Imaging for the diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis

Australian recommendations for the management of hepatocellular carcinoma: a consensus statement

INTRODUCTION

Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at-risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators.

METHODS AND RECOMMENDATIONS

This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.

The diagnostic performance of contrast-enhanced ultrasound (CEUS) for evaluating hepatocellular carcinoma (HCC) juxtaposed to MRI findings; a retrospective single-center analysis of 292 patients

BACKGROUND

HCC is the most frequent primary liver cancer entity. Major risk factors comprise chronic HBC and HCV infections, ALD or NAFLD. Apart from the anamnesis, the clinical examination and serologic analysis, an essential part of the diagnostic HCC work-up is due to imaging findings from sonography, CT or MRI scans. HCC lesions feature a distinct vascularization pattern: hyperenhancement during early arterial and hypoenhancement/wash-out during portal venous or delayed phases. CEUS facilitates dynamic assessment of microperfusion patterns of suspicious liver lesions.

PURPOSE

The purpose of the present retrospective single-center study was to determine the diagnostic value of CEUS for assessing HCC by comparison with findings from MRI scans.

MATERIALS AND METHODS

Between 2004-2018 292 patients with suspicious liver lesions underwent CEUS and MRI. All patients underwent native B-mode, Color Doppler and CEUS after given informed consent. The applied contrast agent was a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Every CEUS examination was performed and interpreted by a single experienced radiologist (EFSUMB Level 3).

RESULTS

CEUS was performed on all included patients without occurrence of any adverse effects. CEUS showed a sensitivity of 96%, a specificity of 91%, a PPV of 95% and a NPV of 94% for analyzing HCC in comparison with MRI as the diagnostic gold standard.

CONCLUSION

With a distinguished safety profile CEUS shows a high diagnostic accuracy in assessing HCC compared to corresponding results from MRI scans.

Guidelines for the Diagnosis and Treatment of Hepatocellular Carcinoma (2019 Edition)

BACKGROUND

Primary liver cancer, around 90% are hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

SUMMARY

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2017 Edition) in 2018, additional high-quality evidence has emerged with relevance to the diagnosis, staging, and treatment of liver cancer in and outside China that requires the guidelines to be updated. The new edition (2019 Edition) was written by more than 70 experts in the field of liver cancer in China. They reflect the real-world situation in China regarding diagnosing and treating liver cancer in recent years.

KEY MESSAGES

Most importantly, the new guidelines were endorsed and promulgated by the Bureau of Medical Administration of the National Health Commission of the People's Republic of China in December 2019.

Diagnostic performance of LI-RADS for MRI and CT detection of HCC: A systematic review and diagnostic meta-analysis

PURPOSE

To perform a meta-analysis evaluating the diagnostic accuracy of the Liver Imaging Reporting and Data System (LI-RADS) category ≥ 3 (LI-RADS 3-5v) for detecting hepatocellular carcinoma (HCC).

METHOD

A systematic PubMed, Embase, and Web of Science electronic database search was performed for original diagnostic studies published through July 31, 2018. Statistical analysis included data pooling, forest plot construction, heterogeneity testing, meta-regression, and subgroup analyses.

RESULTS

Eighteen studies (v2011, v2014 and v2017) involving 3386 patients were included in the meta-analysis. The pooled sensitivity and specificity of LI-RADS ≥ 3 for diagnosing HCC were 0.86 (95 % confidence interval (CI): 0.78-0.91) and 0.85 (95 % CI: 0.78-0.90), respectively. The area under the curve (AUC) was 0.92 (95 % CI: 0.89-0.94). Meta-regression analysis showed that the publication year, blinding to the reference standard and the number of readers were significant factors affecting heterogeneity. In subgroup analyses, magnetic resonance imaging (MRI) demonstrated higher sensitivity (0.82 vs. 0.73) and comparable specificity (0.79 vs. 0.78) than computed tomography (CT). For HCCs ≤30 mm, LI-RADS showed lower sensitivity of 0.72 and specificity of 0.80 compared with HCC of all sizes. LR-5 showed higher sensitivity and specificity than LR-3 (sensitivity: 0.67 vs. 0.07, P = 0.02; specificity: 0.93 vs. 0.75, p < 0.001) and higher sensitivity than LR-4 (sensitivity: 0.67 vs. 0.29, P = 0.02; specificity: 0.93 vs. 0.80, p = 0.75). LR ≥ 5 had higher specificity at the cost of decreased sensitivity than LR ≥ 3 (specificity: 0.94 vs. 0.68, p < 0.001; sensitivity: 0.66 vs. 0.74, P = 0.70) and LR ≥ 4 (specificity: 0.94 vs. 0.84, p < 0.001; sensitivity: 0.66 vs. 0.74, P = 0.77).

CONCLUSIONS

LI-RADS ≥ 3 shows high diagnostic accuracy for HCCs, with a pooled sensitivity of 0.86 and specificity of 0.85. The specificity is higher for LR-5 and LR ≥ 5. However, further prospective studies on LI-RADS ≥ 3 are needed to elucidate its value for diagnosing small HCCs (≤20 mm).

Evaluation of diagnostic accuracy of serum calcium channel α2δ1 subunit in hepatocellular carcinoma-related cirrhosis

Background

Hepatocellular carcinoma (HCC) is one of the commonest malignancies worldwide that carries a bad prognosis particularly in Egypt due to the high prevalence of HCV burden. Late diagnosis of HCC especially in cirrhosis suffering-liver is one of the causes that worsen HCC outcome. Identification of molecular pathways of HCC will open the gate for early diagnosis and effective management. Oscillation of calcium controlled by the α2δ1 subunit has been proposed as one of the mechanisms in tumor-initiating cell properties of HCC. In this study, we aim to evaluate the serum α2δ1 subunit level as a biological marker for HCC. A total of 90 participants were enrolled, 40 patients with HCC, 40 patients with cirrhosis, and 10 healthy volunteers; serum level of α2δ1 was assessed in all participants with ELISA

Results

The mean serum levels of α2δ1 were significantly higher in HCC group (19.53 ± 6.87 ng/dL) than cirrhotic (6.24 ± 2.64 ng/dL) and control groups (0.67 ± 0.48 ng/dL) (P = 0.001). There was no significance between α2δ1 and etiology of liver disease as viral (HCV, HBV) or non-viral (P = 0.14).

Conclusion

α2δ1 subunit may serve as a potential non-invasive marker with excellent sensitivity for diagnosis of HCC regardless of the etiology of liver disease.

Hepatobiliary phase of gadoxetic acid-enhanced MRI in patients with HCC: prognostic features before resection, ablation, or TACE

OBJECTIVES

Patients with hepatocellular carcinoma (HCC) receiving different treatments might have specific prognostic factors that can be captured in the hepatobiliary phase (HBP) of gadoxetic acid-enhanced magnetic resonance imaging (GA-MRI). We aimed to identify the clinical findings and HBP features with prognostic value in patients with HCC.

METHODS

In this retrospective, single-institution study, we included patients with Barcelona Clinic Liver Cancer very early/early stage HCC who underwent GA-MRI before treatment. After performing propensity score matching, 183 patients received the following treatments: resection, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE) (n = 61 for each). Cox regression models were used to identify clinical factors and HBP features associated with disease-free survival (DFS) and overall survival (OS).

RESULTS

In the resection group, large tumor size was associated with poor DFS (hazard ratio [HR] 4.159 per centimeter; 95% confidence interval [CI], 1.669-10.365) and poor OS (HR 8.498 per centimeter; 95% CI, 1.072-67.338). In the RFA group, satellite nodules on HBP images were associated with poor DFS (HR 5.037; 95% CI, 1.061-23.903) and poor OS (HR 9.398; 95% CI, 1.480-59.668). Peritumoral hypointensity on HBP images was also associated with poor OS (HR 13.062; 95% CI, 1.627-104.840). In addition, serum albumin levels and the prothrombin time-international normalized ratio were associated with DFS and/or OS. Finally, in the TACE group, no variables were associated with DFS/OS.

CONCLUSIONS

Different HBP features and clinical factors were associated with DFS/OS among patients with HCC receiving different treatments.

KEY POINTS

• In patients who underwent resection for HCC, a large tumor size on HBP images was associated with poor disease-free survival and overall survival. • In the RFA group, satellite nodules and peritumoral hypointensity on HBP images, along with decreased serum albumin levels and PT-INR, were associated with poor disease-free survival and/or overall survival. • In the TACE group, no clinical or HBP imaging features were associated with disease-free survival or overall survival.

A radiomics nomogram for the prediction of overall survival in patients with hepatocellular carcinoma after hepatectomy

Background

Hepatocellular carcinoma (HCC) is associated with a dismal prognosis, and prediction of the prognosis of HCC can assist in therapeutic decision-makings. An increasing number of studies have shown that the texture parameters of images can reflect the heterogeneity of tumors, and may have the potential to predict the prognosis of patients with HCC after surgical resection. The aim of this study was to investigate the prognostic value of computed tomography (CT) texture parameters in patients with HCC after hepatectomy and to develop a radiomics nomogram by combining clinicopathological factors and the radiomics signature.

Methods

In all, 544 eligible patients were enrolled in this retrospective study and were randomly divided into the training cohort (n = 381) and the validation cohort (n = 163). The tumor regions of interest (ROIs) were delineated, and the corresponding texture parameters were extracted. The texture parameters were selected by using the least absolute shrinkage and selection operator (LASSO) Cox model in the training cohort, and a radiomics signature was established. Then, the radiomics signature was further validated as an independent risk factor for overall survival (OS). The radiomics nomogram was established based on the Cox regression model. The concordance index (C-index), calibration plot and decision curve analysis (DCA) were used to evaluate the performance of the radiomics nomogram.

Results

The radiomics signature was formulated based on 7 OS-related texture parameters, which were selected in the training cohort. In addition, the radiomics nomogram was developed based on the following five variables: α-fetoprotein (AFP), platelet-to-lymphocyte ratio (PLR), largest tumor size, microvascular invasion (MVI) and radiomics score (Rad-score). The nomogram displayed good accuracy in predicting OS (C-index = 0.747) in the training cohort and was confirmed in the validation cohort (C-index = 0.777). The calibration plots also showed excellent agreement between the actual and predicted survival probabilities. The DCA indicated that the radiomics nomogram showed better clinical utility than the clinicopathologic nomogram.

Conclusion

The radiomics signature is a potential prognostic biomarker of HCC after hepatectomy. The radiomics nomogram that integrated the radiomics signature can provide a more accurate estimation of OS than the clinicopathologic nomogram for HCC patients after hepatectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40644-020-00360-9.

Role of Biomarkers and Biopsy in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is increasing in prevalence and is the third leading cause of cancer-related death worldwide. Unlike other malignancies, HCC can be diagnosed with dynamic imaging with very high accuracy, and tissue diagnosis is not needed for cancer therapy. There is a unique role of established as well as developing biomarkers in diagnosis, prognosis, and management of HCC. Sequencing HCC tumors has yielded substantial insights into HCC tumor biology and has raised the possibility of precision oncology in which therapy decisions are guided by cancer genetics. However, it is not ready for prime time yet.

Characterizing Computed Tomography-Detected Arterial Hyperenhancing-Only Lesions in Patients at Risk of Hepatocellular Carcinoma: Can Non-Contrast Magnetic Resonance Imaging Be Used for Sequential Imaging?

Objective

To test the feasibility of non-contrast magnetic resonance imaging (MRI) in a sequential imaging study for characterizing computed tomography (CT)-detected arterial-enhancing nodules that do not washout in patients at risk of hepatocellular carcinoma (HCC).

Materials and Methods

In this retrospective study, 134 patients (mean age ± standard deviation, 56.8 ± 10.0 years) with 151 arterial enhancing-only nodules measuring up to 2 cm during multiphasic CT that were subsequently evaluated using gadoxetic acid-enhanced MRI in treatment-naïve at-risk patients from three tertiary referral centers were included. Tentative diagnostic criteria for HCC and hepatic malignancy were defined as the presence of one of eight MRI features favoring HCC in combinations of the following sequences: T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), T1-weighted dual gradient-echo in-phase and out-of-phase imaging (Dual-GRE), and hepatobiliary phase imaging (HBP). Typical hemangiomas and arterioportal shunts were excluded from the analysis. Diagnostic performance for HCC and hepatic malignancy was calculated and compared between the abbreviated MRI and full-sequence gadoxetic acid-enhanced MRI.

Results

Of 151 nodules (mean size, 1.2 cm) 68 HCCs and 83 non-HCC benignities and malignancies were included. The combination of T2WI, DWI, and Dual-GRE showed per-lesion sensitivity, specificity, and accuracy of 88.2%, 90.4%, and 89.4%, respectively, comparable to those of full-sequence MRI. Applying the same sequence combination to diagnose hepatic malignancy had per-lesion sensitivity, specificity, and accuracy of 86.8%, 97.3%, and 92.1%. In nodules < 1 cm, adding HBP increased sensitivity by up to 13% without compromising the specificity or accuracy.

Conclusion

The non-contrast MRI protocol comprising T2WI, DWI, and Dual-GRE showed reasonable and comparable performance to full-sequence MRI for discriminating HCC and primary liver malignancies in CT-detected indeterminate arterial enhancing-only nodules in at-risk patients, and can be potentially used for sequential imaging in place of a full-sequence MRI. In nodules < 1 cm, HBP may still be needed to preserve sensitivity.

Development of a novel melatonin-modified near-infrared fluorescent probe for in vivo hepatocellular carcinoma imaging

Hepatocellular carcinoma (HCC) is a common malignancy worldwide with poor prognosis. The early identification and precise resection of HCC are essential for improving the prognosis and overall survival of patients. In clinical practice, fluorescence imaging is a powerful technology to identify and remove HCC lesions, but accurate and reliable detection of HCC continues to remain a challenge due to non-specificity and false-positive uptake of probes. To circumvent these problems, it is crucial to design a specific probe for the accurate detection of HCC. Herein, we reported the design and synthesis of an NIR fluorescent probe by conjugating IRDye800CW with melatonin, which plays a significant role in the HCC development. The in vivo imaging revealed that IRDye800-MT was uptake specifically by the HCC tumor with a high tumor-to-background ratio. These results demonstrated that IRDye800-MT might hold clinical potentials for future diagnosis of HCC patients.

Alcohol and hepatocarcinogenesis

An excessive alcohol intake may result in fatty liver, acute/chronic hepatitis, cirrhosis, and lead to hepatocellular carcinoma (HCC). The aim of this review is to clarify the present condition and the mechanisms of alcohol-related hepatocarcinogenesis and clinical risk factors for alcohol-related HCC. There are several possible mechanisms through which alcohol may induce hepatocarcinogenesis, including the mutagenic effects of acetaldehyde toxicity through the formation of protein and DNA adducts and the production of reactive oxygen species due to the excessive hepatic deposition of iron, changes to lipid peroxidation and metabolism, inflammation and an impaired immune response and modifications to DNA methylation. Furthermore, it has been reported that alcohol accelerates liver carcinogenesis through several signaling pathways including gut-liver axis. From a clinical perspective, it is well known that alcohol interacts with other factors, such as age, gender, viral hepatitis, obesity, and diabetes leading to an increased risk of HCC.

Advanced Fusion Imaging and Contrast-Enhanced Imaging (CT/MRI-CEUS) in Oncology

Fusion imaging depicts an innovative technique that facilitates combining assets and reducing restrictions of advanced ultrasound and cross-sectional imaging. The purpose of the present retrospective study was to evaluate the role of fusion imaging for assessing hepatic and renal lesions. Between 02/2011-08/2020, 92 patients in total were included in the study, of which 32 patients had hepatic lesions, 60 patients had renal lesions. Fusion imaging was technically successful in all patients. No adverse side effects upon intravenous (i.v.) application of SonoVue® (Bracco, Milan, Italy) were registered. Fusion imaging could clarify all 11 (100%) initially as indeterminate described hepatic lesions by computed tomography/magnetic resonance imaging (CT/MRI). Moreover, 5/14 (36%) initially suspicious hepatic lesions could be validated by fusion imaging, whereas in 8/14 (57%), malignant morphology was disproved. Moreover, fusion imaging allowed for the clarification of 29/30 (97%) renal lesions initially characterized as suspicious by CT/MRI, of which 19/30 (63%) underwent renal surgery, histopathology revealed malignancy in 16/19 (84%), and benignity in 3/19 (16%). Indeterminate findings could be elucidated by fusion imaging in 20/20 (100%) renal lesions. Its accessibility and repeatability, even during pregnancy and in childhood, its cost-effectiveness, and its excellent safety profile, make fusion imaging a promising instrument for the thorough evaluation of hepatic and renal lesions in the future.

Imaging Modalities for Hepatocellular Carcinoma Surveillance: Expanding Horizons beyond Ultrasound

In Asian countries favoring loco-regional treatment such as surgical resection or ablation, very early-stage hepatocellular carcinoma (HCC) should be the main target for surveillance. Even though ultrasound (US) has been accepted as a primary imaging modality for HCC surveillance, its performance in detecting very early-stage HCCs is insufficient. Moreover, in more than 20% of patients at high risk for HCC, visualization of the liver on US may be limited owing to the advanced distortion and heterogeneity of the liver parenchyma. Recently revised HCC clinical guidelines allow the use of alternative surveillance tools including computed tomography or magnetic resonance imaging in patients with inadequate US exams. This paper summarizes the findings of recent studies using imaging modalities other than US as surveillance tools for HCC as well as strengths and limitations of these modalities.

Factors Associated With Detection and Survival of T1 Hepatocellular Carcinoma in the United States: National Cancer Database Analysis

Background: It remains unknown to what extent hepatocellular carcinomas (HCCs) are detected very early (T1 stage; ie, unifocal <2 cm) in the United States. The aim of this study was to investigate the trends and factors associated with very early detection of HCC and resultant outcomes. Methods: Patients with HCC diagnosed from 2004 through 2014 were identified from the National Cancer Database. Logistic regression was used to identify factors associated with T1 HCC detection, and Cox proportional hazard analyses identified factors associated with overall survival among patients with T1 HCC. Results: Of 110,182 eligible patients, the proportion with T1 HCC increased from 2.6% in 2004 to 6.8% in 2014 (P<.01). The strongest correlate of T1 HCC detection was receipt of care at an academic institution (odds ratio, 3.51; 95% CI, 2.31–5.34). Older age, lack of insurance, high Model for End-Stage Liver Disease (MELD) score, high alpha-fetoprotein, increased Charlson-Deyo comorbidity score, and nonsurgical treatment were associated with increased mortality, and care at an academic center (hazard ratio [HR], 0.27; 95% CI, 0.15–0.48) was associated with reduced mortality in patients with T1 HCC. Liver transplantation (HR, 0.27; 95% CI, 0.20–0.37) and surgical resection (HR, 0.67; 95% CI, 0.48–0.93) were independently associated with improved survival compared with ablation. This is the first study to examine the trend of T1 HCC using the National Cancer Database, which covers approximately 70% of all cancer diagnoses in the United States, using robust statistical analyses. Limitations of the study include a retrospective study design using administrative data and some pertinent data that were not available. Conclusions: Despite increases over time, <10% of HCCs are detected at T1 stage. The strongest correlates of survival among patients with T1 HCC are receiving care at an academic institution and surgical treatment.

Diagnostic Value of High Frame Rate Contrast-enhanced Ultrasonography and Post-processing Contrast Vector Imaging for Evaluation of Focal Liver Lesions: A Feasibility Study

This study evaluated the feasibility of contrast vector imaging (CVI) to characterize focal liver lesions. From July to October 2019, we prospectively enrolled 30 patients with focal liver lesions (hepatocellular carcinoma [HCC] [n = 19], metastasis [n = 8], combined HCC-cholangiocarcinoma [CC] [n = 1], intra-hepatic CC [n = 1] and sclerosed hemangioma [n = 1]). Contrast-enhanced ultrasound (CEUS) was performed with high frame rate contrast harmonic imaging technique by one radiologist, and post-processing CVI was obtained and analyzed by two radiologists. On combined CVI with CEUS, the staining pattern was significantly predominant in HCCs (9/11, 81.8%), while peripheral rim was frequent in non-HCCs (5/8, 62.5%) (p = 0.020). HCCs exhibited feeding arteries (8/11, 45.5%) and high velocity variance (10/11, 90.9 %), whereas non-HCCs showed detour pattern (4/8, 50.0%) with either a high or low velocity variance (4/8, 50.0%, both), with no significant inter-group differences (p = 0.052 and 0.080, respectively). In conclusion, CVI was feasible and provided quantitative and multi-parametric information of different types of hepatic tumors.

Role of imaging in management of hepatocellular carcinoma: surveillance, diagnosis, and treatment response

Imaging plays a notable role in hepatocellular carcinoma (HCC) surveillance, diagnosis, and treatment response assessment. Whereas HCC surveillance among at-risk patients, including those with cirrhosis, has traditionally been ultrasound-based, there are increasing data showing that this strategy is operator-dependent and has insufficient sensitivity when used alone. Several novel blood-based and imaging modalities are currently being evaluated to increase sensitivity for early HCC detection. Multi-phase computed tomography (CT) or contrast-enhanced magnetic resonance imaging (MRI) should be performed in patients with positive surveillance tests to confirm a diagnosis of HCC and perform cancer staging, as needed. HCC is a unique cancer in that most cases can be diagnosed radiographically without histological confirmation when demonstrating characteristic features such as arterial phase hyperenhancement and delayed phase washout. The Liver Imaging Reporting and Data System offers a standardized nomenclature for reporting CT or MRI liver findings among at-risk patients. Finally, cross-sectional imaging plays a critical role for assessing response to any HCC therapy as well as monitoring for HCC recurrence in those who achieve complete response.

Diagnostic value of the γ-glutamyltransferase and alanine transaminase ratio, alpha-fetoprotein, and protein induced by vitamin K absence or antagonist II in hepatitis B virus-related hepatocellular carcinoma

Hepatocellular carcinoma is a common type of malignancy with a poor prognosis. Identification and utilisation of markers for monitoring and diagnosis are urgently needed. Alpha-fetoprotein (AFP) and Protein Induced by Vitamin K Absence or Antagonist-II (PIVKA-II) have been proved to be efficient biomarkers for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). The combination of the two markers could improve the detection rate. However, these indicators cannot meet the need of clinical diagnosis.It is necessary to discover novel serological markers and more cost-effective, appropriate combination of these markers for the diagnosis and surveillance of HBV-related HCC. Accordingly, in this study, we aimed to evaluate the diagnostic value of γ-glutamyltransferase (γ-GT) to alanine amino transferase (ALT) ratio alone or in combination with AFP and PIVKA-II for HBV-related HCC. 234 patients with HBV-related HCC and 396 patients with chronic hepatitis B (CHB) were enrolled in this study and approved by the institutional review board. Our results showed levels of AFP and PIVKA-II, and γ-GT/ALT ratio in cases with early-stage HCC, HCC, HCC plus HBV DNA positivity, and HCC plus HBV DNA negativity were higher than those in the corresponding CHB control group. Additionally, the levels of serum AFP and PIVKA-II, and the γ-GT/ALT ratio were positively correlated with tumour sizes in patients with HBV-related HCC. The areas under the ROC curves (AUROCs) of the γ-GT/ALT ratio in patients with early-stage HCC, HCC, HCC plus HBV DNA positivity, and HCC plus HBV DNA negativity were 0.795, 0.846,0.855, and 0.837, respectively; AUROCs of combination of the γ-GT/ALT ratio and PIVKA-II were 0.858, 0.928, 0.948, and 0.902, respectively; AUROCs of combination of the γ-GT/ALT ratio and AFP were 0.822, 0.886, 0.896, and 0.873, respectively;AUROCs of combination of the γ-GT/ALT ratio and PIVKA-II with AFP were 0.857, 0.928, 0.946, and 0.907, respectively, and AUROCs of combination of PIVKA-II and AFP were 0.804, 0.904, 0.942, and 0.863, respectively. In conclusion, the γ-GT/ALT ratio was a useful biomarker for the diagnosis of HBV-related HCC and that the combination of AFP and PIVKA-II with the γ-GT/ALT ratio could improve the diagnostic value of these biomarkers for HBV-related HCC. Moreover, the ratio of γ-GT/ALT may be a useful index in monitoring patients for progression of HBV-related HCC.

Magnetic Resonance Imaging With Extracellular Contrast Detects Hepatocellular Carcinoma With Greater Accuracy Than With Gadoxetic Acid or Computed Tomography

BACKGROUND & AIMS

Computed tomography (CT) and magnetic resonance imaging (MRI) are used to detect hepatocellular carcinoma (HCC). We performed a prospective study to compare the diagnostic performance of CT, MRI with extracellular contrast agents (ECA-MRI), and MRI with hepatobiliary agents (HBA-MRI) in the detection of HCC using the liver imaging reporting and data system (LI-RADS).

METHODS

We studied 125 participants (102 men; mean age, 55.3 years) with chronic liver disease who underwent CT, ECA-MRI, or HBA-MRI (with gadoxetic acid) before surgery for a nodule initially detected by ultrasound at a tertiary center in Korea, from November 2016 through February 2019. We collected data on major features and assigned LI-RADS categories (v2018) from CT and MRI examinations. We then compared the diagnostic performance for LR-5 for each modality alone, and in combination.

RESULTS

In total, 163 observations (124 HCCs, 13 non-HCC malignancies, and 26 benign lesions; mean size, 20.7 mm) were identified. ECA-MRI detected HCC with 83.1% sensitivity and 86.6% accuracy, compared to 64.4% sensitivity and 71.8% accuracy for CT (P < .001) and 71.2% sensitivity (P = .005) and 76.5% accuracy for HBA-MRI (P = .005); all technologies detected HCC with 97.4% specificity. Adding CT to either ECA-MRI (89.2% sensitivity, 91.4% accuracy; both P < .05) or HBA-MRI (82.8% sensitivity, 86.5% accuracy; both P < .05) significantly increased its diagnostic performance in detection of HCC compared with the MRI technologies alone. ECA-MRI identified arterial phase hyperenhancement in a significantly higher proportion of patients (97.6%) than CT (81.5%; P < .001) or HBA-MRI (89.5%; P = .002). ECA-MRI identified non-peripheral washout in 79.8% of patients, vs 74.2% of patients for CT and 73.4% of patients for HBA-MRI (differences not significant). ECA-MRI identified enhancing capsules in 85.5% of patients, vs 33.9% for CT (P < .001) and 41.4% for HBA-MRI (P < .001).

CONCLUSION

In a prospective study of patients with chronic liver disease and a nodule detected by ultrasound, ECA-MRI detected HCC with higher levels of sensitivity and accuracy than CT or HBA-MRI, based on LI-RADS. Diagnostic performance was best when CT was used in combination with MRI compared with MRI alone.

Hepatic enhancement in cirrhosis in the portal venous phase: what are the differences between gadoxetate disodium and gadobenate dimeglumine?

PURPOSE

To compare the level of parenchymal and portal venous enhancement in the portal venous phase (PVP) in cirrhotic patients undergoing gadoxetate disodium- and gadobenate dimeglumine-enhanced MRI.

METHODS

In this retrospective study, 84 cirrhotic patients (mean age ± SD: 66 ± 13 years) who underwent contrast-enhanced MRI with both gadoxetate disodium and gadobenate dimeglumine between 2012 and 2018 were included. Two readers measured signal intensities of hepatic parenchyma, portal vein and psoas muscle on precontrast and PVP. Relative enhancement (RE), image contrast, and portal vein-to-liver contrast difference were calculated. Intraindividual differences were compared with the Wilcoxon signed rank-sum test and inter-reader differences with the intraclass correlation coefficient (ICC).

RESULTS

In PVP, gadoxetate disodium provided lower RE than gadobenate dimeglumine (Reader 1: 42.4 ± 44.6 vs. 56.1 ± 58.8, p = 0.044; Reader 2: 42.4 ± 42.9 vs. 57.7 ± 60.5, p = 0.027;), lower image contrast (Reader 1: 0.27 ± 0.11 vs. 0.35 ± 0.11, respectively; p < 0.001; Reader 2: 0.29 ± 0.10 vs. 0.37 ± 0.07, respectively; p < 0.001), and lower portal vein-to-liver contrast difference (Reader 1: 0.89 ± 0.39 vs. 1.42 ± 0.90, p < 0.001; Reader 2: 0.95 ± 0.40 vs. 1.28 ± 0.37, p < 0.001). ICC was 0.94, 0.79, and 0.69 for RE, image contrast, and portal vein-to-liver contrast difference, respectively.

CONCLUSION

In cirrhotic patients, gadoxetate disodium yielded lower enhancement of the hepatic parenchyma and lower contrast of the portal vein than gadobenate dimeglumine in PVP.

Virtual monoenergetic images preserve diagnostic assessability in contrast media reduced abdominal spectral detector CT

OBJECTIVES

To investigate if low-keV virtual monoenergetic images (VMI_40keV) from abdominal spectral detector CT (SDCT) with reduced intravenous contrast media application (RCM) provide abdominal assessment similar to conventional images with standard contrast media (SCM) dose.

METHODS

78 patients with abdominal SDCT were retrospectively included: 41 patients at risk for adverse reactions who received 44 RCM examinations with 50 ml and 37 patients who underwent 44 SCM examinations with 100 ml of contrast media (CM) and who were matched for effective body diameters. RCM, SCM images and RCM-VMI_40keV were reconstructed. Attenuation and signal-to-noise ratio (SNR) of liver, pancreas, kidneys, lymph nodes, psoas muscle, aorta and portal vein were assessed ROIs-based. Contrast-to-noise ratios (CNR) of lymph nodes vs aorta/portal vein were calculated. Two readers evaluated organ/vessel contrast, lymph node delineation, image noise and overall assessability using 4-point Likert scales.

RESULTS

RCM were inferior to SCM images in all quantitative/qualitative criteria. RCM-VMI_40keV and SCM images showed similar lymph node and muscle attenuation (p = 0.83,0.17), while for all other ROIs, RCM-VMI_40keV showed higher attenuation (p ≤ 0.05). SNR was comparable between RCM-VMI_40keV and SCM images (p range: 0.23-0.99). CNR of lymph nodes was highest in RCM-VMI_40keV (p ≤ 0.05). RCM-VMI_40keV received equivalent or higher scores than SCM in all criteria except for organ contrast, overall assessability and image noise, where SCM were superior (p ≤ 0.05). However, RCM-VMI_40keV received proper or excellent scores in 88.6/94.2/95.4% of the referring cases.

CONCLUSIONS

VMI_40keV counteract contrast deterioration in CM reduced abdominal SDCT, facilitating diagnostic assessment.

ADVANCES IN KNOWLEDGE

SDCT-derived VMI_40keV provide adequate depiction of vessels, organs and lymph nodes even at notable CM reduction.

Intraindividual Comparison between Gadoxetate-Enhanced Magnetic Resonance Imaging and Dynamic Computed Tomography for Characterizing Focal Hepatic Lesions: A Multicenter, Multireader Study

OBJECTIVE

To compare the diagnostic accuracy of dynamic computed tomography (CT) and gadoxetate-enhanced magnetic resonance imaging (MRI) for characterization of hepatic lesions by using the Liver Imaging Reporting and Data System (LI-RADS) in a multicenter, off-site evaluation.

MATERIALS AND METHODS

In this retrospective multicenter study, we evaluated 231 hepatic lesions (114 hepatocellular carcinomas [HCCs], 58 non-HCC malignancies, and 59 benign lesions) confirmed histologically in 217 patients with chronic liver disease who underwent both gadoxetate-enhanced MRI and dynamic CT at one of five tertiary hospitals. Four radiologists at different institutes independently reviewed all MR images first and the CT images 4 weeks later. They evaluated the major and ancillary imaging features and categorized each hepatic lesion according to the LI-RADS v2014. Diagnostic performance was calculated and compared using generalized estimating equations.

RESULTS

MRI showed higher sensitivity and accuracy than CT for diagnosing hepatic malignancies; the pooled sensitivities, specificities, and accuracies for categorizing LR-5/5V/M were 59.0% vs. 72.4% (CT vs. MRI; p < 0.001), 83.5% vs. 83.9% (p = 0.906), and 65.3% vs. 75.3% (p < 0.001), respectively. CT and MRI showed comparable capabilities for differentiating between HCC and other malignancies, with pooled accuracies of 79.9% and 82.4% for categorizing LR-M, respectively (p = 0.139).

CONCLUSION

Gadoxetate-enhanced MRI showed superior accuracy for categorizing LR-5/5V/M in hepatic malignancies in comparison with dynamic CT. Both modalities had comparable accuracies for distinguishing other malignancies from HCC.

SCCA-IgM in hepatocellular carcinoma patients treated with transarterial chemoembolization: gender-related differences

Aim: Squamous cell carcinoma antigen immune complexed with immunoglobulin M (SCCA-IgM) is a useful but not completely satisfactory biomarker of hepatocellular carcinoma (HCC). Considering its gender-specific behavior in preclinical models, we investigated gender-related differences of SCCA-IgM as a prognostic marker in HCC. Patients & methods: Two hundred and eight prospectively recruited patients treated with transarterial chemoembolization in a single tertiary care hospital were retrospectively evaluated. Correlations between SCCA-IgM levels, clinical characteristics and survival were assessed according to gender. Results: When the disease was advanced, SCCA-IgM was higher in males and lower in females. Levels below 130 AU/ml predicted a significantly longer survival in males (p = 0.007) and a shorter survival in females (p = 0.01). Conclusion: In predicting the prognosis of HCC patients, the interpretation of SCCA-IgM should consider gender as a relevant variable.

Activatable Nanocomposite Probe for Preoperative Location and Intraoperative Navigation for Orthotopic Hepatic Tumor Resection via MSOT and Aggregation-Induced Near-IR-I/II Fluorescence Imaging

The precise location of tumor and completeness of surgical resection are critical to successful tumor surgery; thus, the method capable of preoperatively locating a tumor site and intraoperatively determining tumor margins would be highly ideal. Herein, an activatable nanocomposite probe was developed for preoperatively locating orthotopic hepatic tumor via multispectral optoacoustic tomography imaging and for intraoperative navigation via near-IR-1 (NIR-I) and NIR-II fluorescence imaging. The molecular probe comprises an electronic donor, an acceptor, and a recognition moiety and forms the nanocomposite probe with bovine serum albumin. The probe specifically responds to nitroreductase overexpressed in tumor cells, which transforms the aromatic nitro group into an electron-donating amino group and thus activates the probe. The activated probe with the aggregation-induced emission feature generates strong NIR-I/NIR-II fluorescence and optoacoustic signals for dual-mode imaging. Owing to the in situ response toward nitroreductase in tumor cells in the hepatic region, the probe is found capable of detecting early stage orthotopic liver tumors. Furthermore, with the nanocomposite probe, we can obtain the 3D MSOT images to accurately locate orthotopic liver tumors preoperatively and the NIR-I/NIR-II fluorescence images to provide intraoperative guidance for tumor resection surgery.

Addition of [18 F]Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography to Cross-Sectional Imaging Improves Staging and Alters Management in Hepatocellular Carcinoma

In this work, we characterize the value of positron emission tomography (PET) with computed tomography (CT) in combination with cross-sectional imaging for staging and prognostication of hepatocellular carcinoma (HCC) patients. In this retrospective cohort study, HCC patients underwent PET-CT after initial staging with contrast-enhanced CT or magnetic resonance imaging (MRI). The benefit of PET-CT was measured by the identification of new HCC lesions, and potential harm was quantified by the number of false positives and subsequent diagnostic evaluation. We used multivariate Cox regression analysis to evaluate the association between the highest grade on PET-CT with the risk of extrahepatic metastasis, progression-free, and overall survival. Among 148 patients, PET-CT detected additional extrahepatic metastasis in 11.9% of treatment-naïve and 13.8% of treatment-experienced patients. PET-CT changed the Barcelona Clinic Liver Cancer (BCLC) staging in 5.9% of treatment-naïve and 18.8% of treatment-experienced patients compared with CT/MRI alone, changing HCC management in 9.9% and 21.3% of patients, respectively. Of the patients, 5% (n = 8) experienced severe physical harm requiring additional procedures to evaluate extrahepatic findings. High tumor grade on PET-CT was independently associated with a higher likelihood of extrahepatic metastasis (hazard ratio [HR], 17.1; 95% confidence interval [CI], 3.6-81.5) and worse overall survival (HR, 2.4; 95% CI, 1.4-4.3). Treatment-experienced patients (versus treatment-naïve patients; HR, 9.7; 95% CI, 1.9-49.4) and BCLC stage A (HR, 8.2; 95% CI, 1.5-45.9; P < 0.01) and BCLC stage B (HR, 20.6; 95% CI, 1.5-282.2; P < 0.05) were more likely to have an upstaging with PET-CT compared with BCLC stage C (reference). PET-CT provides prognostic information and improves tumor staging beyond CT/MRI alone, with subsequent changes in management for patients with HCC.

Cure With Interferon-Free Direct-Acting Antiviral Is Associated With Increased Survival in Patients With Hepatitis C Virus-Related Hepatocellular Carcinoma From Both East and West

BACKGROUND AND AIMS

Survival data among patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) after achieving sustained virologic response (SVR) with interferon-free direct-acting antivirals (DAAs) in both Asian and western countries are limited. Survival rates were compared between patients with HCV-related HCC who were untreated for HCV and those who achieved SVR.

APPROACH AND RESULTS

Using data from two U.S. and six Asian centers from 2005 to 2017, we categorized 1,676 patients who were mono-infected with HCV-related HCC into patients untreated for HCV (untreated group) and DAA-treated patients with SVR (SVR group) and matched by propensity score matching (PSM); multivariable Cox regression with HCV treatment status as a time-varying covariate was used to determine mortality risk and landmark analysis to avoid immortal time bias. There were 1,239 untreated patients and 437 patients with SVR. After PSM, background risks of the 321 pairs of matched patients were balanced (all P > 0.05). After time-varying adjustment for HCV treatment initiation compared with untreated patients, patients with SVR had significantly higher 5-year overall survival (87.78% vs. 66.05%, P < 0.001). Multivariable Cox regression showed that SVR was independently associated with a 63% lower risk of 5-year all-cause mortality (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.16-0.83; P = 0.016) and 66% lower risk of 5-year liver-related mortality (HR, 0.34; 95% CI, 0.13-0.88; P = 0.026) with similar trends after removing patients with liver transplants. Landmark analysis at 90, 180, and 360 days showed consistent results (HRs ranged 0.22 to 0.44, all P < 0.05).

CONCLUSION

In this multinational consortium, patients with HCV-related HCC who obtained SVR achieved a 60%-70% improvement in 5-year survival (both all-cause and liver related) compared with patients untreated for HCV. Patients eligible for HCC therapy should also be considered for DAA therapy.

Wisteria floribunda Agglutinin-Positive Mac-2 Binding Protein but not α-fetoprotein as a Long-Term Hepatocellular Carcinoma Predictor

Identification of high-risk patients for hepatocellular carcinoma (HCC) after sustained virological responses (SVR) is necessary to define candidates for long-term surveillance. In this study, we examined whether serum markers after 1 year of SVR could predict subsequent HCC development. Total 734 chronic hepatitis C patients without a history of HCC who achieved SVR with direct-acting antivirals were included. The regular surveillance for HCC started from 24 weeks after the end of treatment (SVR24). Factors at SVR24 and 1 year after SVR24 were analyzed for predicting HCC development. During the mean observation period of 19.7 ± 10 months, 24 patients developed HCC. At SVR24, Wisteria floribunda agglutinin-positive mac-2 binding protein (WFA±M2BP) ≥ 1.85 and α-fetoprotein (AFP) ≥ 6.0 ng/mL were independent factors of HCC development. However, at 1 year after SVR24, WFA±M2BP ≥ 1.85 was associated with subsequent HCC development (hazard ratio: 23.5, 95% confidence interval: 2.68-205) but not AFP. Among patients with WFA±M2BP ≥ 1.85 at SVR24, 42% had WFA±M2BP < 1.85 at 1 year after SVR24 (WFA±M2BP declined group). Subsequent HCC development was significantly lower in the declined group than in the non-declined group (1 year HCC rate: 0% vs. 9.4%, p = 0.04). In conclusion, WFA±M2BP but not AFP could identify high and no-risk cases of HCC at 1 year after SVR. Therefore, it was useful as a real-time monitoring tool to identify the candidates for continuous surveillance for HCC.

ACR Appropriateness Criteria® Chronic Liver Disease

The liver fibrosis stage is the most important clinical determinate of morbidity and mortality in patients with chronic liver diseases. With newer therapies, liver fibrosis can be stabilized and possibly reversed, thus accurate diagnosis and staging of liver fibrosis are clinically important. Ultrasound, CT, and conventional MRI can be used to establish the diagnosis of advanced fibrosis/cirrhosis but have limited utility for assessing earlier stages of fibrosis. Elastography-based ultrasound and MRI techniques are more useful for assessment of precirrhotic hepatic fibrosis. In patients with advanced fibrosis at risk for hepatocellular carcinoma (HCC), ultrasound is the surveillance modality recommended by international guidelines in nearly all circumstances. However, in patients in whom ultrasound does not assess the liver well, including those with severe steatosis or obesity, multiphase CT or MRI may have a role in surveillance for HCC. Both multiphase CT and MRI can be used for continued surveillance in patients with a history of HCC, and contrast-enhanced ultrasound may have an emerging role in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Identification of Candidate Biomarkers for HCV Leading to Hepatocellular Carcinoma Differential Stages From Serum Samples

Background:

Hepatocellular carcinoma (HCC) is one of the most deadly liver malignancy found and Hepatitis C virus (HCV) is a prominent risk factor for this disease. Prognosis of HCC is poor; initiate the need of markers to discover therapeutic targets in HCC.

Introduction:

Clinical staging systems of HCC composed of tumor characteristics along with liver function test are important in prognosis but they are not precise. Molecular profiling can lead to a better understanding of the physiopathology of HCC and can help in the development of novel therapeutic approaches.

Methods:

64 HCC serum samples (shifted from HCV) were graded into stage I- IV; along with +ive (3 Hepatitis C) and -ive control (2 healthy persons). Proteins were separated by sodium dodecyl sulfatepolyacrylamide gel electrophoresis (SDS-PAGE) and differential mRNA expression from serum samples of different HCC stages was confirmed by Real Time Polymerase Chain Reaction (qPCR).

Results:

HCC serum proteins displayed differential expression of glutathione s-transferase (GST), glypican-3 (GPC3), vitronectin (VTN), and clusterin (CLU) by SDS-PAGE. GST was expressed in -ive control, while GPC3 was found in both -ive and +ive control. The qPCR analysis, display more than 0.07 fold decrease in GST in I-IV HCC stages. The highest increase in HCC stages was observed by GPC3; about 4 fold increase in I-IV stages. VTN show 1.7-3.4 fold; while CLU show 2-3.5 fold increase in four stages of HCC.

Conclusion:

GPC3, VTN and CLU in combination can be good potential markers for differentiating stages (I-IV) of HCC.

Indications for abdominal imaging: When and what to choose?

Imaging has a very important role in evaluating abdominal pathology. A good knowledge of indications is of crucial importance in the management of the patient with abdominal pathology. Ultrasound, which on its own can lead to an accurate diagnosis, plays a pivotal role in the management of abdominal pathology. The use of ultrasound contrast agents has significantly improved ultrasound diagnostic capacities in both hepatic and non-hepatic pathology. The use of computed tomography should be limited due to the potential harmful side effects of ionizing radiation, but it has established roles in evaluating severe abdominal traumatic and non-traumatic emergencies as well as in staging oncologic patients. Magnetic resonance imaging has very limited utility in abdominal emergencies due to difficulty of accessing the scanner and the long duration of the examination compared to computed tomography or ultrasound. However, magnetic resonance imaging has well-established clinical roles particularly for evaluating diffuse or focal hepatic pathology, benign and malignant bile duct pathology, pancreatic tumors, inflammatory bowel disease and rectal tumors. The aims of the following paper are to familiarize the clinician with the indications for imaging in abdominal pathology, to guide the clinician and radiologist in choosing the correct technique for a particular clinical situation, to prevent the overuse of imaging techniques and to prevent misdiagnosis of disease and incorrect therapy resulting from inappropriate imaging.

Imaging has a very important role in evaluating abdominal pathology. A good knowledge of indications is of crucial importance in the management of the patient with abdominal pathology. Ultrasound, which on its own can lead to an accurate diagnosis, plays a pivotal role in the management of abdominal pathology. The use of ultrasound contrast agents has significantly improved ultrasound diagnostic capacities in both hepatic and non-hepatic pathology. The use of computed tomography should be limited due to the potential harmful side effects of ionizing radiation, but it has established roles in evaluating severe abdominal traumatic and non-traumatic emergencies as well as in staging oncologic patients. Magnetic resonance imaging has very limited utility in abdominal emergencies due to difficulty of accessing the scanner and the long duration of the examination compared to computed tomography or ultrasound. However, magnetic resonance imaging has well-established clinical roles particularly for evaluating diffuse or focal hepatic pathology, benign and malignant bile duct pathology, pancreatic tumors, inflammatory bowel disease and rectal tumors. The aims of the following paper are to familiarize the clinician with the indications for imaging in abdominal pathology, to guide the clinician and radiologist in choosing the correct technique for a particular clinical situation, to prevent the overuse of imaging techniques and to prevent misdiagnosis of disease and incorrect therapy resulting from inappropriate imaging.

Utility of positron emission tomography-computed tomography scan in detecting residual hepatocellular carcinoma post treatment: Series of case reports

BACKGROUND

Multi-phase computed tomography (CT) or magnetic resonance imaging (MRI) has been the standard of care for hepatocellular carcinoma (HCC) diagnosis for years.

CASE SUMMARY

We report a case series of four patients in whom positron emission tomography-computed tomography (PET-CT) scan complemented the conventional CT/MRI scans in evaluating treatment response. In these four cases the conventional multi-phase CT and MRI failed to identify residual HCC disease post-treatment, while PET-CT complemented and aided in treatment response evaluation. In each case, the addition of PET-CT identified and located residual HCC disease, allowed retreatment, and altered medical management.

CONCLUSION

This case series suggests that PET-CT should perhaps play a role in the HCC management algorithm, in addition to the conventional contrast-enhanced multi-phase scans.

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.

Hepatocyte-Specific Magnetic Resonance Imaging-Based Assessment of Indeterminate Hepatic Nodules in the Liver Transplant Evaluation of Patients With Cirrhosis

We aimed to determine the identities in explants of indeterminate hepatic nodules (IDNs) that had been scanned by dynamic magnetic resonance imaging (MRI) to establish clinicoradiological parameters predicting which IDNs were hepatocellular carcinomas (HCCs). This study included 88 patients with cirrhosis who underwent gadoxetic acid-enhanced MRI in pre-liver transplantation (LT) workup followed within 90 days by primary LT. The MRI detected 168 hepatic nodules that were classified into 6 benign tumors, 49 HCCs, and 113 IDNs, in 5, 34, and 72 patients, respectively. We compared these pre-LT radiologic diagnoses and stagings with explant pathology on a per-lesion basis to enable us to identify features of IDNs related to malignancy. Of the 168 nodules seen on MRI, 119 that were classified radiologically as consisting of 1 benign nodule (33.3%), 46 HCCs (93.9%), and 72 IDNs (63.7%) all turned out to be pathological HCCs. Of 32 patients inside Milan and 54 without HCC staged by MRI, 11 progressed beyond the criteria after LT. High serum alpha-fetoprotein level (≥20 ng/mL) was the only per-patient factor significantly associated with malignant IDNs. Per-tumor analysis of the MRI signals revealed that arterial hyperintensity, hepatobiliary hypointensity, T₂ -weighted mild-to-moderate intensity, and restricted diffusion-weighted images were significantly correlated with malignant IDN. A model combining these 4 MRI factors with alpha-fetoprotein level had the best performance in predicting the identification of IDNs as HCCs in explanted livers. Over 60% of the IDNs seen on dynamic images of cirrhotic livers proved to be HCCs when explanted livers were examined. It may therefore be possible to identify HCCs with reasonable accuracy by means of their hepatocyte-specific MRI features when patients are being assessed for LT.

[Radiological diagnostic workup of liver tumors]

The imaging of focal liver lesions is a common task in daily radiological routine. The objectives of diagnostic imaging are, in addition to lesion detection, the characterization of the lesion as well as the follow-up assessment after surgical or local treatment or under systemic therapy. This article presents the typical morphologies observed in computed tomography and magnetic resonance imaging of hepatocellular carcinomas and intrahepatic cholangiocarcinomas as the most important representatives of primary malignant liver tumors and juxtaposes them with benign primary liver lesions such as adenoma and focal nodular hyperplasia (FNH). In addition, relevant technical aspects of imaging are briefly summarized. Finally, the main and additional criteria of the Liver Imaging Reporting and Data System (LI-RADS®) classification, which are becoming increasingly established clinically for the evaluation of liver lesions in the cirrhotic liver, are presented.

Sirlin C, Song B, Taouli B, Yoshimitsu K, Koh DM. Consensus report from the 8th International Forum for Liver Magnetic Resonance Imaging

OBJECTIVES

The 8th International Forum for Liver Magnetic Resonance Imaging (MRI), held in Basel, Switzerland, in October 2017, brought together clinical and academic radiologists from around the world to discuss developments in and reach consensus on key issues in the field of gadoxetic acid-enhanced liver MRI since the previous Forum held in 2013.

METHODS

Two main themes in liver MRI were considered in detail at the Forum: the use of gadoxetic acid for contrast-enhanced MRI in patients with liver cirrhosis and the technical performance of gadoxetic acid-enhanced liver MRI, both opportunities and challenges. This article summarises the expert presentations and the delegate voting on consensus statements discussed at the Forum.

RESULTS AND CONCLUSIONS

It was concluded that gadoxetic acid-enhanced MRI has higher sensitivity for the diagnosis of hepatocellular carcinoma (HCC), when compared with multidetector CT, by utilising features of hyperenhancement in the arterial phase and hypointensity in the hepatobiliary phase (HBP). Recent HCC management guidelines recognise an increasing role for gadoxetic acid-enhanced MRI in early diagnosis and monitoring post-resection. Additional research is needed to define the role of HBP in predicting microvascular invasion, to better define washout during the transitional phase in gadoxetic acid-enhanced MRI for HCC diagnosis, and to reduce the artefacts encountered in the arterial phase. Technical developments are being directed to shortening the MRI protocol for reducing time and patient discomfort and toward utilising faster imaging and non-Cartesian free-breathing approaches that have the potential to improve multiphasic dynamic imaging.

KEY POINTS

• Gadoxetic acid-enhanced MRI provides higher diagnostic sensitivity than CT for diagnosing HCC. • Gadoxetic acid-enhanced MRI has roles in early-HCC diagnosis and monitoring post-resection response. • Faster imaging and free-breathing approaches have potential to improve multiphasic dynamic imaging.

The Comprehensive Analysis of Efficacy and Safety of CalliSpheres® Drug-Eluting Beads Transarterial Chemoembolization in 367 Liver Cancer Patients: A Multiple-Center, Cohort Study

This study aimed to investigate the efficacy, safety, and prognostic factors of drug-eluting beads transarterial chemoembolization (DEB-TACE) in treating Chinese patients with liver cancer. A total of 367 liver cancer patients from 24 medical centers were consecutively enrolled in this multiple-center, prospective cohort study, including 275 hepatocellular carcinoma (HCC) cases, 37 intrahepatic cholangiocarcinoma (ICC) cases, and 55 secondary liver cancer cases. All the patients received CalliSpheres^® DEB-TACE treatment. Treatment response, overall survival (OS), change of liver function, and adverse events (AEs) were assessed. DEB-TACE treatment achieved 19.9% complete response (CR) and 79.6% objective response rate (ORR), with mean OS of 384 days [95% confidence interval (CI): 375–393 days]. CR and ORR were both higher in HCC patients compared with primary ICC patients and secondary liver cancer patients, while no difference was discovered in OS. Portal vein invasion was an independent risk factor for CR, while portal vein invasion, previous conventional TACE (cTACE) treatment, and abnormal blood creatinine (BCr) were independent risk factors for ORR. In addition, largest nodule size ≥5.0 cm, abnormal albumin (ALB), and abnormal total bilirubin (TBIL) independently correlated with unfavorable OS. Most liver function indexes were recovered to baseline levels at 1–3 months after DEB-TACE. Common AEs were pain, fever, vomiting, and nausea; most of them were at mild grade. CalliSpheres^® DEB-TACE is efficient and well tolerated in Chinese liver cancer patients. Portal vein invasion, previous cTACE treatment, largest nodule size, abnormal BCr, ALB, and TBIL correlate with worse prognosis independently.

Socioeconomic And Survival Differences Among Minorities With Hepatocellular Carcinoma In Florida

Background

Disparities in hepatocellular carcinoma (HCC) have been partly attributed to low socioeconomic status among minorities. We investigated associations between race, socioeconomic characteristics, geographic characteristics and survival in HCC patients in Florida.

Methods

Using the Florida Cancer Data System (FCDS), we analyzed HCC cases diagnosed between 1/1/2004 and 12/31/2013. To ascertain population-level socioeconomic characteristics, we linked FCDS to the 2010–2014 US Census American Community Survey and the 2013 Florida Behavioral Risk Factor Surveillance System. We also estimated patient distance to liver transplant and academic cancer centers. Using Cox proportional hazards, we modeled the association between race and survival.

Results

Of 10,852 patients, 13.1% were Black, 67.1% White, 15.7% Hispanic, and 3.2% Asian. At diagnosis, Blacks were younger with more extensive disease, p <0.001. Transplants were performed in 9.3% of Hispanics, 7.5% of Whites, 5.8% of Asians and 4.2% of Blacks, p <0.001. Median survival was longest in Hispanics and shortest in Blacks, p<0.001 When adjusted for gender, age, payer, SEER stage, surgery type, and receipt of treatment, Blacks had a 17% increased risk of death [hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.07–1.29] and Whites a 9% increased risk of death [HR 1.09, 95% CI 1.02–1.17] compared to Hispanics. As a group, Hispanics lived closest to any transplant or academic cancer center, p <0.001. Neighborhood poverty level was highest where Hispanic patients lived, p <0.001.

Conclusion

Though socioeconomic differences may contribute to disparities, Hispanics survived longer than Blacks and Whites in Florida despite living in the most socioeconomically depressed neighborhoods. Increased access to transplant likely contributed to improved survival. Additional research is needed to identify which individual socioeconomic and geographic determinants contribute most to disparities.

Machine-learning analysis of contrast-enhanced CT radiomics predicts recurrence of hepatocellular carcinoma after resection: A multi-institutional study

Background

Current guidelines recommend surgical resection as the first-line option for patients with solitary hepatocellular carcinoma (HCC); unfortunately, postoperative recurrence rate remains high and there is no reliable prediction tool. We explored the potential of radiomics coupled with machine-learning algorithms to improve the predictive accuracy for HCC recurrence.

Methods

A total of 470 patients who underwent contrast-enhanced CT and curative resection for solitary HCC were recruited from 3 independent institutions. In the training phase of 210 patients from Institution 1, a radiomics-derived signature was generated based on 3384 engineered features extracted from primary tumor and its periphery using aggregated machine-learning framework. We employed Cox modeling to build predictive models. The models were then validated using an internal dataset of 107 patients and an external dataset of 153 patients from Institution 2 and 3.

Findings

Using the machine-learning framework, we identified a three-feature signature that demonstrated favorable prediction of HCC recurrence across all datasets, with C-index of 0.633–0.699. Serum alpha-fetoprotein, albumin-bilirubin grade, liver cirrhosis, tumor margin, and radiomics signature were selected for preoperative model; postoperative model incorporated satellite nodules into above-mentioned predictors. The two models showed superior prognostic performance, with C-index of 0.733–0.801 and integrated Brier score of 0.147–0.165, compared with rival models without radiomics and widely used staging systems (all P < 0.05); they also gave three risk strata for recurrence with distinct recurrence patterns.

Interpretation

When integrated with clinical data sources, our three-feature radiomics signature promises to accurately predict individual recurrence risk that may facilitate personalized HCC management.

•

We identified a three-feature fusion signature using machine-learning framework.

•

The signature coupled with clinical sources accurately predicted HCC recurrence.

•

This signature may serve as an early detector of aggressive disease.

•

We highlight the complementary nature of radiomics and existing variables.

Hepatocellular carcinoma detection in liver cirrhosis: diagnostic performance of contrast-enhanced CT vs. MRI with extracellular contrast vs. gadoxetic acid

OBJECTIVES

To evaluate the diagnostic performance of contrast-enhanced CT vs. MRI with extracellular contrast agents (EC-MRI) vs. MRI with gadoxetic acid (EOB-MRI) for HCC detection in patients with liver cirrhosis using liver explant as the reference. The additional value of hepatobiliary phase (HBP) post Gadoxetic acid was also assessed.

METHODS

Two-hundred seventy-seven consecutive patients who underwent liver transplantation over a 9 year period and imaging within 90 days of were retrospectively included. Imaging consisted in CT (n = 100), EC-MRI (n = 77) and EOB-MRI (n = 100), the latter subdivided into dynamic EOB-MRI and full EOB-MRI (dynamic+HBP). Three radiologists retrospectively categorized lesions ≥ 1 cm using the LI-RADSv2017 algorithm. Dynamic EOB-MRI was re-evaluated with the addition of HBP. Results were correlated with explant pathology.

RESULTS

Pathology demonstrated 265 HCCs (mean size 2.1 ± 1.4 cm) in 177 patients. Per-patient sensitivities were 86.3% for CT, 89.5% for EC-MRI, 92.8% for dynamic EOB-MRI and 95.2% for full EOB-MRI (pooled reader data), with a significant difference between CT and dynamic/full EOB-MRI (p = 0.032/0.002), and between EC-MRI and full EOB-MRI (p = 0.047). Per-lesion sensitivities for CT, EC-MRI, dynamic EOB-MRI and full EOB-MRI were 59.5%,78.5%,69.7% and 76.8%, respectively, with a significant difference between MRI groups and CT (p-range:0.001-0.04), and no difference between EC-MRI and dynamic EOB-MRI (p = 0.949). For HCCs 1-1.9 cm, sensitivities were 34.4%, 64.6%, 57.3% and 67.3%, respectively, with all MRI groups significantly superior to CT (p ≤ 0.01) and full EOB-MRI superior to dynamic EOB-MRI (p = 0.002).

CONCLUSIONS

EOB-MRI outperforms CT and EC-MRI for per-patient HCC detection sensitivity, and is equivalent to EC-MRI for per-lesion sensitivity. MRI methods outperform CT for detection of HCCs 1-1.9 cm.

KEY POINTS

• MRI is superior to CT for HCC detection in patients with liver cirrhosis. • EOB-MRI outperforms CT and MRI using extracellular contrast agents (EC-MRI) for per-patient HCC detection sensitivity, and is equivalent to EC-MRI for per-lesion sensitivity. • The addition of hepatobiliary phase images improves HCC detection when using gadoxetic acid.