Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review

Infiltrative hepatocellular carcinoma: comparison of MRI sequences for lesion conspicuity

AIM

To characterize the magnetic resonance imaging (MRI) features of infiltrative hepatocellular carcinoma (I-HCC), with emphasis on its relative conspicuity on different sequences.

MATERIALS AND METHODS

Nineteen patients exhibiting HCC with non-mass-like appearance and ill-defined margins, and who died within 1 year following diagnosis of I-HCC, were included. For each sequence, two observers independently assessed the lesion's signal intensity relative to benign liver as well as subjective visual conspicuity. The observers also selected the sequence exhibiting the greatest visual conspicuity. A separate radiologist placed regions of interest to measure tumour-to-liver contrast for each lesion. Tumour size and clinical features were also assessed.

RESULTS

Eighteen of the 19 patients exhibited central portal vein tumour thrombus; eight of the 19 patients had metastatic disease. All I-HCC measured over 5 cm. The two observers identified hyperintensity on T2-weighted imaging (WI) in 19 and 19 cases, hyperintensity on high b-value diffusion-weighted imaging (DWI) in 18 and 19 cases, arterial-phase hyperintensity in six and 10 cases, and venous-phase hypo-intensity in 17 and 16 cases. T2WI, DWI, and venous-phase images exhibited significantly greater subjective visual conspicuity than arterial-phase images for both observers (all p ≤ 0.040). Also, T2WI and DWI tended to exhibit greater tumour-to-liver contrast than arterial- and venous-phase images (all p ≤ 0.055). The arterial-phase was not selected as having greatest conspicuity for any case by either reader.

CONCLUSION

I-HCC is an aggressive form of HCC that is often less conspicuous on arterial-phase images than typical mass-forming HCC; T2WI and DWI may be more useful sequences for its diagnosis. Awareness of the distinct imaging features of I-HCC may be important for proper diagnosis.

Serum metabolic profiling study of hepatocellular carcinoma infected with hepatitis B or hepatitis C virus by using liquid chromatography-mass spectrometry

The objective of the present study was to explore the common and specific metabolic alterations of hepatocellular carcinoma (HCC) infected with hepatitis B virus (HBV) or hepatitis C virus (HCV). Serum profiling data revealed that the two HCC groups shared a mainly similar metabolic profile, providing a basis for investigating their common tumor pathogenesis mechanism and early diagnosis biomarkers. Arachidonic acid as a pro-inflammatory precursor increased significantly in the HCC group compared to the cirrhosis and healthy control. And the lysophosphatidylcholines (lysoPCs) with polyunsaturated fatty acid acyl chain with potent anti-inflammatory activity significantly decreased in the HCC and cirrhosis groups compared to those in the healthy control group, which may partly contribute to maintaining chronic inflammation and benefit the initiation and progression of the malignant hepatic tumor. The decreased ratios of polyunsaturated lysoPCs to saturated lysoPCs in HCC groups compared to chronic liver diseases infected with HBV or HCV and healthy control further demonstrated that a malignant liver tumor exerts profound influences independent of virus infection. Especially, serum endocannabinoids anandamide (AEA) and palmitylethanolamide (PEA) were found significantly elevated in HCC groups compared to healthy control, and in HCC with HCV compared to corresponding chronic liver diseases. AEA, PEA, or their combination showed better sensitivity, specificity, and the area under the curve for distinguishing HCC from chronic liver diseases, showing they are potential biomarkers to distinguish the HCC from cirrhosis infected with HCV.

Changes of guidelines diagnosing hepatocellular carcinoma during the last ten-year period

Hepatocellular carcinoma (HCC) is the third most common cause of cancer deaths in the world. There have been many advances in the diagnosis of HCC during the last ten years, especially in the imaging techniques. The Korean Liver cancer study group (KLCSG), European Association for the Study of the Liver (EASL), American Association for the Study of Liver disease (AASLD), and Asian-Pacific Association for the Study of Liver (APASL) have made and changed the HCC guidelines with the advances in the imaging techniques and according to the results of the researches on HCC. We reviewed the changes of the imaging guidelines in HCC diagnosis according to the advances in the imaging techniques. Further studies will be necessary to resolve the controversies in the diagnosis of HCC smaller than 1 cm in size.

Use of magnetic resonance imaging contrast agents in the liver and biliary tract

This article presents an overview of liver and biliary contrast agents including their mechanisms of action, dosage and elimination, current clinical indications, and potential future uses.

Hepatocellular carcinoma in a North American population: does hepatobiliary MR imaging with Gd-EOB-DTPA improve sensitivity and confidence for diagnosis?

PURPOSE

To evaluate the value of hepatobiliary phase imaging for detection and characterization of hepatocellular carcinoma (HCC) in liver MRI with Gd-EOB-DTPA, in a North American population.

MATERIALS AND METHODS

One hundred MRI examinations performed with the intravenous injection of Gd-EOB-DTPA in patients with cirrhosis were reviewed retrospectively. Nodules were classified as HCC (n = 70), indeterminate (n = 33), or benign (n = 22). Five readers independently reviewed each examination with and without hepatobiliary phase images (HBP). Lesion conspicuity scores were compared between the two readings. Lesion detection, confidence scores, and receiver operating characteristic (ROC) analysis were compared.

RESULTS

Lesion detection was slightly improved for all lesion types with the inclusion of the HBP, and was substantially higher for small HCCs (96.0% versus 85.3%). Mean confidence scores for the diagnosis of HCC increased for HCCs overall and each size category (P < 0.001). Diagnostic performance improved with the addition of the HBP (aggregate AROC 87.7% versus 80.0%, P < 0.01), and sensitivity for characterization improved (90.9% versus 78.3%, P < 0.01) while specificity was unchanged.

CONCLUSION

Hepatobiliary phase imaging may improve small lesion detection (<1 cm) and characterization of lesions in general, in MRI of the cirrhotic liver with Gd-EOB-DTPA.

MR imaging of hypervascular lesions in the cirrhotic liver: a diagnostic dilemma

Cirrhosis is characterized by a spectrum of hepatocellular nodules that mark the progression from regenerative nodules to low- and high-grade dysplastic nodules, followed by small and large hepatocellular carcinomas (HCCs). Characterization of small nodules on the basis of imaging and histopathologic findings is complicated by an overlap in findings associated with each type of nodule, a reflection of their multistep transitions. Vascularity patterns change gradually as the nodules evolve, with an increasing shift from predominantly venous to predominantly arterial perfusion. Regenerative and low-grade dysplastic nodules demonstrate predominantly portal perfusion and contrast enhancement similar to that of surrounding parenchyma. Differentiation of high-grade dysplastic nodules and well-differentiated HCCs on the basis of dynamic imaging and histologic findings is challenging, with a high rate of false-negative results. Some small nodules that lack hypervascularity may be early HCCs. Progressed small and large HCCs usually present no diagnostic difficulty because of their characteristic findings. Although characterization of hypervascular lesions in the cirrhotic liver is difficult, it is a key step in disease management and is the radiologist's responsibility.

Serum paraoxonase 1 heteroplasmon, a fucosylated, and sialylated glycoprotein in distinguishing early hepatocellular carcinoma from liver cirrhosis patients

Aberrant glycan structure of serum glycoproteins creates unique patterns in different stages of hepatocellular carcinoma (HCC), which provides potential glycan biomarkers for early diagnosis of HCC. In this study, tandem lectin affinity chromatography using aleuria aurantia lectin (AAL) and wheat germ agglutinin (WGA) was processed to purify both fucosylated and sialylated serum glycoproteins from 27 liver cirrhosis (LC) and 27 early HCC patients, in which 122 glycoproteins were finally screened out by liquid chromatography-tandem mass spectrometry (LC-MSMS). Among the 122 proteins identified by LC-MSMS, 8 of them were only identified in HCC serum and another 6 existed only in LC serum. Serum paraoxonase 1 (PON1) was immunoprecipitated from 47 individual patients and blotted by lectins, showing enhanced fucosylation and sialylation in HCC serum than those in LC serum. The area under the ROC curve (AUROC) for AAL-reactive PON1 was 0.892 with a sensitivity of 71.4% and a specificity of 94.7% in differentiating early HCC from LC. Similarly, WGA-reactive PON1 had an AUROC of 0.902 with a sensitivity of 95.2% and a specificity of 78.9%. The data indicated that the glycan differences of serum PON1 might serve as potential glycan biomarkers for distinguishing early HCC from LC patients.

Histologic characteristics of hepatocellular carcinomas showing atypical enhancement patterns on 4-phase MDCT examination

Objective

To retrospectively define which histologic characteristics of small-sized hepatocellular carcinomas (HCCs) are related to atypical dynamic enhancement on multi-detector computed tomography (MDCT) imaging.

Materials and Methods

Seventy-three patients with 83 HCCs (3 cm or less in diameter) were included in this study. All patients underwent 4-phase MDCT imaging and subsequent surgery within eight weeks. Two independent radiologists blinded to the histologic findings retrospectively classified the HCCs as either typical (showing increased enhancement on arterial phase images followed by washout in late phase images) or atypical lesions demonstrating any other enhancement pattern. From the original pathologic reports, various histologic characteristics including gross morphology, nuclear histologic grades, presence of capsule formation, and capsule infiltration when a capsule was present, were compared among the two groups.

Results

An atypical enhancement pattern was seen in 30 (36.2%) of the 83 HCCs. The mean size of atypical HCCs (1.71 ± 0.764) was significantly smaller than that of typical HCCs (2.31 ± 0.598, p < 0.001). Atypical HCCs were frequently found to be vaguely nodular in gross morphology (n = 13, 43.3%) and to have grade I nuclear grades (n = 17, 56.7%). Capsule formation was significantly more common in typical HCCs (p < 0.001). Capsular infiltration was also more common in typical HCCs (p = 0.001).

Conclusion

HCCs showing atypical dynamic enhancement on MDCT imaging are usually smaller than typical HCCs, vaguely nodular type in gross morphology in most cases, and well-differentiated in nuclear grades, and they lack of capsule formation or capsular infiltration.

The management of hepatocellular carcinoma around the world: a comparison of guidelines from 2001 to 2011

In the past 10 years, many guidelines for hepatocellular carcinoma (HCC) have been published worldwide. To promote standard care for HCC, we systematically evaluated 17 current guidelines for HCC around the world, including 5 guidelines from the USA, 7 from Asia and 5 from Europe, according to the selection criteria of credibility influence and multi-faceted. After a systematic evaluation, we found that these guidelines have both similarities and differences in terms of what organizations or bodies drafted the guidelines and the approach, applicability, content and recent updates of the guidelines as well as in terms of diagnostic and treatment algorithms. The differences could be attributed to various aetiological factors, high-risk patients, health systems, health resources, medical technology, treatment choices and income levels in different countries. Besides, although the full implementation of guidelines could benefit clinicians, patients and authorities, there is still a gap between projected goals and implementation. The factors potentially influencing implementation are what organizations or bodies are drafting guidelines, content and emphasis, modification and consistency of guidelines. Comparative analysis suggested that countries pay close attention to targeted audiences, a basis in evidence, a basis in available resources, applicable patients and systematic evaluation when establishing and implementing domestic guidelines for HCC.

[Ultrasound in oncology: screening and staging]

This is a review on the role of ultrasound for early detection and staging of cancer. In breast cancer screening ultrasound serves to clarify mammographically unclear lesions and is a primary screening tool for hereditary breast cancer. Renal neoplasms are commonly diagnosed as incidental sonographic findings and in this case are more often in a curable stage than symptomatic neoplasms. In chronic hepatitis or liver cirrhosis the annual incidence of hepatocellular cancer is more than 2% and ultrasound is used as a screening tool with 60% sensitivity and 97% specificity. According to the literature the sensitivity of native ultrasound for detecting metastases is 60% and the sensitivity of contrast-enhanced ultrasound (CEUS) is 79% or higher, i.e comparable with the sensitivity of contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Its role in staging is, however, limited as CT and MRI are necessary for local staging of the primary tumor and also include the liver. In the differential diagnosis of liver lesions the specificity of CEUS ranges from 82% to 99% depending on the lesion entity and is thereby comparable to contrast-enhanced CT. For staging of cervical lymph node metastases ultrasound is preferable to CT or MRI as the sensitivity lies between 79% and 90% and specificity is reported to be 90%.

Comparison of usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B endemic area

Background/Aims

We compared the accuracy and usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B virus (HBV)-endemic area.

Methods

We reviewed the medical records of 355 patients who had undergone liver resection or biopsy at our institution between January 2008 and December 2009. These patients were reevaluated using four noninvasive diagnostic criteria for hepatocellular carcinoma proposed by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD), the Korean Liver Cancer Study Group and the National Cancer Center (KLCSG/NCC), and National Comprehensive Cancer Network (NCCN) guidelines.

Results

The overall sensitivity was highest using the KLCSG/NCC criteria (79.8%), followed by the AASLD (51.5%), EASL (38.4%), and NCCN (10.1%; P<0.001) criteria, whereas the specificity (84.5-98.3%) and positive predictive value (96.2-98.3%) were similar for all of the criteria. The KLCSG/NCC criteria had an acceptable false-positive rate and the highest sensitivity among all of the patients, including those positive for HBsAg, those without liver cancer, and those with a tumor of at least 2 cm.

Conclusions

The KLCSG/NCC and AASLD criteria exhibited the highest sensitivity, and all four guidelines had a high specificity among all of the patients. Based on the sensitivity and false-positive rate, the KLCSG/NCC criteria was the most useful in the majority of patients. Inclusion of HBV infection in the clinical diagnostic criteria for hepatocellular carcinoma would be reasonable and may lead to an improvement in the sensitivity, with acceptable false-positive rates, in HBV-endemic areas.

Recent advances in metabolomics in oncology

The burden of cancer is growing worldwide and with it a more desperate need for better tools to detect, diagnose and monitor the disease is required. It is well recognized that cancer cells are characterized by distinct metabolic perturbations. The metabolomics approach involves the comprehensive profiling of the full complement of low MW compounds in a biological system. By applying advanced analytical and statistical tools, the 'metabolome' is mined for biomarkers that are associated with the state of cancer. This review presents an introduction to the main analytical platforms used in metabolomics analyses, such as NMR spectroscopy and MS, as well as the statistical tools used to mine these datasets. The discussion focuses on 'state-of-the-art' investigations on the four cancer types that have received the most study by metabolomics, namely breast, prostate, colorectal and liver cancer.

Primary liver cancer is more aggressive in HIV-HCV coinfection than in HCV infection. A prospective study (ANRS CO13 Hepavih and CO12 Cirvir)

OBJECTIVE

Since HAART, primary liver cancer has emerged as an increasing cause of morbidity and mortality in patients with HIV infection. Our aim was to compare characteristics and outcome of primary liver cancer according to HIV status in HCV cirrhotic patients submitted to periodic ultrasonographic surveillance.

METHODS

All patients with primary liver cancer and cirrhosis were selected from two prospective cohorts (ANRS CO12 Cirvir, viral cirrhosis, n=1081; ANRS CO13 Hepavih, HIV-HCV coinfection, n=1175). Cirrhosis was diagnosed by liver biopsy in monoHCV group and biopsy and/or non-invasive tests in HIV-HCV group. Ultrasonographic surveillance was performed every 6 months. Diagnosis of primary liver cancer was established according to EASL-AASLD guidelines.

RESULTS

Primary liver cancer was diagnosed in 32 patients, 16 in each group, and corresponded to hepatocellular carcinoma in all except for two cholangiocarcinomas in HIV-HCV patients. Ultrasonographic follow-up was similar (median time since last ultrasonographic without focal lesion: 237 days in HIV-HCV group (n=12) versus 208 days in HCV group, NS). At primary liver cancer diagnosis HIV-HCV patients were markedly younger (48 vs. 60 yrs, P<0.001), primary liver cancer was more advanced in HIV-HCV patients (single nodule: 43% vs. 75%, P=0.07; mean diameter of main nodule: 24 vs. 16 mm, P=0.006; portal obstruction: 3 vs. 0). Curative treatment was performed in four HIV-HCV patients versus 11 HCV patients (P=0.017). During follow-up, 10 HIV-HCV patients died versus only one HCV patient (P=0.0005).

CONCLUSIONS

This result suggests more aggressiveness for tumors in HIV infected patients and, if confirmed, could result in shortening the length between ultrasonographic examinations.

Hepatic artery injection of ¹³¹I-labelled metuximab combined with chemoembolization for intermediate hepatocellular carcinoma: a prospective nonrandomized study

PURPOSE

Hepatocellular carcinoma (HCC) is the fifth and seventh most common cause of cancer in men and women, respectively. Transcatheter arterial chemoembolization (TACE) is the standardized therapy for the intermediate stage of HCC. However, the 3-year overall survival remains low (<30 %) in these patients. Thus, there is a critical need for the development of treatment modalities to improve the survival rate. This study aimed to evaluate whether the combination of (131)I-metuximab with chemoembolization could improve treatment efficiency.

METHODS

Between January 2009 and January 2010, a prospective two-arm nonrandomized study was performed in patients with intermediate HCC. Of 138 patients, 68 (combination therapy group) received 132 courses of intraarterial (131)I-metuximab injections combined with chemoembolization (mean 1.94 per patient, median 2, range 1-2), followed by 152 sessions of TACE (mean 2.24 per patient, median 2, range 0-4). The remaining 70 patients (monotherapy group) received 296 sessions of TACE (mean 4.23 per patient, median 4, range 1-7).

RESULTS

The overall median survival times for the combination therapy group and the group treated only with TACE were 26.7 months (95 % CI 20.7-31.3 months) and 20.6 months (95 % CI 15.3-24.7 months), respectively. The combination therapy group had a significantly higher survival rate than the TACE-only group (P = 0.038). Age ≥65 years, serum albumin ≤35 g/l, and treatment category (combination therapy or TACE only) were independent prognostic factors for survival according to multivariate analysis.

CONCLUSION

The combination of (131)I-metuximab and chemoembolization extended survival in patients with intermediate HCC compared with TACE only, and was well tolerated by patients with Child-Pugh class A or B disease. This combination seems to be a promising treatment modality for patients with intermediate HCC.

Which is the best MRI marker of malignancy for atypical cirrhotic nodules: hypointensity in hepatobiliary phase alone or combined with other features? Classification after Gd-EOB-DTPA administration

PURPOSE

To investigate whether the malignancy of atypical nodules in cirrhosis can be identified at gadoxetic-acid-disodium(Gd-EOB-DTPA)-MRI by their hypointensity in the hepatobiliary(HB)-phase alone or combined with any other MR imaging features.

MATERIALS AND METHODS

One hundred eleven atypical nodules detected in 77 consecutive Gd-EOB-DTPA-MRIs were divided, based on arterial-phase behavior, into: Class I, isovascular (n = 82), and Class II, hypervascular without portal/delayed washout (n = 29). The two classes were further grouped based on HB-phase intensity (A/B/C hypo/iso/hyperintensity). Portal/venous/equilibrium-phase behavior and T2w features were also collected. Histology was the gold standard. Per-nodule sensitivity, specificity, negative and positive predictive values (NPV/PPV), and diagnostic accuracy were calculated for HB-phase hypointensity alone, and combined with vascular patterns and T2w hyperintensity.

RESULTS

Histology detected 60 benign and 51 malignant/premalignant nodules [10 overt hepatocellular carcinomas (HCCs) and 41 high-grade dysplastic nodules (HGDN)/early HCC]. Class IA contained 31 (94%) malignancies, IB one (3%), and IC only benign lesions. Class IIA had 100% malignancies, IIB three (37.5%) and IIC only two (28.5%). HB-phase hypointensity alone (Classes I-IIA) had 88% sensitivity, 91% NPV, and 93% diagnostic accuracy, superior (P < 0.05, P < 0.006, and P < 0.05, respectively) to any other MR imaging feature alone or combined.

CONCLUSION

In atypical cirrhotic nodules, HB-phase hypointensity by itself is the strongest marker of malignancy.

Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis, and therapeutics

Hepatocellular carcinoma (HCC) is a common malignancy in developing countries and its incidence is on the rise in the developing world. The epidemiology of this cancer is unique since its risk factors, including hepatitis C and B, have been clearly established. The current trends in the shifting incidence of HCC in different regions of the world can be explained partly by the changing prevalence of hepatitis. Early detection offers the only hope for curative treatment for patients with HCC, hence effective screening strategies for high-risk patients is of utmost importance. Liver transplantation and surgical resection remains the cornerstone of curative treatment. But major advances in locoregional therapies and molecular-targeted therapies for the treatment of advanced HCC have occurred recently. In this review, current trends in the worldwide epidemiology, surveillance, diagnosis, standard treatments, and the emerging therapies for HCC are discussed.

Histological differentiation grade and microvascular invasion of hepatocellular carcinoma predicted by dynamic contrast-enhanced MRI

PURPOSE

To explore the potential use of magnetic resonance imaging (MRI) in predicting the outcome for patients with hepatocellular carcinoma (HCC), imaging characteristics were correlated with pathological findings and clinical outcome.

MATERIALS AND METHODS

With permission from the Ethical Board, clinical data and tissues of resected HCC patients were collected, including the preoperative MRI. The role of MRI characteristics on recurrence and survival were evaluated with univariate and multivariate analyses.

RESULTS

Between January 2000 and December 2008, 87 patients with 104 HCCs were operated on. Microvascular invasion was present in 55 lesions (53%). HCC was characterized as well differentiated in 15 lesions (14%), as moderate in 50 lesions (48%), and as poorly differentiated in 34 lesions (33%). Due to preoperative treatment in five lesions (5%) no vital tumor was left. In 85 lesions (88%) washout of contrast was noted. Of the 87 patients, 28 (32%) with 37 lesions developed HCC recurrence; these patients had microvascular invasion significantly more often and a moderate or poorly differentiated tumor (P < 0.001 and P = 0.025, respectively). MRI more often showed washout when HCC was moderately or poorly differentiated (P < 0.001) or microvascular invasion was present (P = 0.032).

CONCLUSION

Differentiation grade and microvascular invasion are significantly associated with the presence of washout demonstrated on dynamic contrast-enhanced MRI.

Cost-effectiveness analysis on the surveillance for hepatocellular carcinoma in liver cirrhosis patients using contrast-enhanced ultrasonography

AIM

  Sonazoid is a new contrast agent for ultrasonography (US). Contrast-enhanced ultrasonography (CEUS) using Sonazoid enables Kupffer imaging, which improves the sensitivity of hepatocellular carcinoma (HCC) detection. However, there are no studies on the cost-effectiveness of HCC surveillance using Sonazoid.

METHODS

  We constructed a Markov model simulating the natural history of HCV-related liver cirrhosis (LC) patients, and compared three strategies (no surveillance, US surveillance and CEUS surveillance). The transition probability and cost data were obtained from published data. The simulation and analysis were performed using TreeAge pro 2009 software.

RESULTS

  When compared to the no surveillance group, the US and CEUS surveillance groups increased the life expectancy by 1.67 and 1.99 quality-adjusted life-years (QALY), respectively, and the incremental cost effectiveness ratio (ICER) were 17 296 $US/QALY and 18 384 $US/QALY, respectively. These results were both less than the commonly-accepted threshold of $US 50 000/QALY. Even if the CEUS surveillance group was compared with the US surveillance group, the ICER was $US 24 250 and thus cost-effective. Sensitivity analysis showed that the annual incidence of HCC and CEUS sensitivity were two critical parameters. However, when the annual incidence of HCC is more than 2% and/or the CEUS sensitivity is more than 80%, the ICER was also cost-effective.

CONCLUSIONS

  Contrast-enhanced ultrasonography surveillance for HCC is a cost-effective strategy for LC patients and gains their longest additional life years, with similar degree of ICER in the US surveillance group. CEUS surveillance using Sonazoid is expected to be used not only in Japan, but also world-wide.

Hepatocellular carcinoma

Hepatocellular carcinoma is the sixth most prevalent cancer and the third most frequent cause of cancer-related death. Patients with cirrhosis are at highest risk of developing this malignant disease, and ultrasonography every 6 months is recommended. Surveillance with ultrasonography allows diagnosis at early stages when the tumour might be curable by resection, liver transplantation, or ablation, and 5-year survival higher than 50% can be achieved. Patients with small solitary tumours and very well preserved liver function are the best candidates for surgical resection. Liver transplantation is most beneficial for individuals who are not good candidates for resection, especially those within Milano criteria (solitary tumour ≤5 cm and up to three nodules ≤3 cm). Donor shortage greatly limits its applicability. Percutaneous ablation is the most frequently used treatment but its effectiveness is limited by tumour size and localisation. In asymptomatic patients with multifocal disease without vascular invasion or extrahepatic spread not amenable to curative treatments, chemoembolisation can provide survival benefit. Findings of randomised trials of sorafenib have shown survival benefits for individuals with advanced hepatocellular carcinoma, suggesting that molecular-targeted therapies could be effective in this chemoresistant cancer. Research is active in the area of pathogenesis and treatment of hepatocellular carcinoma.

Planning ultrasound for percutaneous radiofrequency ablation to treat small (≤ 3 cm) hepatocellular carcinomas detected on computed tomography or magnetic resonance imaging: a multicenter prospective study to assess factors affecting ultrasound visibility

PURPOSE

To assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency (RF) ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on computed tomography (CT) or magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Patients referred for planning US for percutaneous RF ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. The study enrolled 898 patients (684 men and 214 women, age range 32-86 years). HCCs that were invisible on planning US were compared with visible HCCs with respect to tumor size, distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha fetoprotein (AFP) level, body mass index (BMI), previous treatments for HCC, previous chemoembolization treatments for HCC, institutions, and experience of radiologists.

RESULTS

Among 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each P < .05).

CONCLUSIONS

Smaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of invisible tumors on planning US.

Liver Transplantation for HCC: A Review

Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease or cirrhosis. Liver transplantation for hepatocellular carcinoma has the potential to eliminate both the tumor as well as the underlying cirrhosis and is the ideal treatment for HCC in cirrhotic liver as well as massive HCC in noncirrhotic liver. Limitations in organ availability, necessitate stringent selection of patients who would likely to derive most benefit. Selection criteria have considered tumor size, number, volume as well as biological features. The Milan criteria set the benchmark for tumors that would benefit from liver transplantation but were found to be excessively restrictive. Modest expansion in criteria has also been shown to be associated with equivalent survival. Microvascular invasion is the single most important adverse prognostic factor for survival. Living donor liver transplantation has expanded donor options and has the advantage of lower waiting period and not impacting the non-HCC waiting list. Acceptable outcomes have been obtained with living donor liver transplantation for larger and more numerous tumors in the absence of microvascular invasion. Downstaging of tumors to prevent progression while waiting for an organ or for reduction in size to allow enrolment for transplantation has met with variable success.

Chronological evaluation of liver enhancement in patients with chronic liver disease at Gd-EOB-DTPA-enhanced 3-T MR imaging: does liver function correlate with enhancement?

PURPOSE

To investigate the chronological relationship between scan delay and liver enhancement for the hepatobiliary phase on Gd-EOB-DTPA-enhanced MRI and evaluate the effects of liver function on liver enhancement.

MATERIALS AND METHODS

Hepatobiliary-phase images were retrospectively evaluated in 125 patients with chronic liver disease. Hepatobiliary phase images were obtained at 5, 10, 15, and 20 min after injection. We calculated relative liver enhancement (RLE) at t min after injection by dividing the signal intensity (SI) of the liver at t min by precontrast SI. We compared RLE values at 5, 10, 15, and 20 min and evaluated the detectability of focal hepatic lesions. We analyzed the effect of liver function on RLE with the generalized linear model.

RESULTS

There was not significant difference in RLE and lesion detectability at 15 and 20 min. RLE in the Child-Pugh C group was significantly lower than in the Child-Pugh A and B groups. The serum albumin level and prothrombin time were significantly correlated with the liver enhancement.

CONCLUSION

A delay time of 15 min for the hepatobiliary phase was thought to be adequate in patients with mild liver dysfunction. The serum albumin level and prothrombin time would be predictive of liver enhancement in the hepatobiliary phase.

Hepatocellular carcinoma: management of an increasingly common problem

Hepatocellular carcinoma (HCC) is a common cancer that typically occurs in the setting of cirrhosis and chronic hepatitis virus infections. Hepatitis B and C account for approximately 80% of cases worldwide. HCC is currently the fifth most common malignancy in men and the eighth in women worldwide; its incidence is increasing dramatically in many parts of the world. Recognition of those at risk and early diagnosis by surveillance with imaging, with or without serologic testing, are extremely important. Many highly effective and even curative therapies are now available and include resection, liver transplantation, and local ablation. Appropriate application of these interventions offers hope of prolonged survival to many patients with this otherwise lethal complication of liver disease.

Detection and grading of esophageal varices on liver CT: comparison of standard and thin-section multiplanar reconstructions in diagnostic accuracy

OBJECTIVE

The objective of our study was to evaluate the performance of liver CT in the diagnosis of esophageal varices in patients with cirrhosis and to determine whether thin-section multiplanar reconstructions (MPRs) improve accuracy.

MATERIALS AND METHODS

We identified 109 patients with cirrhosis who underwent endoscopy within 10 weeks after dual-phase liver MDCT supplemented with thin-section axial and coronal portal venous phase reconstructions. Two blinded radiologists independently evaluated each CT examination for the presence and sizes of varices using standard 5-mm axial versus 1- to 3-mm multiplanar images in separate sessions. Sensitivity, specificity, and predictive value calculations and receiver operating characteristic analysis were performed using endoscopy as the reference standard. Interobserver variability and correlation of CT size to variceal grade were assessed.

RESULTS

Twenty-six cases of high-risk esophageal varices were identified; all except two were detected on CT by one of the readers on standard 5-mm images. For both readers, sensitivity and negative predictive value (NPV) for the discrimination of high-risk varices using a criterion of 2 mm or greater were nearly the same for the standard 5-mm images versus the 1- to 3-mm multiplanar images (sensitivity and NPV: reader 1, 96% and 98% vs 96% and 99%; reader 2, and 89% and 95% vs 89% and 96%, respectively). Standard 5-mm images yielded a lower specificity for high-risk esophageal varices than the thin-section multiplanar images, and this difference was statistically significant for reader 2. Substantial interobserver agreement was noted for both esophageal varices detection and size measurements.

CONCLUSION

Standard liver CT is sensitive for the detection of high-risk varices and deserves further investigation as a potential cost-effective screening tool for the evaluation of patients with cirrhosis. The addition of 1- to 3-mm MPRs may increase specificity for risk stratification based on size measurements.

Secreted ERBB3 isoforms are serum markers for early hepatoma in patients with chronic hepatitis and cirrhosis

Most hepatocellular carcinoma (HCC) is generated from chronic hepatitis and cirrhosis. To discover new markers for early HCC in patients with chronic hepatitis and cirrhosis, we initiated our search in the interstitial fluid of tumor (TIF) via differential gel electrophoresis and antibody arrays and identified secreted ERBB3 isoforms (sERBB3). The performance of serum sERBB3 in diagnosis of HCC was analyzed using receiver operating characteristic curves (ROC). The serum sERBB3 level was significantly higher in HCC than in cirrhosis (p < 0.001) and chronic hepatitis (p < 0.001). The accuracy of serum sERBB3 in detection of HCC was further validated in two independent sets of patients. In discrimination of early HCC from chronic hepatitis or cirrhosis, serum sERBB3 had a better performance than alpha-fetoprotein (AFP) (areas under ROC [AUC]: sERBB3 vs AFP = 93.1 vs 81.0% from chronic hepatitis and 70.9 vs 62.7% from cirrhosis). Combination of sERBB3 and AFP further improved the accuracy in detection of early HCC from chronic hepatitis (AUC = 97.1%) or cirrhosis (AUC = 77.5%). Higher serum sERBB3 levels were associated with portal-vein invasion and extrahepatic metastasis of HCC (p = 0.017). Therefore, sERBB3 are serum markers for early HCC in patients with chronic hepatitis and cirrhosis.

[Malignant focal liver lesions]

Focal liver lesions are a very common occurrence. The detection and differentiation of such lesions is particularly important for the management of oncology patients and is a core task for radiology. The early and conclusive detection of malignant liver processes in a cost-efficient manner and with a low radiation dose for the patient requires systematic and skillful use of the various radiological methods. This review explains the application of current radiological methods for the detection and differentiation of malignant liver lesions and the typical appearance of the most commonly found liver malignancies.

Molecularly targeted therapies for hepatocellular carcinoma: sorafenib as a stepping stone

Since sorafenib, a multikinase inhibitor targeting angiogenesis of hepatocellular carcinoma (HCC), demonstrated survival benefits in recent clinical trials, it has changed the treatment paradigm and become the standard first-line treatment for patients with advanced HCC. However, disease stabilization with sorafenib lasts a few months, possibly due to the development of resistance, and thus the survival advantage was modest, even in patients with preserved liver function. Furthermore, there is currently no biomarker for monitoring the response or resistance to sorafenib. Currently, various kinds of molecularly targeted agents have been developed and are being evaluated in clinical trials. There are several steps required to improve the outcome from sorafenib therapy. First, a reliable predictive and prognostic biomarker is urgently needed. Second, a compelling indication of sorafenib treatment for HCC needs more clinical studies and consensus. Third, the actual benefits of sorafenib to patients with advanced liver dysfunction should be clarified and a more effective strategy for targeted therapy needs to be developed, for example, using a combination of targeted agents acting on different pathways or different levels of a key pathway. Finally, sorafenib could be used with other treatment modalities, such as local ablation or transarterial chemoembolization, to synergize efficacy. Based on the successful introduction of sorafenib, future studies should focus on plans to further improve the outcome of HCC patients by overcoming resistance and maximizing the efficacy of molecularly targeted therapy.

Diagnosis and management of hepatocellular carcinoma: results of a consensus meeting of The Ottawa Hospital Cancer Centre

Hepatocellular carcinoma (HCC) is an uncommon tumour, but its incidence is increasing in Canada and elsewhere. Currently, there are no Canadian recommendations for diagnosis and treatment of hcc, and possible options may have regional limitations. A consensus symposium was held in the Ottawa region to consider current diagnostic and management options for hcc. These recommendations were developed: Diagnosis-with adequate imaging, a biopsy is not required pre-surgery, but is required before the start of systemic therapy; lesions smaller than 1 cm should be followed and not biopsied; repeat biopsies should be core tissue biopsies; magnetic resonance imaging is preferred, but triphasic computed tomography imaging can be useful. Resection-recommended for localized HCC. Radiofrequency ablation-recommended for unresectable or non-transplantable HCC; should not be performed in the presence of ascites. Trans-arterial chemoembolization (TACE)-doxorubicin with lipiodol is the agent of choice; trans-catheter embolization is an alternative for patients if TACE is not tolerated or is contraindicated. Medical management-first-line sorafenib should be considered the standard of care. Transplantation-suitable patients meeting Milan criteria should be assessed for a graft regardless of other treatments offered. The authors feel that the recommendations from this consensus symposium may be of interest to other regions in Canada.

Recent advances in cytogenetics and molecular biology of adult hepatocellular tumors: implications for imaging and management

Focal nodular hyperplasia (FNH), hepatocellular adenoma (HCA), and hepatocellular carcinoma (HCC) compose hepatocellular neoplasms that occur in adults. These tumors demonstrate characteristic epidemiologic and histopathologic features and clinical and imaging manifestations. HCAs are monoclonal neoplasms characterized by increased predilection to hemorrhage or rupture and occasional transformation to HCC. On the other hand, FNH is a polyclonal tumorlike lesion that occurs in response to increased perfusion and has an indolent clinical course. Up to 90% of HCCs occur in the setting of cirrhosis. Chronic viral hepatitis (hepatitis B and hepatitis C) infection and metabolic syndrome are major risk factors that can induce HCCs in nonfibrotic liver. Recent advances in pathology and genetics have led to better understanding of the histogenesis, natural history, and molecular events that determine specific oncologic pathways used by these neoplasms. HCAs are now believed to result from specific genetic mutations involving TCF1 (transcription factor 1 gene), IL6ST (interleukin 6 signal transducer gene), and CTNNB1 (β catenin-1 gene); FNHs are characterized by an "imbalance" of angiopoietin. While the β catenin signaling pathway is associated with well- and moderately differentiated HCCs, mutations involving p53 (tumor protein 53 gene), MMP14 (matrix metalloproteinase 14 gene), and RhoC (Ras homolog gene family, member C) are associated with larger tumor size, higher tumor grade with resultant shortened tumor-free survival, and poor prognosis. Fibrolamellar carcinoma (FLC), a unique HCC subtype, exhibits genomic homogeneity that partly explains its better overall prognosis. On the basis of recent study results involving cytogenetics and oncologic pathways of HCCs, novel drugs that act against molecular targets are being developed. Indeed, sorafenib (a multikinase inhibitor) is currently being used in the successful treatment of patients with advanced HCC. Characterization of genetic abnormalities and genotype-phenotype correlations in adult hepatocellular tumors provides better understanding of tumor pathology and biology, imaging findings, prognosis, and response to molecular therapeutics.

Hepatic arterial iodine-131-labeled metuximab injection combined with chemoembolization for unresectable hepatocellular carcinoma: interim safety and survival data from 110 patients

Few options are available to treat patients with hepatocellular carcinoma (HCC). It was tested whether the combination of iodine-131(¹³¹I)-metuximab with chemoembolization could improve outcomes in patients with intermediate HCC. Between April 2008 and April 2009, 110 patients with unresectable HCC were treated with 113 intra-arterial ¹³¹I-metuximab injections combined with chemoembolization (mean, 1.03 per patient; median, 1; range, 1-2), followed by 264 sessions of transcatheter arterial chemoembolization (mean, 2.4 per patient; median, 3; range, 1-6). The survival rates at 6, 12, and 18 months were 88.2%, 79.1%, and 57.4%, respectively, by the Kaplan-Meier method. Of these patients, 12% exhibited grade 3/4 bilirubin toxicity, 5% exhibited grade 3/4 white blood count toxicity, and 7% exhibited grade 3/4 platelet toxicity. Response rates based on World Health Organization and European Association for the Study of the Liver criteria were 42.73% and 61.82%, respectively. The combination of ¹³¹I-metuximab and chemoembolization appeared to extend survival in patients with unresectable HCC compared with historical controls, as well as being well tolerated by patients with Child-Pugh A and B. This combination may represent a promising treatment modality for patients with intermediate HCC.

Diagnostic imaging and biopsy use among elderly medicare beneficiaries with hepatocellular carcinoma

PURPOSE

Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general community.

PATIENTS AND METHODS

This cohort study used Surveillance, Epidemiology, and End Results (SEER) -Medicare data (2002-2005) evaluating biopsy, imaging modalities (ultrasound, computed tomography [CT] scan, and/or magnetic resonance imaging [MRI]), and HCC risk factors.

RESULTS

Of 3,696 patients, 1,197 (32.4%) underwent one or more biopsies, with no change in yearly biopsy rate (trend test, P = .64). Patients with tumors > 5 cm were most likely to receive biopsies (35.3%), with increasing rates of biopsy for larger tumors (P = .001). Patients who received biopsies underwent more imaging than those who did not (P < .001) and were more likely to have an HCC risk factor. Tumor size > 5 cm in the setting of a concurrent HCC risk factor increased the odds of biopsy. In 47.8% of patients, the diagnostic sequence was not consistent with contemporary evidence-based guidelines.

CONCLUSIONS

Despite widespread availability and use of CT scan and MRI, one third of HCC patients undergo biopsy, suggesting a problem with the performance and/or quality of diagnostic imaging or that providers do not believe imaging alone is sufficient to establish the diagnosis. Understanding factors that drive biopsy use may help improve the care of patients with HCC.

Serum and urine metabolite profiling reveals potential biomarkers of human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignancy in the world with high morbidity and mortality rate. Identification of novel biomarkers in HCC remains impeded primarily because of the heterogeneity of the disease in clinical presentations as well as the pathophysiological variations derived from underlying conditions such as cirrhosis and steatohepatitis. The aim of this study is to search for potential metabolite biomarkers of human HCC using serum and urine metabolomics approach. Sera and urine samples were collected from patients with HCC (n = 82), benign liver tumor patients (n = 24), and healthy controls (n = 71). Metabolite profiling was performed by gas chromatography time-of-flight mass spectrometry and ultra performance liquid chromatography-quadrupole time of flight mass spectrometry in conjunction with univariate and multivariate statistical analyses. Forty three serum metabolites and 31 urinary metabolites were identified in HCC patients involving several key metabolic pathways such as bile acids, free fatty acids, glycolysis, urea cycle, and methionine metabolism. Differentially expressed metabolites in HCC subjects, such as bile acids, histidine, and inosine are of great statistical significance and high fold changes, which warrant further validation as potential biomarkers for HCC. However, alterations of several bile acids seem to be affected by the condition of liver cirrhosis and hepatitis. Quantitative measurement and comparison of seven bile acids among benign liver tumor patients with liver cirrhosis and hepatitis, HCC patients with liver cirrhosis and hepatitis, HCC patients without liver cirrhosis and hepatitis, and healthy controls revealed that the abnormal levels of glycochenodeoxycholic acid, glycocholic acid, taurocholic acid, and chenodeoxycholic acid are associated with liver cirrhosis and hepatitis. HCC patients with alpha fetoprotein values lower than 20 ng/ml was successfully differentiated from healthy controls with an accuracy of 100% using a panel of metabolite markers. Our work shows that metabolomic profiling approach is a promising screening tool for the diagnosis and stratification of HCC patients.

Hepatic incidentalomas

Recent advances in multidetector-row computed tomography, magnetic resonance imaging, and ultrasonography have led to the detection of incidental hepatic lesions in both the oncology and nononcology patient population that in the past remained undiscovered. These incidental hepatic lesions have created a management dilemma for both clinicians and radiologists. In this review, guidelines concerning the diagnosis and management of some of the more common hepatic incidentalomas are presented.

Tumors of the liver and intrahepatic bile ducts: radiologic-pathologic correlation

Primary tumors of the liver can be classified pathologically based on their cell of origin into epithelial tumors, arising from hepatocytes or biliary epithelium, and nonepithelial tumors, including mesenchymal tumors and lymphoma. Characteristic findings on MR imaging can be seen in many cases. This article reviews the MR imaging appearance of these tumors with pathologic correlation.

Optimization of imaging diagnosis of 1-2 cm hepatocellular carcinoma: an analysis of diagnostic performance and resource utilization

BACKGROUND & AIMS

To determine the optimal imaging scan or combinations in terms of diagnostic performance and resource utilization for 1-2 cm nodules found on surveillance for hepatocellular carcinoma.

METHODS

Eighty-four cirrhotic patients with 101, 1-2 cm nodules (34 malignant, 67 non-malignant) prospectively underwent standardized contrast-enhanced ultrasound, CT, and MRI scans. Sensitivity/specificity and potential imaging/biopsy utilization of individual imaging modalities and two-modality combinations performed at the same time (coincidental) or in sequence were measured. Final diagnosis was determined by biopsy (23), growth (10), recurrence (1), or stability in size for ≥ 18 months (67).

RESULTS

For single imaging scans, sensitivities/specificities ranged between 53-62% and 91-100%. When two scans were combined requiring both to be positive, sensitivities/specificities ranged between 29-41% and 99-100%. When two scans were combined sequentially, requiring only one to be positive, sensitivities/specificities ranged between 74-89% and 91-99%. When comparing combination of two positive tests (MRI and CT) to MRI alone, there was a significant drop in sensitivity (41% vs. 62%, p=0.02), no change in specificity (both 100%), with twice as many scans performed, and 9% rise in potential biopsies or 7% rise in follow-up scans. When comparing the combination of MRI then CT (if MRI negative) to MRI alone, there was an insignificant rise in sensitivity (74% vs. 62%, p=0.13), drop in specificity (97% vs. 100%), with 77% more scans performed, and 6% drop in potential biopsies or 7% drop in potential follow-up scans.

CONCLUSIONS

Single imaging scans have similar specificity to two coincidental positive scans with much less resource utilization. Sequential imaging provides the best sensitivity but with diminished specificity.

Diagnostic sensitivity of hepatocellular carcinoma imaging and its application to non-cirrhotic patients

BACKGROUND AND AIMS

The American Association for the Study of Liver Disease issued guidelines that proposed that hepatocellular carcinoma (HCC) can be diagnosed if a mass is larger than 2 cm in a cirrhotic liver and shows typical features of HCC at triphasic liver computed tomography (CT) or dynamic magnetic resonance imaging (MRI). In non-cirrhotic livers, the criteria were not applicable. The aim of the present study was to retrospectively analyze the sensitivity of imaging by samples of definite HCC postoperatively and test their application to diagnose HCC in non-cirrhotic livers.

METHODS

From January 2006 to November 2008, a total of 343 pathologically-diagnosed HCC patients via surgical resection were reviewed. Among the 343 patients, 204 patients had undergone liver CT examination, and 80 patients underwent MRI examination; serum α-fetoprotein had been checked for all 343 patients prior to operation. The diagnostic sensitivity of HCC by imaging was evaluated and compared in patients with/without cirrhosis by ultrasound and histology.

RESULTS

The diagnostic sensitivity of HCC by single imaging was approximately 65-80% (liver CT or MRI). A higher sensitivity of HCC diagnosis was found in patients with ultrasound-diagnosed cirrhosis than non-cirrhosis, but the difference in sensitivity disappeared after histologically-cirrhotic validation. The results indicated that regardless of the presence or absence of cirrhosis (histology), a typical vascular pattern could diagnose HCC with equally high sensitivity.

CONCLUSIONS

We provide evidence that the sensitivity of HCC diagnosis by imaging is not influenced by the cirrhotic background. Further study is needed to validate the specificity and accuracy.

Fecal metabolome profiling of liver cirrhosis and hepatocellular carcinoma patients by ultra performance liquid chromatography-mass spectrometry

Fecal metabolome of healthy humans and patients suffering from liver cirrhosis and hepatocellular carcinoma (HCC) were studied using ultra performance liquid chromatography coupled to quadrupole-time-of-flight mass spectrometry (UPLC/Q-TOF MS). Metabolic features detected by the method were then statistically treated using partial least squares to latent structure-discriminant analysis (PLS-DA) models to discriminate between healthy and diseased states. PLS-DA was also used to discriminate between cirrhosis and HCC stressed fecal metabolomes and to identify potential biomarkers for cirrhosis and HCC that are expressed at significantly different amounts in fecal metabolomes. Score plots of pattern recognition analysis distinguished liver cirrhosis and HCC patients from healthy humans. Based on the variable of importance in the project (VIP) values and S-plots, six metabolites were considered as potential biomarkers with a strong increase in lysophosphatidylcholines and a dramatic decrease in bile acids and bile pigments in patients with liver cirrhosis and HCC in comparison with healthy humans. Results demonstrate the potential of UPLC-MS as an efficient and convenient method that can be applied to screen fecal samples and aid in the early diagnosis of cirrhosis and hepatocellular carcinoma.

CT and MRI improve detection of hepatocellular carcinoma, compared with ultrasound alone, in patients with cirrhosis

BACKGROUND & AIMS

In patients with cirrhosis, hepatocellular carcinoma (HCC) is detected by ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI); US is recommended for screening and surveillance. We performed a retrospective analysis of the abilities of these cross-sectional imaging modalities to detect HCC.

METHODS

We analyzed data from 638 consecutive adult patients with cirrhosis who received liver transplants within 6 months of imaging at a tertiary care institution. Imaging reports and serum alpha-fetoprotein levels were compared with results from pathology analysis of explants as the reference standard. Sensitivities of US, CT, and MRI were calculated overall and in defined size categories. False-positive imaging results and patient-based specificities were evaluated.

RESULTS

Of the 638 patients, 225 (35%) had HCC, confirmed by pathology analysis of liver explants. In 23 cases, the lesions were infiltrative or extensively multifocal. In the remaining 202 explants (337 numerable, discrete nodules), respective lesion-based sensitivities of US, CT, and MRI were 46%, 65%, and 72% overall and 21%, 40%, and 47% for small (<2 cm) HCC. The sensitivity of US increased with the availability of CT or MRI data (P = .049); sensitivity values were 62% and 85% for lesions 2-4 and ≥ 4 cm, respectively. Patient-based specificities of US, CT, and MRI were 96%, 96%, and 87%, respectively.

CONCLUSIONS

US, CT, and MRI did not detect small HCC lesions with high levels of sensitivity, although CT and MRI provide substantial improvements over unenhanced US in patients with cirrhosis who received liver transplants.

[Radiological diagnosis of hepatocellular carcinoma in 2010]

The aim of diagnosis imaging is to detect hepatocellular carcinoma at an early stage, when a curative treatment is available. Biopsy is no longer required prior to treatment, and diagnosis of hepatocellular carcinoma is heavily dependent of imaging characteristics. Therefore, the purpose of this article is to describe the typical features of small (<20mm) and larger hepatocellular carcinomas with noninvasive diagnostic criteria, including ultrasound, computed tomography and MRI. Advances in these imaging modalities have greatly improved the detection of small hepatic nodules on liver cirrhosis, including the different steps of carcinogenesis, from regenerative to dysplastic nodules, and we emphasize the difficulties of radiological differentiation of precancerous lesions and small hepatocellular carcinomas.