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

A 30-year, population-based study shows improved management and prognosis of hepatocellular carcinoma

BACKGROUND & AIMS

Little is known about the impact of changes in the management of hepatocellular carcinoma (HCC) over time. We assessed trends in the pattern of care and in prognosis at a population level.

METHODS

Data on diagnostic conditions, treatment, and prognosis from 1976-2005 were collected by the population-based digestive cancer registry of Burgundy (France). A nonconditional logistic regression was used to identify factors associated with treatment for cure. A multivariate relative survival analysis was also performed.

RESULTS

The context of HCC diagnosis has changed; the proportion of asymptomatic patients increased from 5.6% (1976-1985) to 37.2% (1996-2005). The proportion of cases diagnosed on the basis of morphologic criteria increased from 14% during 1976-1985 to 35.6% during 1996-2005, whereas histologically verified cases decreased from 62.2% to 41.2% between the same time periods. The proportion of patients who were treated with intent to cure increased from 2.7% (1976-1985) to 19.6% (1996-2005). This increase was associated with improvements in relative survival from 4.7% (1976-1985) to 32.8% (1996-2005) at 1 year and from 1.4% to 10.0% at 5 years. The 5-year relative survival of patients treated with curative intent increased, reaching 46.6% for the 1996-2005 period. In the multivariate relative survival analysis, age, period of diagnosis, clinical presentation, alpha-fetoprotein level, and treatment were independent prognostic factors.

CONCLUSIONS

During a 30-year period, there was an increase in the number of HCCs diagnosed in asymptomatic subjects that was associated with the development of new effective therapies; this association might account for improvements in prognosis of patients with HCC.

Serum N-glycome biomarker for monitoring development of DENA-induced hepatocellular carcinoma in rat

BACKGROUND

There is a demand for serum markers for the routine assessment of the progression of liver cancer. We previously found that serum N-linked sugar chains are altered in hepatocellular carcinoma (HCC). Here, we studied glycomic alterations during development of HCC in a rat model.

RESULTS

Rat HCC was induced by the hepatocarcinogen, diethylnitrosamine (DENA). N-glycans were profiled using the DSA-FACE technique developed in our laboratory.In comparison with control rats, DENA rats showed a gradual but significant increase in two glycans (R5a and R5b) in serum total N-glycans during progression of liver cirrhosis and cancer, and a decrease in a biantennary glycan (P5). The log of the ratio of R5a to P1 (NGA2F) and R5b to P1 [log(R5a/P1) and log(R5b/P1)] were significantly (p < 0.0001) elevated in HCC rats, but not in rats with cirrhosis or fibrosis or in control rats. We thus propose a GlycoTest model using the above-mentioned serum glycan markers to monitor the progression of cirrhosis and HCC in the DENA-treated rat model. When DENA-treated rats were subsequently treated with farnesylthiosalicyclic acid, an anticancer drug, progression to HCC was prevented and GlycoTest markers (P5, R5a and R5b) reverted towards non-DENA levels, and the HCC-specific markers, log(R5a/P1) and log(R5b/P1), normalized completely.

CONCLUSIONS

We found an increase in core-alpha-1,6-fucosylated glycoproteins in serum and liver of rats with HCC, which demonstrates that fucosylation is altered during progression of HCC. Our GlycoTest model can be used to monitor progression of HCC and to follow up treatment of liver tumors in the DENA rat. This GlycoTest model is particularly important because a rapid non-invasive diagnostic procedure for tumour progression in this rat model would greatly facilitate the search for anticancer drugs.

Macrophage migration inhibitory factor plays a pivotal role in hepatocellular carcinoma and may be a noninvasive imaging target

Macrophage migration inhibitory factor (MIF) has emerged to play a central role in the control of the host inflammatory and immune response. Several reports have documented that MIF can inactivate the tumor suppresser activity of p53; overexpression of MIF was significantly higher in both the sera and the local lesions from patients with HCC than from patients with normal controls. These findings indicate that MIF may contribute to multiple aspects of tumor progression and neoplasia, thus MIF may be an effective therapeutic target molecule. We speculate that MIF is important for the development and progression of hepatocellular carcinoma, and can be used as a marker for tumor detection.

Surveillance and early diagnosis of hepatocellular carcinoma

Patients at high risk for developing hepatocellular carcinoma (HCC) should be enrolled in surveillance programs based on ultrasound (US) examinations performed at 6-month intervals. Nodules found during US surveillance that are smaller than 1 cm should be followed-up with US at 3-month intervals. If the nodule found during US surveillance is larger than 1 cm, it should be investigated further with contrast-enhanced dynamic radiological studies, including US, multidetector computed tomography, or magnetic resonance imaging. If the appearance is typical for HCC (i.e., the lesion shows hypervascularization in the arterial phase with washout in the portal venous or the equilibrium phase), biopsy is considered unnecessary and the lesion can be treated as HCC. For nodules between 1 and 2 cm, it is currently recommended that such non-invasive diagnosis be based on the evidence of coincidental features typical for HCC from at least two dynamic imaging techniques. If the vascular profile on imaging is not characteristic or the nodule is detected in a non-cirrhotic liver, biopsy should be performed. If the biopsy is negative for HCC, patients should be followed-up by imaging studies performed at 3-month intervals until the nodule either disappears, enlarges, or displays diagnostic characteristics of HCC.

A seven-gene set associated with chronic hypoxia of prognostic importance in hepatocellular carcinoma

PURPOSE

Hepatocellular carcinomas (HCC) have an unpredictable clinical course, and molecular classification could provide better insights into prognosis and patient-directed therapy. We hypothesized that in HCC, certain microenvironmental regions exist with a characteristic gene expression related to chronic hypoxia which would induce aggressive behavior.

EXPERIMENTAL DESIGN

We determined the gene expression pattern for human HepG2 liver cells under chronic hypoxia by microarray analysis. Differentially expressed genes were selected and their clinical values were assessed. In our hypothesis-driven analysis, we included available independent microarray studies of patients with HCC in one single analysis. Three microarray studies encompassing 272 patients were used as training sets to determine a minimal prognostic gene set, and one recent study of 91 patients was used for validation.

RESULTS

Using computational methods, we identified seven genes (out of 3,592 differentially expressed under chronic hypoxia) that showed correlation with poor prognostic indicators in all three training sets (65/139/73 patients) and this was validated in a fourth data set (91 patients). Retrospectively, the seven-gene set was associated with poor survival (hazard ratio, 1.39; P = 0.007) and early recurrence (hazard ratio, 2.92; P = 0.007) in 135 patients. Moreover, using a hypoxia score based on this seven-gene set, we found that patients with a score of >0.35 (n = 42) had a median survival of 307 days, whereas patients with a score of < or =0.35 (n = 93) had a median survival of 1,602 days (P = 0.005).

CONCLUSIONS

We identified a unique, liver-specific, seven-gene signature associated with chronic hypoxia that correlates with poor prognosis in HCCs.

N-glycan based models improve diagnostic efficacies in hepatitis B virus-related hepatocellular carcinoma

The early diagnosis of hepatocellular carcinoma (HCC) is of great clinical desirable due to lack of specific and sensitive markers. Alterations in the sugar chains of glycoprotein synthesized by the liver contribute to the molecular basis of abnormalities in carcinogenesis. This study aims to construct and assess the diagnostic value of N-glycan based diagnostic model in HCC identification and follow-up. A total of 393 subjects including HBV-related HCC, liver fibrosis and healthy controls were recruited. Follow-up was carried out before and after surgical treatment in HCC. N-glycome of serum glycoprotein was profiled by DNA sequencer-assisted fluorophore-assisted carbohydrate electrophoresis (DSA-FACE). Multiparameters diagnostic models were constructed based on N-glycan markers. The result found that 2 N-glycan structure abundances (NG1A2F, Peak 4; NA3Fb, Peak 9) were useful as N-glycan markers. The diagnostic efficacy of the log ratio [log(p9/4)] was similar to that of AFP in differentiating HCC from fibrosis. The accuracy and sensitivity of the diagnostic model combining AFP and N-glycan markers (Cscore B) were increased 7-10% compared with that of AFP. Log(p9/4) was more efficient in monitoring the progression of HCC with regarding to vascular invasion at improved specificity (16%) and accuracy (8%) compared with that of AFP. The N-glycan markers were found to be changed significantly after surgical resection in HCC follow-up. We conclude that the branching alpha (1,3)-fucosylated triantennary glycan and a biantennary glycan are promising as N-glycan markers. The diagnostic models based on the N-glycan markers and AFP improve the efficacy in HCC diagnosis and progression monitoring.

[Rapid progression of hepatocellular carcinoma after surgery: apropos of a case and review of the literature]

We report the case of a young man with chronic hepatitis B infection of probable perinatal acquisition who was diagnosed with hepatocellular carcinoma at a very early stage (BCLC 0) with a highly favorable prognosis. However, the tumor progressed rapidly and the patient died within months. Currently, there are few data that could help to identify cases likely to show rapid progression and which could prompt initiation of aggressive therapies that might prevent or control such progression.

Targeted sonography for small hepatocellular carcinoma discovered by CT or MRI: factors affecting sonographic detection

OBJECTIVE

The purpose of this study was to evaluate the detection rate of targeted sonography for small (<or= 3 cm) hepatocellular carcinomas (HCCs) primarily discovered by CT or MRI and to assess factors affecting lesion visibility on targeted sonography.

SUBJECTS AND METHODS

Between October 2005 and April 2008, targeted sonography for small (<or= 3 cm) HCC was prospectively performed in cirrhotic patients. Targeted sonography was performed by a radiologist with knowledge of the size and location of the HCC. Invisible HCCs were compared with visible HCCs with regard to size, distance from the diaphragm, segmental location, subcapsular location, cause of liver cirrhosis, presence or absence of previous treatment, Child-Pugh class, and serum alpha-fetoprotein by using univariate and multivariate analyses.

RESULTS

A total of 93 consecutive patients (65 men and 28 women; mean age, 59 years) with 93 HCCs (mean size +/- SD, 1.8 +/- 0.6 cm) were enrolled in this study. Of those, 73 (78.5%) HCCs were visible on targeted sonography. The detection rate was 36.4% (4/11) for HCC <or= 1.0 cm, 77.6% (38/49) for HCC between 1.1 and 2.0 cm, and 93.9% (31/33) for HCC between 2.1 and 3.0 cm. In both univariate and multivariate analyses, the size of the tumor and distance between the tumor and the diaphragm were statistically significant factors affecting sonographic visibility.

CONCLUSION

The overall detection rate for small (<or= 3 cm) HCC on targeted sonography was 78.5%. Small size and subphrenic location of the tumor were two independent predictors of sonographic invisibility.

Enhanced detection of early hepatocellular carcinoma by serum SELDI-TOF proteomic signature combined with alpha-fetoprotein marker

Background

Biomarkers for accurate diagnosis of early hepatocellular carcinoma (HCC) are limited in number and clinical validation. We applied SELDI-TOF-MS ProteinChip technology to identify serum profile for distinguishing HCC and liver cirrhosis (LC) and to compare the accuracy of SELDI-TOF-MS profile and alpha-fetoprotein (AFP) level in HCC diagnosis.

Patients and Methods

Serum samples were obtained from 120 HCC and 120 LC patients for biomarker discovery and validation studies. ProteinChip technology was employed for generating SELDI-TOF proteomic features and analyzing serum proteins/peptides.

Results

A diagnostic model was established by CART algorithm, which is based on 5 proteomic peaks with m/z values at 3324, 3994, 4665, 4795, and 5152. In the training set, the CART algorithm could differentiate HCC from LC subjects with a sensitivity and specificity of 98% and 95%, respectively. The results were assessed in blind validation using separate cohorts of 60 HCC and 60 LC patients, with an accuracy of 83% for HCC and 92% for LC patients. The diagnostic odd ratio (DOR) indicated that SELDI-TOF proteomic signature could achieve better diagnostic performance than serum AFP level at a cutoff of 20 ng/mL (AFP₂₀) (92.72 vs 9.11), particularly superior for early-stage HCC (87% vs 54%). Importantly, a combined use of both tests could enhance the detection of HCC (sensitivity, 95%; specificity, 98%; DOR, 931).

Conclusion

Serum SELDI-TOF proteomic signature, alone or in combination with AFP marker, promises to be a good tool for early diagnosis and/screening of HCC in at-risk population with liver cirrhosis.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Hepatobiliary-specific MR contrast agents: role in imaging the liver and biliary tree

Hepatobiliary-specific contrast agents are one of several classes of contrast agents available for magnetic resonance (MR) imaging of the liver. These agents are taken up by functioning hepatocytes and excreted in the bile, and their paramagnetic properties cause shortening of the longitudinal relaxation time (T1) of the liver and biliary tree. The three contrast agents that have been developed are mangafodipir trisodium (Mn-DPDP), gadobenate dimeglumine (Gd-BOPTA), and gadoxetic acid (Gd-EOB-DTPA). These three MR contrast agents vary in mode of administration and dose, mechanism of cellular uptake, degree of excretion through the biliary pathway, and imaging characteristics. In the liver, hepatobiliary-specific agents can be used to improve lesion detection, to characterize lesions as hepatocellular or nonhepatocellular, and to specifically characterize some hepatocellular lesions, notably focal nodular hyperplasia. Biliary excretion of these agents can be used to evaluate the anatomic structure and function of the biliary tree. In the future, hepatobiliary-specific contrast agents may have wider applications, such as grading of cirrhosis and quantification of liver function.

Magnetic resonance imaging findings of hepatocellular carcinoma: typical and atypical findings

Background: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Magnetic resonance imaging has been widely used for detection and characterization of HCC. Objective: Describe MRI findings of HCC and to define the typical and atypical appearances of HCC on magnetic resonance images. Methods: We retrospectively reviewed MRI findings of 100 HCC in 78 patients. Diagnosis was confirmed by angiography, pathology or follow up imaging. The signal intensity, size, margins, enhancement pattern, and other features were evaluated. Imaging findings between small HCC (< 2 cm) and large HCC (>2 cm) were compared. Results: The most common signal intensity of HCC on unenhanced T1- and T2-weighted images was hypointense on T1-weighted images and hyperintense on T2-weighted images (65%). Most HCC (91%) were hyperintense on T2-weighted images. Isointensity on T2-weighted images were found in 9% of HCC. The typical enhancement pattern of HCC was enhancement on the arterial phase and washout on the portovenous phase (84%). Atypical enhancement pattern of HCC were enhancement on the portovenous phase in 5%, rim enhancement on the arterial phase or portovenous phase were demonstrated in 2%. Hyperintensity of the tumor on delayed phase was found in 19%. There was no statistically significant difference in signal intensity, enhancement, and washout pattern between small and large HCC. Fatty metamorphosis, mosaic pattern, necrosis, capsule and vascular involvement were found in 18%, 42%, 5%, 62%, and 6%, respectively. Mosaic pattern, necrosis, capsule, and vascular involvement were observed more frequently in large HCC. Conclusion: The typical appearance of HCC was hypointense on T1-weighted, hyperintense on T2-weighted images, arterial enhancement and portovenous washout. Atypical appearances of HCC were rim enhancement on the arterial phase or portovenous phase and persistent enhancement on the delayed phase

Present and future possibilities for early diagnosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents the fifth most common cancer in the world, and the third most frequent oncological cause of death. The incidence of HCC is on the increase. HCC typically develops in patients with chronic liver diseases, and cirrhosis, usually with viral etiology, is the strongest predisposing factor. Nowadays HCC diagnosis is a multistage process including clinical, laboratory, imaging and pathological examinations. The prognosis of HCC is mostly poor, because of detection at an advanced, non-resectable stage. Potentially curative treatment (surgery) is limited and really possible only for cases with small HCC malignancies. For this reason, more effective surveillance strategies should be used to screen for early occurrence of HCC targeted to the population at risk. So far, the generally accepted serological marker is α-fetoprotein (AFP). Its diagnostic accuracy is unsatisfactory and questionable because of low sensitivity, therefore there is a strong demand by clinicians for new HCC-specific biomarkers. In this review, we will focus on other biomarkers that seem to improve HCC diagnosis, such as AFP-L3, des-γ-carboxyprothrombin, α-l-fucosidase, γ-glutamyl transferase, glypican-3, squamous cell carcinoma antigen, a new generation of immunoglobulin M-immunocomplexes, and very promising gene-expression profiling.

[Practice guidelines for management of hepatocellular carcinoma 2009]

Hepatocellular carcinoma (HCC) is a major cancer in Korea, typically has a poor prognosis, and constitutes the majority of primary hepatic malignancies. It is the number one cause of death among people in their 50s in Korea. The five-year survival rate of liver cancer is poor; at 18.9%. Efforts to increase the survival rate through early diagnosis of HCC and optimal treatments are keenly needed. Western guideline for the management of HCC were developed, but these guidelines are somewhat unsuitable for Korean patients. Thus, the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC), Korea jointly produced the Clinical Practice Guidelines for HCC for the first time in Korea in 2003. Owing to medical advances over the following six years, diagnosis and treatment of HCC has changed considerably. As more national and foreign data are accumulated, KLCSG and NCC, Korea recently revised the Clinical Practice Guidelines for HCC. Forty or more specialists in the field of hepatology, general surgery, radiology and radiation oncology participated, and meticulously reviewed national and foreign papers, and collected opinions through advisory committee conferences. These multidisciplinary, evidence-based guidelines summarized diagnosis, surgical resection, liver transplantation, local treatments, transarterial chemoembolization, radiation therapy, chemotherapy, preemptive antiviral treatments, and response evaluation of HCC. These Korean guidelines are expected to be useful for clinical management of and research on HCC.

Management of hepatocellular carcinoma in Asia: consensus statement from the Asian Oncology Summit 2009

Asia has a disproportionately large share of the world's hepatocellular carcinoma (HCC), mainly because of the endemic status of chronic hepatitis B and C viruses, which leads to liver cirrhosis and an increased risk of HCC. This etiological factor presents important opportunities for prevention, early detection, diagnosis, and treatment of HCC. This consensus statement reviews the available medical evidence for management of HCC in Asia, and gives treatment recommendations that are adapted to resource availability in this diverse region with disparate health-care delivery systems.

Advancement in HCC imaging: diagnosis, staging and treatment efficacy assessments: hepatocellular carcinoma: imaging in assessing treatment efficacy

Imaging studies play a crucial role in the diagnosis and staging of hepatocellular carcinoma (HCC). Yet, assessment of tumor response is another important goal for imaging. The imaging techniques most commonly used for assessing tumor response include computed tomography and magnetic resonance imaging. Imaging modalities and imaging criteria vary according to the treatment (surgical resection and transplantation or nonsurgical treatments such as transarterial chemoembolization, radiofrequency ablation, and molecular targeted therapy). Efficacy of nonsurgical treatments for malignancy is usually evaluated with RECIST criteria. These criteria, based on tumor shrinkage, are often inappropriate in HCCs. The response criteria should take into account tumor necrosis induced by treatment. Today, tumor necrosis is estimated by a disappearance of hypervascularization on contrast-enhanced imaging. New tools such as functional imaging (perfusion imaging, diffusion-weighted MR imaging) could be of major importance. In this article, we present a summary of the most recent information on the role of imaging in assessing treatment efficacy in HCCs.

A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy?

BACKGROUND

Despite a growing body of evidence reporting the deleterious mechanical and oncological complications of biopsy of hepatic malignancy, a small but significant number of patients undergo the procedure prior to specialist surgical referral. Biopsy has been shown to result in poorer longterm survival following resection and advances in modern imaging modalities provide equivalent, or better, diagnostic accuracy.

METHODS

The literature relating to needle-tract seeding of primary and secondary liver cancers was reviewed. MEDLINE, EMBASE and the Cochrane Library were searched for case reports and series relating to the oncological complications of biopsy of liver malignancies. Current non-invasive diagnostic modalities are reviewed and their diagnostic accuracy presented.

RESULTS

Biopsy of malignant liver lesions has been shown to result in poorer longterm survival following resection and does not confer any diagnostic advantage over a combination of non-invasive imaging techniques and serum tumour markers.

CONCLUSIONS

Given that chemotherapeutic advances now often permit downstaging and subsequent resection of 'unresectable' disease, the time has come to abandon biopsy of solid lesions outside the setting of a specialist multi-disciplinary team meeting (MDT).

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Surveillance and diagnosis of hepatocellular carcinoma in patients with cirrhosis

Early identification of hepatocellular carcinoma (HCC) is more frequent because of surveillance programs for HCC worldwide. The optimal strategy of surveillance in cirrhosis is a current topical issue. In terms of diagnosis, recent advances in non-invasive imaging technology, including various techniques of harmonic ultrasound, new ultrasound contrast agents, multi-slice helical computed tomography and rapid high quality magnetic resonance, have all improved the accuracy of diagnosis. Consequently the role of liver biopsy in diagnosis of HCC has declined. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. However, with recent advances in genomics and proteomics a great number of potential serum and tissue markers have been identified and are being developed as new candidate markers for both diagnosis and prognosis of hepatocellular carcinoma, and may increase the need for liver biopsy.

Evaluation of esophageal varices on liver computed tomography: receiver operating characteristic analyses of the performance of radiologists and endoscopists

BACKGROUND AND AIM

Recent liver multi-detector row computed tomography (MDCT) always covers the distal esophagus with an excellent image quality. The aim of this study was to compare the performance of faculty abdominal radiologists with those of radiology residents and endoscopists for the detection of esophageal varices and high-risk esophageal varices on liver MDCT.

METHODS

A total of 104 cirrhotic patients that had undergone liver MDCT 4 weeks or less before an upper endoscopy were evaluated. Two faculty abdominal radiologists, two radiology residents, and two endoscopists independently interpreted all of the CT images to detect the presence of esophageal varices and high-risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, their performances were compared by using receiver operating characteristic (ROC) curve analysis.

RESULTS

The areas under the ROC curves for the detection of esophageal varices indicated better performance of the abdominal radiologists (A(z) = 0.868), compared with the radiology residents (A(z) = 0.798) (P = 0.007) and endoscopists (A(z) = 0.784) (P = 0.006). For the detection of high-risk esophageal varices, however, the performance of the abdominal radiologists (A(z) = 0.914) was similar to those of radiology residents (A(z) = 0.900) and endoscopists (A(z) = 0.907) (each P > 0.05).

CONCLUSIONS

Experienced readers have a better ability to detect esophageal varices on liver MDCT, but had no higher performance to evaluate high-risk esophageal varices. As the accuracy of detecting high-risk esophageal varices with clinical relevance on liver MDCT is excellent, even by endoscopists, the evaluation of esophageal varices from a recent liver MDCT may be useful to avoid the use of low-yield endoscopy.

Small (Radiol Med 2009;114:1239-66. [PMID: 19697104 DOI: 10.1007/s11547-009-0439-x]

PURPOSE

We prospectively compared gadoliniumenhanced magnetic resonance imaging (dynamic MRI), superparamagnetic iron oxide (SPIO) (ferucarbotran) MRI and multidetector-row computed tomography (MDCT) and the combination of dynamic MRI plus MDCT vs. dynamic MRI plus SPIO-MRI (double-contrast MRI: DC-MRI) for the detection of small (

MATERIALS AND METHODS

Sixty-three patients with liver cirrhosis and suspicious nodules detected during ultrasound (US) surveillance underwent DC-MRI in the same imaging session and MDCT within 15 days. The final diagnosis was established at pathology on the explanted liver (n=10), resection (n=6) and biopsy (n=38) specimens or at 2-years' follow-up (n=9).

RESULTS

One hundred and twenty-three nodules were detected: 87 were confirmed HCCs in 54 patients. The accuracy of SPIO-MRI and dynamic MRI were similar, both being superior to MDCT. Dynamic MRI demonstrated the highest sensitivity (83.9%; p<0.001). especially for lesions <1 cm (90.6%) - coupled with a lower specificity (36.1%) than SPIO-MRI, particularly in subcentimeter lesions (28.6%). SPIO-MRI demonstrated the highest sensitivity for nodules >1 cm and the highest specificity (83.3%) superior to dynamic MRI (p<0.0001). In the per-lesion analysis, SPIO-MRI demonstrated a positive predictive value higher than dynamic MRI (p=0.0059) and than both the combinations dynamic MRI/MDCT and DC-MRI (p=0.0021 and p=0.0087, respectively). DC-MRI showed the highest sensitivity (97.7%) and accuracy (78.9%), detecting hypovascular and atypical HCCs >1 cm. Furthermore its per-patient negative predictive value was the highest (100%), and significantly higher than all the other methods.

CONCLUSIONS

DC-MRI is the most sensitive and accurate method and can be confidently used as a single-step procedure for the detection of small HCCs, with the exception of lesions <1 cm.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/diagnostic imaging
• Contrast Media
• Dextrans
• Female
• Ferrosoferric Oxide
• Follow-Up Studies
• Gadolinium DTPA
• Humans
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/diagnostic imaging
• Liver Neoplasms/diagnosis
• Liver Neoplasms/diagnostic imaging
• Magnetic Resonance Imaging
• Magnetite Nanoparticles
• Male
• Middle Aged
• Predictive Value of Tests
• Prospective Studies
• Sensitivity and Specificity
• Tomography, X-Ray Computed

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Grants Collapse

Affiliation(s)

R Golfieri Radiologia Malpighi, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Università di Bologna, Via Albertoni 15, 40138, Bologna, Italy.
E Marini
A Bazzocchi
F Fusco
F Trevisani
C Sama
G Mazzella
S Cavuto
F Piscaglia
L Bolondi

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Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

A majority of studies investigating the accuracy of ultrasound for detecting hepatocellular carcinoma (HCC) do not reflect how this test is used for surveillance vs. diagnosis.

AIM

To determine the performance characteristics of surveillance with ultrasound for the detection of HCC, particularly early HCC as defined by the Milan criteria.

METHODS

A systematic literature review using the MEDLINE and SCOPUS databases yielded six studies that evaluated the accuracy of ultrasound for HCC at any stage and 13 studies that were specific to early HCC.

RESULTS

Surveillance ultrasound detected the majority of tumours before they presented clinically, with a pooled sensitivity of 94%. However, ultrasound was less effective for detecting early HCC with a sensitivity of 63%. Alpha-fetoprotein provided no additional benefit to ultrasound. Meta-regression analysis demonstrated a significantly higher sensitivity for early HCC with ultrasound every 6 months than with annual surveillance. Current studies have limitations such as verification bias and are of suboptimal quality.

CONCLUSIONS

Surveillance with ultrasound demonstrates limited sensitivity for early HCC, although this may be improved by testing at 6-month intervals. Currently available evidence evaluating surveillance ultrasound has significant limitations and future studies are necessary to determine optimal surveillance methods for early HCC.

Metabolomic profiling of human urine in hepatocellular carcinoma patients using gas chromatography/mass spectrometry

With the technique of metabolomics, gas chromatography/mass spectrometry (GC/MS), urine or serum metabolites can be assayed to explore disease biomarkers. In this work, we present a metabolomic method to investigate the urinary metabolic difference between hepatocellular carcinoma (HCC, n - 20) male patients and normal male subjects (n - 20). The urinary endogenous metabolome was assayed using chemical derivatization followed by GC/MS. After GC/MS analysis, 103 metabolites were detected, of which 66 were annotated as known compounds. By a two sample t-test statistics with p < 0.05, 18 metabolites were shown to be significantly different between the HCC and control groups. A diagnostic model was constructed with a combination of 18 marker metabolites or together with alphafetoprotein, using principal component analysis and receiver-operator characteristic curves. The multivariate statistics of the diagnostic model yielded a separation between the two groups with an area under the curve value of 0.9275. This non-invasive technique of identifying HCC biomarkers from urine may have clinical utility.

Application of surveillance programs for hepatocellular carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is a potential target for cancer surveillance (or screening) as it occurs in well-defined, at-risk populations and curative therapy is possible only for small tumors. Surveillance has been recommended by regional liver societies and is practiced widely, but its benefits are not clearly established. Hepatic ultrasonography with or without alpha fetoprotein (AFP) performed every 6 months is the preferred program. Surveillance of HCC has been well shown to detect small tumors for curative treatment, which may be translated to improved patient survival. However, most studies are limited by lead-time bias, length bias for early diagnosis of small HCC, different tumor growth rates and poor compliance with surveillance. Cost-effectiveness of surveillance programs depends on the rate of small HCC detected 'accidentally' (routine imaging) in a comparator group, annual incidence of HCC with various etiologies, patient age and the availability of liver transplantation. The incremental cost-effectiveness for 6-monthly AFP and ultrasound has been estimated from approximately $US 26,000-74,000/quality adjusted life years (QALY). All cirrhotic patients are therefore recommended for HCC surveillance unless the disease is too advanced for any curative treatment. As chronic hepatitis B can develop into HCC without going through liver cirrhosis, high-risk non-cirrhotic chronic hepatitis B patients are also recommended for HCC surveillance. In conclusion, HCC surveillance could be effective at reducing disease-specific mortality with acceptable cost-effectiveness among selected patient groups, provided it is a well-organized program.

Diagnosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the commonest cancers worldwide, particularly in parts of the developing world, and is increasing in incidence. This article reviews the current modalities employed for the diagnosis of HCC, including serum markers, radiological techniques and histological evaluation, and summarises international guidelines for the diagnostic approach to HCC.

Diagnostic test systematic reviews: bibliographic search filters ("Clinical Queries") for diagnostic accuracy studies perform well

BACKGROUND

Systematic reviews of health care topics are valuable summaries of all pertinent studies on focused questions. However, finding all relevant primary studies for systematic reviews remains challenging.

OBJECTIVES

To determine the performance of the Clinical Queries sensitive search filter for diagnostic accuracy studies for retrieving studies for systematic reviews.

METHODS

We compared the yield of the sensitive Clinical Queries diagnosis search filter for MEDLINE and EMBASE to retrieve studies in diagnostic accuracy systematic reviews reported in ACP Journal Club in 2006.

RESULTS

Twelve of 22 diagnostic accuracy reviews (452 included studies) met the inclusion criteria. After excluding 11 studies not in MEDLINE or EMBASE, 95% of articles (417 of 441) were captured by the sensitive Clinical Queries diagnosis search filter (MEDLINE and EMBASE combined). Of 24 studies not retrieved by the filter, 22 were not diagnostic accuracy studies. Reanalysis of the Clinical Queries filter without these 22 nondiagnosis articles increased its performance to 99% (417 of 419). We found no substantive impact of the two articles missed by the Clinical Queries filter on the conclusions of the systematic reviews in which they were cited.

CONCLUSION

The sensitive Clinical Queries diagnostic search filter captured 99% of articles and 100% of substantive articles indexed in MEDLINE and EMBASE in diagnostic accuracy systematic reviews.

Management of hepatocellular carcinoma in the age of liver transplantation

Hepatocellular carcinoma is one of the most frequently encountered malignancies worldwide. Its association with cirrhosis increases the difficulty of diagnosis and therapy. Different approaches, ranging from medical treatment to highly complex ablative and surgical therapies, including liver resection and transplantation have significantly improved the outcome of this disease. This article reviews the current diagnostic challenges and the available surveillance and classification protocols. Available therapeutic approaches, indications, contraindications and outcome of liver resection, liver transplantation, living donor liver transplantation, are outlined in detail. Ablative procedures and their role and efficiency as "bridging" methods to liver transplantation are included in the review.

Chromogranin A levels in chronic liver disease and hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the relevant cause of death in patients with compensated cirrhosis. Alpha-fetoprotein (AFP) is used for screening HCC, with limited success.

AIM

We evaluated plasma chromogranin A (CgA) as a marker of HCC.

PATIENTS

CgA plasma levels and AFP serum levels were prospectively measured in 30 patients with HCC, 14 with cirrhosis, 79 with chronic hepatitis and 65 controls.

METHODS

CgA was measured with an enzyme-linked immunosorbent assay (DAKO A/S Glostrup, Denmark). AFP was measured by electrochemiluminoimmunoassay (Elecsys, Roche S.p.A., Italy).

RESULTS

CgA levels were significantly higher in the three groups of patients than in controls and in patients with HCC they were significantly higher than in chronic hepatitis patients [median 44.5 (interquartile range 21-145.9)U/L vs. 15.3 (10.9-29.25)U/L, p<0.001]. AFP values were above the upper reference limit in 75% of patients with HCC, 50% of cirrhotic patients and 11% of chronic hepatitis patients (p<0.005). CgA values significantly correlated with AFP levels (r(s)=0.42, p<0.0001). The overall diagnostic accuracy of CgA was 75% (CI 66-82), with a sensitivity of 70% (CI 50.6-85.2) and a specificity of 67% (CI 55.9-76.3).

CONCLUSIONS

Despite the evidence of higher CgA levels in patients with HCC, this test has low-diagnostic accuracy. Its pathophysiological meaning remains unknown, even if it could suggest an endocrine phenotype of HCC.

N-glycan profiles as tools in diagnosis of hepatocellular carcinoma and prediction of healthy human ageing

Protein glycosylation, the most common form of co-translational modification of proteins, is the enzymatic addition of sugars or oligosaccharides (glycans) to proteins. Protein glycosylation increases the diversity of the functions of proteins encoded in the genome. The result is that different glycomes of the same protein may have different functional, kinetic or physical properties. The glycosylation pathway is largely regulated by the condition of the cells, which means that the sugar chains can be altered by the physiological or pathophysiological condition of the cell. Thus, the type of glycans produced by cells, tissues, or organism could reflect their current physiological state. We determined the N-glycan profiles of serum proteins by using DNA sequencer-based carbohydrate analytical profiling technology. We show that two N-glycan structures (NGA2F and NA2F) present in human blood glycoproteins change with ageing, and that one triantennary glycan (NA3Fb) is correlated with tumor stage in HCC patients. Therefore, examining alterations in serum glycan fingerprint by using our platform could be a suitable tool for monitoring the healthiness of ageing and for the follow-up of pathophysiological conditions such as liver cancer.

Liver transplantation for hepatocellular carcinoma without preoperative tumor biopsy

BACKGROUND

Progress in liver imaging has made pretransplantation tumor biopsy no longer systematic in patients with hepatocellular carcinoma (HCC).

OBJECTIVES

Our aim was to evaluate the accuracy of a preoperative diagnosis of HCC based on clinical and radiological findings in 102 cirrhotics qualified for liver transplantation (LT) between January 1995 and August 2003 at our institution.

METHODS

The diagnostic accuracy of our policy was assessed by comparing pretransplant diagnosis with the pathologic report of explanted livers.

RESULTS

Sensitivity, specificity, positive, and negative predictive values for the preoperative clinical and radiological diagnosis of HCC were 89%, 94.3%, 77%, and 93.3%, respectively. A false-positive preoperative diagnosis was made in 20 of 102 patients (19.6%) (dysplastic nodules [n=9], regenerative nodules [n=5] cholangiocellular carcinoma [n=1], hemangioma [n=1], and no lesion [n=4]). All tumors larger than 3 cm were correctly diagnosed, irrespective of serum alpha-fetoprotein (sAFP) levels. The risk of overestimating the diagnosis of HCC in the subgroup of patients with tumors less than 3 cm was conversely correlated with preliver transplantation sAFP (sAFP<or=100 ng/L: 28%; sAFP>100: 11%; sAFP>200: 0%).

CONCLUSION

In cirrhotics with nodules larger than 3 cm irrespective of sAFP or nodules less than 3 cm with sAFP greater than 200 ng/L, the pretransplant diagnosis of HCC can be made without performing biopsy. In other cases (i.e., nodules less than 3 cm and sAFP lower than 200 ng/L), histologic confirmation of HCC or a close follow-up imaging should be considered.

A serum metabolomic investigation on hepatocellular carcinoma patients by chemical derivatization followed by gas chromatography/mass spectrometry

The purpose of this study was to investigate the serum metabolic difference between hepatocellular carcinoma (HCC, n = 20) male patients and normal male subjects (n = 20). Serum metabolome was detected through chemical derivatization followed by gas chromatography/mass spectrometry (GC/MS). The acquired GC/MS data was analyzed by stepwise discriminant analysis (SDA) and support vector machine (SVM). The metabolites including butanoic acid, ethanimidic acid, glycerol, L-isoleucine, L-valine, aminomalonic acid, D-erythrose, hexadecanoic acid, octadecanoic acid, and 9,12-octadecadienoic acid in combination with each other gave the strongest segregation between the two groups. By applying these variables, our method provided a diagnostic model that could well discriminate between HCC patients and normal subjects. More importantly, the error count estimate for each group was 0%. The total classifying accuracy of the discriminant function tested by SVM 20-fold cross validation was 75%. This technique is different from traditional ones and appears to be a useful tool in the area of HCC diagnosis.

Guidelines for imaging focal lesions in liver cirrhosis

Imaging cirrhotic patients for early detection of hepatocellular carcinoma remains a challenging issue despite many technological advances. In fact, nonmalignant hepatocellular lesions, such as regenerative or dysplastic nodules, may mimic a small tumor. Imaging protocols are aimed at showing the different vascular supply to the lesion. It is accepted that dynamic contrast-enhanced imaging techniques, including contrast ultrasound, multidetector computed tomography and magnetic resonance imaging, can establish the diagnosis of hepatocellular carcinoma in nodular lesions larger than 1 cm showing arterial hypervascularization with venous washout. Magnetic resonance imaging in combination with liver-specific contrast agents, including hepatocyte-targeted and reticuloendothelial system-targeted agents, may be useful to clarify questionable cases, due to its ability to show changes in hepatobiliary function or Kuppfer cell content associated with malignancy. However, even optimized imaging techniques remain relatively insensitive for the detection of tiny satellite nodules associated with the main tumor.

Combined SPIO-gadolinium magnetic resonance imaging in cirrhotic patients: negative predictive value and role in screening for hepatocellular carcinoma

BACKGROUND

The objective of our study was to assess the negative predictive value (NPV) of double-contrast MRI (DC-MRI) with SPIO and gadolinium, and to determine the role of DC-MRI in screening for hepatocellular carcinoma (HCC) in cirrhotic patients.

METHODS

We retrospectively included 160 DC-MRI scans done as second-line investigations in 119 patients with cirrhosis over a 25-month period. Two radiologists independently classified the MRI scans as strongly suggesting HCC (HCC Group), showing benign nodules (benign nodules Group), showing no nodules (no-nodules Group) or indeterminate; they assigned a diagnostic confidence score (DCS) using a 0-10 scale. The reference standard was histology or results of follow-up investigations. Mean follow-up was 16.9 months (12-28 months).

RESULTS

The radiologists disagreed for two scans (kappa = 0.98). Of 112 scans [benign nodules Group (n = 32) and no-nodules Group (n = 80)], 11 were excluded (3 patients lost to follow-up and 8 who died with no known cancer) while a HCC was detected during follow-up in 8 patients, yielding a NPV of 92% (93/101) (95% confidence interval, 85%-97%). The DCS was in the 4-6 range (indicating uncertainty) for only 6 (3.75%) scans.

CONCLUSIONS

DC-MRI is reliable and reproducible. Its high NPV suggests a role as a second-line investigation after ultrasonography, for HCC screening.

Clinical significance of alpha-fetoprotein: involvement in proliferation, angiogenesis, and apoptosis of hepatocellular carcinoma

BACKGROUND AND AIM

Hepatocellular carcinoma is one of the most common cancers. alpha-Fetoprotein is strongly expressed in most patients with hepatocellular carcinoma, and high levels of alpha-fetoprotein expression have been reported as an independent prognostic factor. However, there have been few reports on the reasons for poor prognosis.

METHODS

We analyzed the correlation between serum alpha-fetoprotein levels and clinicopathological findings in 37 hepatocellular carcinoma patients undergoing curative surgery. alpha-Fetoprotein mRNA expression in tissue samples was analyzed by quantitative reverse transcription-polymerase chain reaction (RT-PCR), while protein expression was assessed by immunohistochemistry. To assess the mechanistic correlations between alpha-fetoprotein and tumor progression, we further analyzed cell proliferation (Ki-67), angiogenesis (CD34), and apoptosis (TdT-mediated dUTP-biotin nick end labeling [TUNEL] assay).

RESULTS

Post-operative serum alpha-fetoprotein levels were correlated with disease-free and overall survival, and were an independent prognostic factor for survival. alpha-Fetoprotein expression, as assessed by immunohistochemistry, was strong and heterogeneous in hepatocellular carcinoma. Control livers did not express alpha-fetoprotein and there was weak expression of alpha-fetoprotein in adjacent regions in hepatocellular carcinoma patients. The Ki-67 labeling index in the high serum alpha-fetoprotein cases was significantly higher than in alpha-fetoprotein-negative cases (P = 0.042). The alpha-fetoprotein-positive cases also showed a significantly higher microvessel density than alpha-fetoprotein-negative cases (P = 0.035), whereas hepatocellular carcinoma without alpha-fetoprotein overexpression had a higher apoptotic index when compared to hepatocellular carcinoma with alpha-fetoprotein overexpression (P = 0.033).

CONCLUSION

These results indicate that the poor prognosis associated with high alpha-fetoprotein is due to high cell proliferation, high angiogenesis, and low apoptosis.

Percutaneous radiofrequency ablation of liver dome hepatocellular carcinoma invisible on ultrasonography: a new targeting strategy

Targeting of index tumours is prerequisite to their radiofrequency ablation. However, small hepatocellular carcinomas (HCCs) in the liver dome are often invisible on ultrasonography, thus causing difficulty in their targeting. In cases with multinodular HCCs, adjacent HCC lesions with compact iodized oil retention can be used as anatomic landmarks to guide radiofrequency (RF) ablation of such nodules under fluoroscopy. We present two cases in which nodules that were difficult to target with conventional methods were successfully treated by RF ablation using this targeting strategy.

MR Imaging of hepatocellular carcinoma in the cirrhotic liver: challenges and controversies

The incidence of hepatocellular carcinoma (HCC) is expected to increase in the next 2 decades, largely due to hepatitis C infection and secondary cirrhosis. HCC is being detected at an earlier stage owing to the implementation of screening programs. Biopsy is no longer required prior to treatment, and diagnosis of HCC is heavily dependent on imaging characteristics. The most recent recommendations by the American Association for the Study of Liver Diseases (AASLD) state that a diagnosis of HCC can be made if a mass larger than 2 cm shows typical features of HCC (hypervascularity in the arterial phase and washout in the venous phase) at contrast material-enhanced computed tomography or magnetic resonance (MR) imaging or if a mass measuring 1-2 cm shows these features at both modalities. There is an ever-increasing demand on radiologists to detect smaller tumors, when curative therapies are most effective. However, the major difficulty in imaging cirrhosis is the characterization of hypervascular nodules smaller than 2 cm, which often have nonspecific imaging characteristics. The authors present a review of the MR imaging and pathologic features of regenerative nodules and dysplastic nodules and focus on HCC in the cirrhotic liver, with particular reference to small tumors and lesions that may mimic HCC. The authors also review the sensitivity of MR imaging for the detection of these tumors and discuss the staging of HCC and the treatment options in the context of the guidelines of the AASLD and the imaging criteria required by the United Network for Organ Sharing for transplantation. MR findings following ablation and chemoembolization are also reviewed.

Investigation of volatile biomarkers in liver cancer blood using solid-phase microextraction and gas chromatography/mass spectrometry

Solid-phase microextraction (SPME) followed by gas chromatography/mass spectrometry (GC/MS) was used for the detection of liver cancer volatile biomarkers. Headspace SPME conditions (fiber coating, extraction temperature and extraction time) and desorption conditions were optimized and applied to the determination of volatiles in human blood. Between the liver cancer group (n = 19) and the normal group (n = 18), positive rates of 19 volatile compounds among the total of 47 detected were found to be different with statistical significance (p < 0.05, chi-squared test). We suggested hexanal, 1-octen-3-ol and octane, of the 19 compounds, as biomarkers of liver cancer with clinical diagnostic value. The sensitivity and specificity of 94.7% and 100% for hexanal, 84.2% and 100% for 1-octen-3-ol, and 89.5% and 100% for octane were obtained, respectively, after the cutoff values had been properly established. These results show that SPME-GC/MS is a simple, rapid and sensitive method for the investigation of volatile disease markers in human blood.

Significance of CD90+ cancer stem cells in human liver cancer

This study characterized cancer stem cells (CSCs) in hepatocellular carcinoma (HCC) cell lines, tumor specimens, and blood samples. The CD90+ cells, but not the CD90(-) cells, from HCC cell lines displayed tumorigenic capacity. All the tumor specimens and 91.6% of blood samples from liver cancer patients bore the CD45(-)CD90+ population, which could generate tumor nodules in immunodeficient mice. The CD90+CD44+ cells demonstrated a more aggressive phenotype than the CD90+CD44(-) counterpart and formed metastatic lesions in the lung of immunodeficient mice. CD44 blockade prevented the formation of local and metastatic tumor nodules by the CD90+ cells. Differential gene expression profiles were identified in the CD45(-)CD90+ and CD45(-)CD90(-) cells isolated from tissue and blood samples from liver cancer patients and controls.

Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography

AIM

To investigate the diagnostic value for the diagnosis of small (1-2 cm) hepatic nodules detected by surveillance ultrasound in patients with cirrhosis using contrast-enhanced ultrasound (CEUS) compared with that of contrast-enhanced helical computed tomography (CECT).

METHODS

Seventy-two liver cirrhosis patients with 103 small hepatic nodules (1-2 cm) detected by surveillance ultrasound were enrolled in the present study. All patients underwent CEUS with SonoVue as well as CECT. Nodules which appeared by contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CECT were diagnosed as malignant (hepatocellular carcinoma [HCC]). Histopathology obtained from biopsy or surgery served as the gold standard.

RESULTS

According to the above diagnostic criteria, the sensitivity (i.e. rate of correct diagnosis of HCC) was 91.1% (51/56 HCC) for CEUS and the specificity (i.e. the rate of correct exclusion of HCC) was 87.2% (41/47 regenerative nodules [RN]).Therefore, the diagnostic accuracy of CEUS was 89.3% (92/103 all nodules). Using the same diagnostic criteria, the sensitivity, specificity and accuracy of CECT were 80.4% (45/56 HCC), 97.9% (46/47 RN), and 88.4% (91/103 all nodules). Overall, there was no significant difference between CEUS and CECT in the diagnostic confidence of small hepatic nodules. Eighty-six nodules (45 HCC and 41 RN) were correctly diagnosed by both modalities and six (five HCC and one RN) were misdiagnosed by both.

CONCLUSION

The ability of CEUS in the characterization of small nodules (1-2 cm) detected by surveillance US in patients with liver cirrhosis is similar to that of CECT.

Proton beam therapy for hepatocellular carcinoma adjacent to the porta hepatis

PURPOSE

To evaluate the efficacy and safety of proton beam therapy (PBT) for patients with hepatocellular carcinoma (HCC) located adjacent to the porta hepatis.

METHODS AND MATERIALS

Subjects of the study were 53 patients with HCC located within 2 cm of the main portal vein. All patients had tumor confined to the radiation field with no evidence of metastatic disease. All patients had hepatic function levels of a Child-Pugh score of 10 or less, Eastern Cooperative Oncology Group performance status of 2 or less, and no uncontrolled ascites. Patients underwent PBT of 72.6 GyE in 22 fractions from Sept 2001 to Dec 2004.

RESULTS

After 3 years, the actuarial survival rate was 45.1% and local control rate was 86.0%. Prognostic factors for survival included Child-Pugh score, number of tumors, and alpha-fetoprotein levels. No late treatment-related toxicity of Grade 2 or higher was observed.

CONCLUSIONS

The PBT delivering 72.6 GyE in 22 fractions appears to be effective and safe for HCC adjacent to the porta hepatis.

[Diagnostic imaging of liver tumours. Current status]

Nowadays, contrast enhanced ultrasound (CEUS) is an imaging technique equivalent to multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for the detection and characterization of focal liver lesions. These methods have comparable sensitivity and specificity in differentiating a liver lesion as "benign" or "malignant". For benign lesions, CEUS is the recommended method of the choice. In unclear cases, or if CEUS is not available, MRI or CT are the methods of the second choice. If a benign tumor remains unclear, then a needle biopsy is recommended. In the case of a malignant tumor, it is necessary to use a second imaging technique besides CEUS. In addition to the detection and characterization of a liver tumor, CT and MRI provide information on the extrahepatic spread of a tumor, particularly into the lung or retroperitoneum. The rapid development of surgical and interventional approaches requires accurate information on the character and number of malignant liver lesions. Therefore, the combined use of CEUS and MDCT or MRI currently represents the most modern and optimal standard of imaging. The standardization of CT and MRI protocols has increased the general diagnostic level of these images. Adequate training and a certificate for the use of CEUS is recommended in order to maintain the high diagnostic level of this method (EFSUMB guide lines). An optimal interdisciplinary imaging strategy for focal liver lesions minimises unnecessary invasive or potentially harmful imaging and reduces health costs.

Angiogenesis soluble factors as hepatocellular carcinoma noninvasive markers for monitoring hepatitis C virus cirrhotic patients awaiting liver transplantation

BACKGROUND

Physiological angiogenesis occurs during liver regeneration, leading to the formation of new functional sinusoids. Pathological angiogenesis occurs in hepatocellular carcinoma (HCC). We aimed to evaluate the expression of angiogenic factors in hepatitis C virus (HCV)-HCC tissues and the utility of angiogenesis soluble factors as noninvasive markers of HCC and tumor growth.

METHODS

Thirty-eight HCV-HCC tumors with 10 corresponding nontumor cirrhotic tissues, as well as 42 independent HCV cirrhotic and 6 normal liver tissues were studied using high-density oligonucleotide arrays. Human angiogenesis microarray was used for the protein detection of EGF, TIMP-1, TIMP-2, HGF, angiopn-1, angiopn-2, VEGF-A, IP-10, PDGF, KGF, angiogenin, VEGF-D, ICAM-1, and FGF in plasma samples from 40 patients (30 HCCs and 10 HCV cirrhosis).

RESULTS

From the gene expression analysis of the HCV-HCC tumors compared to normal livers, we found an important number of genes related to angiogenesis differentially expressed (alpha=0.01), including VEGF, PDGF, AGPTL2, ANG, EGFL6, EGFR, angiopn-1, angiopn-2, ICAM2, TIMP-2, among others. Moreover, angiogenic genes were also differentially expressed when HCV-HCC samples were compared to HCV cirrhotic tissues (alpha=0.01; VEGF, EGFL3, EGFR, VEGFB, among others). Ten out of 14 angiogenic proteins analyzed were statistically differentially expressed between HCV cirrhosis and HCV-HCC groups (TIMP-1, TIMP-2, HGF, angiopn-1, angiopn-2, VEGF-A, IP-10, PDGF, KGF, and FGF; P<0.05). In addition, we observed that angiopn-2 was the most significant predictor (area under the curve: 0.83).

CONCLUSION

Differentially expressed angiogenesis genes were observed between HCV patients with and without HCC. Soluble angiogenic factors might be useful for monitoring high-risk HCV patients.