techniques, have shown promising data in phase II case-control studies and may concurrently help address issues of surveillance underuse; however, these tools require validation in phase III and IV cohort studies. While awaiting prospective validation data for these emerging strategies, ultrasound with or without alpha-fetoprotein remains the current gold standard HCC surveillance strategy.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Indian College of Radiology and Imaging Guidelines on Interventions in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies and a significant cause of cancer-related death. Treatment of HCC depends on the stage of the tumor. As many patients with HCC are not deemed fit for surgical resection or liver transplantation, locoregional therapies play an essential role in the management. Image-guided locoregional treatments include percutaneous ablative therapies and endovascular therapies. The choice of an individual or a combination of therapies is guided by the tumor and patient characteristics. As the outcomes of image-guided locoregional treatments depend on the ability to achieve necrosis of the entire tumor along with a safety margin around it, it is mandatory to follow standard guidelines. In this manuscript, we discuss in detail the various aspects of image-guided locoregional therapies to guide interventional radiologists involved in the care of patients with HCC.

Mesoporous Nanoparticles for Diagnosis and Treatment of Liver Cancer in the Era of Precise Medicine

Primary liver cancer is the seventh-most-common cancer worldwide and the fourth-leading cause of cancer mortality. In the current era of precision medicine, the diagnosis and management of liver cancer are full of challenges and prospects. Mesoporous nanoparticles are often designed as specific carriers of drugs and imaging agents because of their special morphology and physical and chemical properties. In recent years, the design of the elemental composition and morphology of mesoporous nanoparticles have greatly improved their drug-loading efficiency, biocompatibility and biodegradability. Especially in the field of primary liver cancer, mesoporous nanoparticles have been modified as highly tumor-specific imaging contrast agents and targeting therapeutic medicine. Various generations of complexes and structures have been determined for the complicated clinical management requirements. In this review, we summarize these advanced mesoporous designs in the different diagnostic and therapeutic fields of liver cancer and discuss the relevant advantages and disadvantages of transforming applications. By comparing the material properties, drug-delivery characteristics and application methods of different kinds of mesoporous materials in liver cancer, we try to help determine the most suitable drug carriers and information media for future clinical trials. We hope to improve the fabrication of biomedical mesoporous nanoparticles and provide direct evidence for specific cancer management.

Potential of a Non-Contrast-Enhanced Abbreviated MRI Screening Protocol (NC-AMRI) in High-Risk Patients under Surveillance for HCC

PURPOSE

To evaluate NC-AMRI for the detection of HCC in high-risk patients.

METHODS

Patients who underwent yearly contrast-enhanced MRI (i.e., full MRI protocol) of the liver were included retrospectively. For all patients, the sequences that constitute the NC-AMRI protocol, namely diffusion-weighted imaging (DWI), T2-weighted (T2W) imaging with fat saturation, and T1-weighted (T1W) in-phase and opposed-phase imaging, were extracted, anonymized, and uploaded to a separate research server and reviewed independently by three radiologists with different levels of experience. Reader I and III held a mutual training session. Levels of suspicion of HCC per patient were compared and the sensitivity, specificity, and area under the curve (AUC) using the Mann-Whitney U test were calculated. The reference standard was a final diagnosis based on full liver MRI and clinical follow-up information.

RESULTS

Two-hundred-and-fifteen patients were included, 36 (16.7%) had HCC and 179 (83.3%) did not. The level of agreement between readers was reasonable to good and concordant with the level of expertise and participation in a mutual training session. Receiver operating characteristics (ROC) analysis showed relatively high AUC values (range 0.89-0.94). Double reading showed increased sensitivity of 97.2% and specificity of 87.2% compared with individual results (sensitivity 80.1%-91.7%-97.2%; specificity 91.1%-72.1%-82.1%). Only one HCC (2.8%) was missed by all readers.

CONCLUSION

NC-AMRI presents a good potential surveillance imaging tool for the detection of HCC in high-risk patients. The best results are achieved with two observers after a mutual training session.

Comparison of a multitarget blood test to ultrasound and alpha-fetoprotein for hepatocellular carcinoma surveillance: Results of a network meta-analysis

Ultrasound‐based surveillance has suboptimal sensitivity for early detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. There are several emerging alternatives, including a novel multitarget HCC blood test (Mt‐HBT). We compared performance of mt‐HBT against ultrasound with or without alpha‐fetoprotein (AFP) for early HCC detection in patients with cirrhosis. Per the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines, two reviewers searched PubMed, Cochrane, Embase, and clinicaltrials.gov databases from January 1990 through December 2020 to identify studies reporting sensitivity and/or specificity of ultrasound and AFP for overall and early stage HCC detection in patients with cirrhosis. Mt‐HBT diagnostic performance was derived from a clinical validation study. A network meta‐analysis model was built for comparative assessment, and pooled estimates of sensitivity at a fixed specificity were estimated based on Bayesian binormal receiver operating characteristic models for each modality. Forty‐one studies (comprising 62,517 patients with cirrhosis) met inclusion criteria. Ultrasound‐alone sensitivity was 51.6% (95% credible interval [CrI], 43.3%–60.5%) for early stage HCC detection, which increased with the addition of AFP to 74.1% (95% CrI, 62.6%–82.4%); however, this was offset by decreased specificity (87.9% vs. 83.9%, respectively). With specificity fixed at 90%, mt‐HBT sensitivity for early stage HCC detection was higher than ultrasound alone (18.2%; 95% CrI, 0.2%–37.7%) and similar to ultrasound with AFP (−3.3%; 95% CrI, −22.3%–17.4%). Pairwise posterior probabilities suggested a preference for mt‐HBT over ultrasound alone in 97.4% of cases but only 36.3% of cases versus ultrasound with AFP. Conclusion: A blood‐based mt‐HBT has higher sensitivity than ultrasound alone for early stage HCC detection but similar sensitivity compared to ultrasound and AFP. Mt‐HBT could be a comparable alternative to existing methods for HCC surveillance in patients who are at risk.

Abbreviated magnetic resonance imaging vs ultrasound for surveillance of hepatocellular carcinoma in high-risk patients

BACKGROUND & AIMS

We aimed to compare the performance of gadoxetic acid-enhanced abbreviated MRI (AMRI)-based surveillance and ultrasound-only surveillance in high-risk patients for hepatocellular carcinoma (HCC).

METHODS

Prospectively recruited high-risk patients (>5% annual risk of HCC) who underwent one to three rounds of complete gadoxetic acid-enhanced MRI (CMRI) and ultrasound at 6-months intervals were retrospectively analysed. AMRI consisted of diffusion-weighted, T2-weighted, and hepatobiliary phase imaging. The sensitivity, specificity, and accuracy of CMRI followed by AMRI (CAA), AMRI-only (AAA), and ultrasound-only (US) were compared using generalized estimating equations. Image quality was assessed.

RESULTS

In 382 patients, HCC was diagnosed in 43 (11.3%), including 42 with early-stage HCCs. The sensitivities of CAA (90.7%, 39/43) and AAA (86.0%, 37/43) were higher than US (27.9% [12/43]; P < 0.001), whereas the sensitivities of the two MRI approaches did not significantly differ (P = 0.56). The specificity of CAA (97.1%, 983/1012) was higher than AAA (95.6% [967/1012]; P = 0.01) and not significantly different from US (96.3% [975/1012]; P = 0.59). The CAA approach had the best accuracy of 96.9% (1022/1055), higher than the AAA approach (95.2% [1004/1055]; P = 0.01) and the US approach (93.6% [987/1055]; P = 0.01). Image quality was inadequate in 33.7% (356/1055) of US examinations but in only 10.0% (105/1055) of the AAA and 11.1% (117/1055) of the CAA approach.

CONCLUSIONS

In high-risk patients, AMRI-based surveillance approaches had higher sensitivities than ultrasound-only surveillance for early-stage HCC. A sequential MRI approach of CMRI followed by AMRIs showed superior accuracy than the AMRI-only or ultrasound-only approach.

Abbreviated non-enhanced magnetic resonance imaging in patients with acute necrotizing pancreatitis

AIM

To investigate the performance of T2-weighted abbreviated magnetic resonance imaging (T2W-AMRI) protocol in evaluating patients with acute necrotizing pancreatitis (ANP).

METHODS

A retrospective analysis of consecutive hospitalized patients with ANP who underwent MRI (contrast-enhanced, CE or non-contrast, NC) between January 2017 and November 2020 was performed. The T2W-AMRI and complete MRI (cMRI) sequences were anonymized, and subsequently, two separate sets of data (AMRI and cMRI) were created for presentation to the radiologists involved in reading the data. The T2W-AMRI was based on a single-axial T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence. The pancreatic and extrapancreatic findings were recorded and tabulated independently by two radiologists on T2W-AMRI and cMRI. In addition, the interobserver agreement and association of findings between T2W-AMRI and cMRI were analyzed.

RESULTS

Twenty-eight patients (mean age 31.7 ± 12.2 years, 17 females) were included. Thirteen patients had CE-cMRI, while the rest underwent NC-cMRI. There was no significant difference in the identification of pancreatic necrosis on T2W-AMRI vs. cMRI (p = 1.00). However, T2W-AMRI underestimated necrosis in one patient. Collections were accurately detected in all patients on T2W-AMRI. The mean size of the collection was larger on cMRI (6.5 ± 3.7 cm) than T2W-AMRI (6 ± 3.7 cm) with p = 0.006. cMRI detected more patients with disrupted pancreatic duct (n = 9) than T2W-AMRI (n = 6). However, the difference was not statistically significant (p = 0.375). There was a good to an excellent interobserver agreement between the readers for T2W-AMRI (k = 0.62-1).

CONCLUSION

T2W-AMRI may offer a suitable alternative to cMRI in ANP, especially severe disease, as it can be acquired rapidly without the need for contrast injection.

Early detection of hepatocellular carcinoma: roadmap for improvement

INTRODUCTION

Hepatocellular carcinoma (HCC) has a poor prognosis, related, in part, to frequent late-stage diagnosis. Improved implementation of effective HCC surveillance is critical to reduce HCC mortality.

AREAS COVERED

We performed a targeted literature review to identify intervention targets for improving HCC surveillance effectiveness, including enriched risk stratification tools, improved surveillance tools with higher accuracy for early HCC detection, and increasing surveillance adherence.

EXPERT OPINION

HCC surveillance has been demonstrated to be efficacious in several cohort studies but has lower surveillance effectiveness in clinical practice. HCC surveillance is currently recommended in all patients with cirrhosis, and improved risk stratification using clinical risk scores, genetic scores, and novel biomarkers are important to move from a 'one-size-fits-all' strategy to one more aligned with values of precision medicine. Current surveillance modalities, ultrasound, and AFP, miss over one-third of HCC at an early stage and are associated with potential surveillance harms, underscoring a need for alternative surveillance strategies with higher accuracy. MRI- and biomarker-based surveillance strategies have promising early data in phase II studies but require validation in phase III cohorts before routine use in practice. Finally, surveillance is underused in clinical practice, highlighting a need for intervention strategies to increase utilization.

Magnetic resonance imaging for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and third in terms of cancer deaths. In clinical practice, magnetic resonance imaging (MRI) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-fetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study (computed tomography (CT) or MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is considered valid to diagnose hepatocellular carcinoma. The detection of hepatocellular carcinoma amenable to surgical resection could improve the prognosis. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma may, therefore, be missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of MRI may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of MRI in people with chronic liver disease who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma.

OBJECTIVES

Primary: to assess the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease. Secondary: to assess the diagnostic accuracy of MRI for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease, and to identify potential sources of heterogeneity in the results.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test of Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, and three other databases to 9 November 2021. We manually searched articles retrieved, contacted experts, handsearched abstract books from meetings held during the last 10 years, and searched for literature in OpenGrey (9 November 2021). Further information was requested by e-mails, but no additional information was provided. No data was obtained through correspondence with investigators. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and we tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 34 studies, with 4841 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time interval between the index test and the reference standard was rarely defined. Regarding applicability, we judged 15% (5/34) of studies to be at low concern and 85% (29/34) of studies to be at high concern mostly owing to characteristics of the participants, most of whom were on waiting lists for orthotopic liver transplantation, and due to pathology of the explanted liver being the only reference standard. MRI for hepatocellular carcinoma of any size and stage: sensitivity 84.4% (95% CI 80.1% to 87.9%) and specificity 93.8% (95% CI 90.1% to 96.1%) (34 studies, 4841 participants; low-certainty evidence). MRI for resectable hepatocellular carcinoma: sensitivity 84.3% (95% CI 77.6% to 89.3%) and specificity 92.9% (95% CI 88.3% to 95.9%) (16 studies, 2150 participants; low-certainty evidence). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results.

AUTHORS' CONCLUSIONS

We found that using MRI as a second-line imaging modality to diagnose hepatocellular carcinoma of any size and stage, 16% of people with hepatocellular carcinoma would be missed, and 6% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 16% of people with resectable hepatocellular carcinoma would improperly not be resected, while 7% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.

Editorial: screening for hepatocellular carcinoma in NAFLD-towards abbreviated MRI alternative in patients with obesity?

This article is linked to Huang et al papers. To view these articles, visit https://doi.org/10.1111/apt.16844 and https://doi.org/10.1111/apt.16908

Predicting the risk of hepatocellular carcinoma in chronic hepatitis B patients receiving antiviral therapy: Validating the CAMD and AASL scores in China

BACKGROUND

We aimed to validate the predictive value of the cirrhosis, age, male sex, and diabetes (CAMD) score and age, albumin, sex, and liver cirrhosis (AASL) score for chronic hepatitis B (CHB) patients, treated with nucleos(t)ide analogues (NUCs) in Northeast China.

METHODS

From January 2009 to June 2020, 945 patients diagnosed with CHB who received NUC therapy at China-Japan Union Hospital of Jilin University were included. Comprehensive medical records were retrospectively analyzed, and the predictive values of the CAMD score and AASL score for hepatocellular carcinoma (HCC) were evaluated.

RESULTS

A total of 58 patients (5.94%) were diagnosed with HCC. Multivariate analysis revealed that age [odds ratio (OR) = 1.041, 95% confidence interval (CI) 1.009-1.073, P < 0.011] and cirrhosis (OR = 3.297, 95% CI 1.383-7.861, P < 0.007) were independent predictors of HCC. Either the CAMD or AASL score was significantly higher in the HCC group compared to the non-HCC group. The area under the receiver operating characteristic (ROC) curve (AUC) of CAMD and AASL was 0.721 (95% CI 0.663-0.780) and 0.718 (95% CI 0.662-0.774), respectively. Risk stratification using either CAMD or AASL revealed significant differences in the one-, three-, and five-year cumulative incidence rates of HCC between the low-, intermediate-, and high-risk groups (all P < 0.001, log-rank test).

CONCLUSIONS

Both CAMD and AASL scores have predictive value for HCC risk of CHB patients in Northeast China. In future, the optimal monitoring frequency and methods should be personalized.

Early hepatocellular carcinoma detection using magnetic resonance imaging is cost-effective in high-risk patients with cirrhosis

Background & Aims

Reinforced hepatocellular carcinoma (HCC) surveillance using magnetic resonance imaging (MRI) could increase early tumour detection but faces cost-effectiveness issues. In this study, we aimed to evaluate the cost-effectiveness of MRI for the detection of very early HCC (Barcelona Clinic Liver Cancer [BCLC] 0) in patients with an annual HCC risk >3%.

Methods

French patients with compensated cirrhosis included in 4 multicentre prospective cohorts were considered. A scoring system was constructed to identify patients with an annual risk >3%. Using a Markov model, the economic evaluation estimated the costs and life years (LYs) gained with MRI vs. ultrasound (US) monitoring over a 20-year period. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the incremental costs by the incremental LYs.

Results

Among 2,513 patients with non-viral causes of cirrhosis (n = 840) and/or cured HCV (n = 1,489)/controlled HBV infection (n = 184), 206 cases of HCC were detected after a 37-month follow-up. When applied to training (n = 1,658) and validation (n = 855) sets, the construction of a scoring system identified 33.4% and 37.5% of patients with an annual HCC risk >3% (3-year C-Indexes 75 and 76, respectively). In patients with a 3% annual risk, the incremental LY gained with MRI was 0.4 for an additional cost of €6,134, resulting in an ICER of €15,447 per LY. Compared to US monitoring, MRI detected 5x more BCLC 0 HCC. The deterministic sensitivity analysis confirmed the impact of HCC incidence. At a willingness to pay of €50,000/LY, MRI screening had a 100% probability of being cost-effective.

Conclusions

In the era of HCV eradication/HBV control, patients with annual HCC risk >3% represent one-third of French patients with cirrhosis. MRI is cost-effective in this population and could favour early HCC detection.

Lay summary

The early identification of hepatocellular carcinoma in patients with cirrhosis is important to improve patient outcomes. Magnetic resonance imaging could increase early tumour detection but is more expensive and less accessible than ultrasound (the standard modality for surveillance). Herein, using a simple score, we identified a subgroup of patients with cirrhosis (accounting for >one-third), who were at increased risk of hepatocellular carcinoma and for whom the increased expense of magnetic resonance imaging would be justified by the potential improvement in outcomes.

Rational HCC screening approaches for patients with NAFLD

Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of developing hepatocellular carcinoma (HCC), especially among those who have cirrhosis or advanced fibrosis, but 20-30% of cases of NAFLD-related HCC occur in the absence of advanced fibrosis. The prevalence of NAFLD-related HCC is increasing in most countries worldwide. There are few direct data to support or refute the efficacy or effectiveness of HCC surveillance in NAFLD or to guide its application. We use evidence on surveillance in other conditions and studies on the clinical course of patients with NAFLD to arrive at recommendations for rational approaches to HCC surveillance in this growing cohort of patients. We also outline gaps in research and practice, including opportunities to advance the field.

Inter-reader agreement of abbreviated magnetic resonance imaging for hepatocellular carcinoma detection: a systematic review and meta-analysis

PURPOSE

To determine the inter-reader agreement of abbreviated magnetic resonance imaging (AMRI) for the detection of hepatocellular carcinoma (HCC) and explore the causes of heterogeneity between the reported results.

METHODS

Original studies reporting the inter-reader agreement of AMRI for detecting HCC were identified in MEDLINE, EMBASE, and Cochrane databases. The pooled kappa coefficient (κ) was calculated using the DerSimonian-Laird random-effects model. Subgroup analyses were performed according to the AMRI protocol (non-contrast [NC]-AMRI, dynamic contrast-enhanced [DCE]-AMRI, and hepatobiliary phase [HBP]-AMRI). Meta-regression analyses were performed to further explore study heterogeneity.

RESULTS

In the eight included studies (1182 patients), the overall pooled κ was 0.76 (95% confidence interval [CI], 0.70-0.82; I² = 74.4%). The κ of NC-AMRI, DCE-AMRI, and HBP-AMRI were 0.72 (95% CI, 0.62-0.82), 0.80 (95% CI, 0.78-0.82), and 0.98 (95% CI, 0.95-1.00), respectively. In the NC-AMRI, the pooled κ of NC-AMRI using only diffusion-weighted imaging (DWI) was 0.64, which was lower than the values using two or more imaging sequences (κ = 0.74-0.77). In subgroup analysis, no study heterogeneity was noted in studies using DCE-AMRI (I² = 0%), whereas high heterogeneity was noted with NC-AMRI (I² = 80.5%). Especially, NC-AMRI including more than two imaging sequences showed high residual heterogeneity (I² = 87.6%). Meta-regression analysis found that difference in reader experience was significantly associated with study heterogeneity (p = .02).

CONCLUSION

AMRI for detecting HCC showed substantial inter-reader agreement across all examined protocols. NC-AMRI, notably NC-AMRI using only DWI, had relatively low inter-reader agreement. Therefore, DCE-AMRI or HBP-AMRI may be more reliable than NC-AMRI using only DWI.

Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance

While ultrasound (US) is considered an important tool for hepatocellular carcinoma (HCC) surveillance, it has limited sensitivity for detecting early-stage HCC. Abbreviated MRI (AMRI) has recently gained popularity owing to better sensitivity in its detection of early-stage HCC than US, while also minimizing the time and cost in comparison to complete contrast-enhanced MRI, as AMRI includes only a few essential sequences tailored for detecting HCC. Currently, three AMRI protocols exist, namely gadoxetic acid-enhanced hepatobiliary-phase AMRI, dynamic contrast-enhanced AMRI, and non-enhanced AMRI. In this study, we discussed the rationale and technical details of AMRI techniques for achieving optimal surveillance performance. The strengths, weaknesses, and current issues of each AMRI protocol were also elucidated. Moreover, we scrutinized previously performed AMRI studies regarding clinical and technical factors. Reporting and recall strategies were discussed while considering the differences in AMRI protocols. A risk-stratified approach for the target population should be taken to maximize the benefits of AMRI and the cost-effectiveness should be considered. In the era of multiple HCC surveillance tools, patients need to be fully informed about their choices for better adherence to a surveillance program.

Imaging Diagnosis of HCC: Future directions with special emphasis on hepatobiliary MRI and contrast-enhanced ultrasound

Hepatocellular carcinoma (HCC) is a unique cancer entity that can be noninvasively diagnosed using imaging modalities without pathologic confirmation. In 2018, several major guidelines for HCC were updated to include hepatobiliary contrast agent magnetic resonance imaging (HBA-MRI) and contrast-enhanced ultrasound (CEUS) as major imaging modalities for HCC diagnosis. HBA-MRI enables the achievement of high sensitivity in HCC detection using the hepatobiliary phase (HBP). CEUS is another imaging modality with real-time imaging capability, and it is reported to be useful as a second-line modality to increase sensitivity without losing specificity for HCC diagnosis. However, until now, there is an unsolved discrepancy among guidelines on whether to accept “HBP hypointensity” as a definite diagnostic criterion for HCC or include CEUS in the diagnostic algorithm for HCC diagnosis. Furthermore, there is variability in terminology and inconsistencies in the definition of imaging findings among guidelines; therefore, there is an unmet need for the development of a standardized lexicon. In this article, we review the performance and limitations of HBA-MRI and CEUS after guideline updates in 2018 and briefly introduce some future aspects of imaging-based HCC diagnosis.

[Current Status and Future Directions of Hepatocellular Carcinoma Surveillance Test Based on Cost-effective Analysis]

Detection of hepatocellular carcinoma (HCC) at an early stage enables patients to receive curative treatment with survival gains. Current international liver society guidelines recommend the enrollment of patients at high risk for HCC in surveillance programs. In Korea, surveillance for HCC advocated for patients with chronic hepatitis B, chronic hepatitis C, and liver cirrhosis. The established surveillance tool for HCC is liver ultrasonography plus serum alpha-fetoprotein measurement every 6 months. However, there would be obstacles to the improvement of efficacy and cost-effectiveness of the HCC surveillance test. Assessing who is at risk of developing HCC remains incompletely validated. Also, which surveillance tools to use according to patients' characteristics are controversial. The present paper reviews the latest knowledge regarding the strategies and cost-effectiveness of HCC surveillance.

Hepatocellular Carcinoma in 2021: An Exhaustive Update

Primary liver cancer is a challenging global health concern with an estimated more than a million persons to be affected annually by the year 2025. The commonest type is hepatocellular carcinoma (HCC), which has been increasing in incidence the world over, mostly due to chronic viral hepatitis B infection. In the last decade, paradigm changes in the etiology, understanding of molecular biology, and pathogenesis, including the role of gut microbiota; medical and surgical treatments, and outcome trends are notable. The application of omics-based technology has helped us unlock the molecular and immune landscape of HCC, through which novel targets for drug treatment such as immune-checkpoint inhibitors have been identified. Novel tools for the surveillance and diagnosis of HCC include protein-, genomics-, and composite algorithm-based clinical/biomarker panels. Magnetic resonance imaging-based novel techniques have improved HCC diagnosis through ancillary features that enhance classical criteria while positron emission tomography has shown value in prognostication. Identification of the role of gut microbiota in the causation and progression of HCC has opened areas for novel therapeutic research. A select group of patients still benefit from modified surgical and early interventional radiology treatments. Improvements in radiotherapy protocols, identification of parameters of futility among radiological interventions, and the emergence of novel first-line systemic therapies that include a combination of antiangiogenic and immune-checkpoint inhibitors have seen a paradigm change in progression-free and overall survival. The current review is aimed at providing exhaustive updates on the etiology, molecular biology, biomarker diagnosis, imaging, and recommended treatment options in patients with HCC.

Screening for Hepatocellular Carcinoma in Chronic Hepatitis B: An Update

(1) Background: Hepatocellular carcinoma (HCC) is an important cause of mortality in individuals with chronic hepatitis B infection, with screening of high-risk groups recommended in all major international guidelines. Our understanding of the risk factors involved has improved over time, encouraging researchers to develop models that predict future risk of HCC development. (2) Methods: A literature search of the PubMed database was carried out to identify studies that derive or validate models predicting HCC development in patients with chronic hepatitis B. Subsequently, a second literature search was carried out to explore the potential role of novel viral biomarkers in this field. (3) Results: To date, a total of 23 models have been developed predicting future HCC risk, of which 12 have been derived from cohorts of treatment-naïve individuals. Most models have been developed in Asian populations (n = 20), with a smaller number in Caucasian cohorts (n = 3). All of the models demonstrate satisfactory performance in their original derivation cohorts, but many lack external validation. In recent studies, novel viral biomarkers have demonstrated utility in predicting HCC risk in patients with chronic hepatitis B, amongst both treated and treatment-naïve patients. (4) Conclusion: Several models have been developed to predict the risk of HCC development in individuals with chronic hepatitis B infection, but many have not been externally validated outside of the Asian population. Further research is needed to refine these models and facilitate a more tailored HCC surveillance programme in the future.

Meta-Analysis of the Accuracy of Abbreviated Magnetic Resonance Imaging for Hepatocellular Carcinoma Surveillance: Non-Contrast versus Hepatobiliary Phase-Abbreviated Magnetic Resonance Imaging

Simple Summary

Ultrasonography is recommended as a standard surveillance modality, but the performance of surveillance ultrasound for detecting early-stage hepatocellular carcinoma (HCC) is limited. Motivated to provide a more sensitive method, abbreviated magnetic resonance imaging (AMRI) protocols have been introduced for HCC surveillance. We aimed to systematically determine the diagnostic performance of surveillance AMRI for detecting HCC. This meta-analysis of 10 studies comprising 1547 patients found that the pooled sensitivity and specificity of surveillance AMRI for detecting HCC were 86% and 96%, respectively. Hepatobiliary phase contrast-enhanced AMRI showed significantly higher sensitivities for detecting HCC than non-contrast AMRI (87% vs. 82%), but significantly lower specificities (93% vs. 98%). Therefore, surveillance AMRI had overall good diagnostic performance for detecting HCC and might be clinically useful for HCC surveillance. In addition, AMRI protocol should be selected with consideration of the advantages and disadvantages of each protocol.

Abstract

We aimed to determine the performance of surveillance abbreviated magnetic resonance imaging (AMRI) for detecting hepatocellular carcinoma (HCC), and to compare the performance of surveillance AMRI according to different protocols. Original research studies reporting the performance of surveillance AMRI for the detection of HCC were identified in MEDLINE, EMBASE, and Cochrane databases. The pooled sensitivity and specificity of surveillance AMRI were calculated using a hierarchical model. The pooled sensitivity and specificity of contrast-enhanced hepatobiliary phase (HBP)-AMRI and non-contrast (NC)-AMRI were calculated and compared using bivariate meta-regression. Ten studies, including 1547 patients, reported the accuracy of surveillance AMRI. The pooled sensitivity and specificity of surveillance AMRI for detecting any-stage HCC were 86% (95% confidence interval (CI), 80–90%; I² = 0%) and 96% (95% CI, 93–98%; I² = 80.5%), respectively. HBP-AMRI showed a significantly higher sensitivity for detecting HCC than NC-AMRI (87% vs. 82%), but significantly lower specificity (93% vs. 98%) (p = 0.03). Study quality and MRI magnet field strength were factors significantly associated with study heterogeneity (p ≤ 0.01). In conclusion, surveillance AMRI showed good overall diagnostic performance for detecting HCC. HBP-AMRI had significantly higher sensitivity for detecting HCC than NC-AMRI, but lower specificity.

Abbreviated MRI Protocol for the Assessment of Ablated Area in HCC Patients

Background: Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of hepatocellular carcinoma (HCC) following loco regional therapy. The aim of this study was to compare sensitivity of standard MRI protocol versus abbreviated protocol (only T1-Weigthed fat suppressed (FS) sequences pre- and post-contrast phase) in the detection of ablated area according to LI-RADS Treatment Response (LR-TR) categories. Methods: From January 2015 to June 2020, we selected 64 patients with HCC, who underwent Radiofrequency ablation (RFA) or Microwave ablation (MWA) treatment. According to inclusion criteria, 136 pathologically proven treated HCC (median 2, range 1–3 per patient; mean size 20.0 mm; range 15–30 mm) in 58 patients (26 women, 32 men; median age, 74 years; range, 62–83 years) comprised our study population. For each ablated area, abbreviated protocol, and standard Magnetic Resonance Imaging (MRI) studies were independently and blindly assessed in random order within and between three expert radiologists. Each radiologist assessed the ablated area by using the following categories: “LR-TR Non-viable” = 1; “LR-TR Equivocal” = 2 and “LR-TR Viable” = 0. Results: According to the concordance between MRI and Contrast enhancement ultrasound (CEUS) among 136 treated HCCs, 115 lesions were assessed as non-viable or totally ablate and 21 as viable or partially ablate. The accuracy for standard MRI protocol and abbreviated MRI protocol for predicting pathologic tumor viability of a consensus reading was 98.6% (sensitivity = 100%; specificity = 98.3%; positive predictive value = 91.3% and negative predictive value = 100%). No differences were found in sensitivity or specificity between standard MRI LR-TR viable and abbreviated MRI LR-TR viable categories (p value > 0.05 at McNemar test). Conclusion: The abbreviated dynamic protocol showed similar diagnostic accuracy to conventional MRI study in the assessment of treated HCCs, with a reduction of the acquisition study time of 30% respect to conventional MRI.