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Sanchez JI, Fontillas AC, Kwan SY, Sanchez CI, Calderone TL, Lee JL, Elsaiey A, Cleere DW, Wei P, Vierling JM, Victor DW, Beretta L. Metabolomics biomarkers of hepatocellular carcinoma in a prospective cohort of patients with cirrhosis. JHEP Rep 2024; 6:101119. [PMID: 39139459 PMCID: PMC11321296 DOI: 10.1016/j.jhepr.2024.101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 08/15/2024] Open
Abstract
Background & Aims The effectiveness of surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is limited, due to inadequate risk stratification and suboptimal performance of current screening modalities. Methods We developed a multicenter prospective cohort of patients with cirrhosis undergoing surveillance with MRI and applied global untargeted metabolomics to 612 longitudinal serum samples from 203 patients. Among them, 37 developed HCC during follow-up. Results We identified 150 metabolites with significant abundance changes in samples collected prior to HCC (Cases) compared to samples from patients who did not develop HCC (Controls). Tauro-conjugated bile acids and gamma-glutamyl amino acids were increased, while acyl-cholines and deoxycholate derivatives were decreased. Seven amino acids including serine and alanine had strong associations with HCC risk, while strong protective effects were observed for N-acetylglycine and glycerophosphorylcholine. Machine learning using the 150 metabolites, age, gender, and PNPLA3 and TMS6SF2 single nucleotide polymorphisms, identified 15 variables giving optimal performance. Among them, N-acetylglycine had the highest AUC in discriminating Cases and Controls. When restricting Cases to samples collected within 1 year prior to HCC (Cases-12M), additional metabolites including microbiota-derived metabolites were identified. The combination of the top six variables identified by machine learning (alpha-fetoprotein, 6-bromotryptophan, N-acetylglycine, salicyluric glucuronide, testosterone sulfate and age) had good performance in discriminating Cases-12M from Controls (AUC 0.88, 95% CI 0.83-0.93). Finally, 23 metabolites distinguished Cases with LI-RADS-3 lesions from Controls with LI-RADS-3 lesions, with reduced abundance of acyl-cholines and glycerophosphorylcholine-related lysophospholipids in Cases. Conclusions This study identified N-acetylglycine, amino acids, bile acids and choline-derived metabolites as biomarkers of HCC risk, and microbiota-derived metabolites as contributors to HCC development. Impact and implications The effectiveness of surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is limited. There is an urgent need for improvement in risk stratification and new screening modalities, particularly blood biomarkers. Longitudinal collection of paired blood samples and MRI images from patients with cirrhosis is particularly valuable in assessing how early blood and imaging markers become positive during the period when lesions are observed to obtain a diagnosis of HCC. We generated a multicenter prospective cohort of patients with cirrhosis under surveillance with contrast MRI, applied untargeted metabolomics on 612 serum samples from 203 patients and identified metabolites associated with risk of HCC development. Such biomarkers may significantly improve early-stage HCC detection for patients with cirrhosis undergoing HCC surveillance, a critical step to increasing curative treatment opportunities and reducing mortality.
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Affiliation(s)
- Jessica I. Sanchez
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Antoine C. Fontillas
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Suet-Ying Kwan
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caren I. Sanchez
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tiffany L. Calderone
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jana L. Lee
- Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed Elsaiey
- Department of Gastroenterology, Houston Methodist Hospital, Houston, TX, USA
| | - Darrel W. Cleere
- Department of Gastroenterology, Houston Methodist Hospital, Houston, TX, USA
| | - Peng Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M. Vierling
- Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - David W. Victor
- Department of Gastroenterology, Houston Methodist Hospital, Houston, TX, USA
| | - Laura Beretta
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lani L, Stefanini B, Trevisani F. Surveillance for Hepatocellular Carcinoma in Patients with Successfully Treated Viral Disease of the Liver: A Systematic Review. Liver Cancer 2024; 13:376-388. [PMID: 39114761 PMCID: PMC11305665 DOI: 10.1159/000535497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/23/2023] [Indexed: 08/10/2024] Open
Abstract
Background Surveillance for hepatocellular carcinoma (HCC) has been proven to increase the proportion of tumors detected at early stages and the chance of receiving curative therapies, reducing mortality by about 30%. Summary Current recommendations consist of a semi-annual abdominal ultrasound with or without serum alpha-fetoprotein measurement in patients with cirrhosis and specific subgroups of populations with chronic viral hepatitis. Antiviral therapies, such as nucleot(s)ide analogs that efficiently suppress the replication of hepatitis B virus (HBV) and direct-acting antiviral drugs able to eliminate the hepatitis C virus (HCV) in >90% of patients, have radically changed the outcomes of viral liver disease and decreased, but not eliminated, the risk of HCC in both cirrhotic and non-cirrhotic patients. HCC risk is a key starting point for implementing a cost-effective surveillance and should also guide the decision-making process concerning its modality. As the global number of effectively treated viral patients continues to rise, there is a pressing need to identify those for whom the benefit-to-harm ratio of surveillance is favorable and to determine how to conduct cost-effective screening on such patients. Key Messages This article addresses this topic and attempts to determine which patients should continue HCC surveillance after HBV suppression or HCV eradication, based on cost-effectiveness principles and the fact that HCC risk declines over time. We also formulate a proposal for a surveillance algorithm that switches the use of surveillance for HCC from the "one-size-fits-all" approach to individualized programs based on oncologic risk (precision surveillance).
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Affiliation(s)
- Lorenzo Lani
- Unit of Semeiotics, Liver, and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benedetta Stefanini
- Unit of Semeiotics, Liver, and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Franco Trevisani
- Unit of Semeiotics, Liver, and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Vithayathil M, Qurashi M, Vicente PR, Alsafi A, Naik M, Graham A, Khan S, Lewis H, Dhar A, Smith B, Selvapatt N, Manousou P, Possamai L, Izadi H, Lim A, Tait P, Sharma R. Prospective Study of Non-Contrast, Abbreviated MRI for Hepatocellular Carcinoma Surveillance in Patients with Suboptimal Hepatic Visualisation on Ultrasound. Cancers (Basel) 2024; 16:2709. [PMID: 39123437 PMCID: PMC11312001 DOI: 10.3390/cancers16152709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Biannual ultrasound (US) is recommended for hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis. However, US has limited sensitivity for early-stage HCC, particularly in overweight cohorts, where hepatic visualisation is often inadequate. Currently there are no robust imaging surveillance strategies in patients with inadequate US visualisation. We investigated the ability of non-contrast, abbreviated magnetic resonance imaging (aMRI) to adequately visualise the liver for HCC surveillance in patients with previously inadequate US. METHODS Patients undergoing US surveillance, where liver visualisation was inadequate (LI-RADS VIS-B and VIS-C), were prospectively recruited. Patients underwent non-contrast T2-weighted and diffusion-weighted aMRI. The images were reviewed and reported by an expert liver radiologist. Three independent, blinded radiologists assessed the aMRI visualisation quality using a binary score assessing five parameters (parenchymal definition, vascular definition, coverage of the liver, uniformity of liver appearance and signal-to-noise ratio). RESULTS Thirty patients completed the aMRI protocol. The majority (90%) had underlying cirrhosis and were overweight (93.3%), with 50% obese and 20% severely obese. A total of 93.3% of the aMRI scans were of satisfactory quality. Six patients (20%) had hepatic abnormalities detected with aMRI that were not seen on their US: one HCC, one haemangioma and three clinically insignificant lesions. For the aMRI visualisation quality assessment, the coverage of the liver, vascular definition and parenchymal definition were consistently rated to be of sufficient quality by all three radiologists. CONCLUSIONS Non-contrast aMRI provided good visualisation of the liver and detection of abnormalities in patients with inadequate US. aMRI should be further explored in a larger, prospective study as an alternative surveillance strategy in patients with inadequate US.
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Affiliation(s)
- Mathew Vithayathil
- Department of Surgery and Cancer, Imperial College London, London W12 0NN, UK; (M.V.)
| | - Maria Qurashi
- Department of Surgery and Cancer, Imperial College London, London W12 0NN, UK; (M.V.)
| | | | - Ali Alsafi
- Department of Interventional Radiology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Mitesh Naik
- Department of Nuclear Medicine, Imperial College Healthcare NHS Trust, London W12 0HS, UK;
| | - Alison Graham
- Department of Interventional Radiology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Shahid Khan
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Heather Lewis
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Ameet Dhar
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Belinda Smith
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Nowlan Selvapatt
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Pinelopi Manousou
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Lucia Possamai
- Department of Hepatology, Imperial College Healthcare NHS Trust, London W12 0HS, UK (A.D.); (N.S.)
| | - Hooshang Izadi
- School of Engineering, Computing and Mathematics, Oxford Brookes University, Oxford OX3 0BP, UK
| | - Adrian Lim
- Department of Radiology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Paul Tait
- Department of Interventional Radiology, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Rohini Sharma
- Department of Surgery and Cancer, Imperial College London, London W12 0NN, UK; (M.V.)
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EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Obes Facts 2024; 17:374-444. [PMID: 38852583 PMCID: PMC11299976 DOI: 10.1159/000539371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024] Open
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Tacke F, Horn P, Wai-Sun Wong V, Ratziu V, Bugianesi E, Francque S, Zelber-Sagi S, Valenti L, Roden M, Schick F, Yki-Järvinen H, Gastaldelli A, Vettor R, Frühbeck G, Dicker D. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024:S0168-8278(24)00329-5. [PMID: 38851997 DOI: 10.1016/j.jhep.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Chen QF, Chen S, Yi JZ, Wang JL, Zhong SX, Jiang XY, Hu Y, Tan GJ, Xu J, Lyu N, Zhao M. Recommended 10-Year Follow-Up Strategy for Small Hepatocellular Carcinoma After Radiofrequency Ablation: A Cost-Effectiveness Evaluation. Am J Gastroenterol 2024:00000434-990000000-01086. [PMID: 38526213 DOI: 10.14309/ajg.0000000000002774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/13/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION An optimal follow-up schedule for small (≤3-cm) hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) remains unclear in clinical guidelines. We aimed to assess the cost-effectiveness of follow-up strategies in patients with small HCC after RFA. METHODS In total, 11,243 patients were collected from global institutions to calculate recurrence rates. Subsequently, a Markov model covering a 10-year period was developed to compare 25 surveillance strategies involving different surveillance techniques (computed tomography [CT], magnetic resonance imaging or ultrasonography [US], and α-fetoprotein [AFP]) and intervals (3 or 6 months). The study endpoint was incremental cost-effectiveness ratio (ICER), which represented additional cost per incremental quality-adjusted life year. Sensitivity analysis was conducted by varying the values of input parameters to observe the ICER. RESULTS In a base case analysis, the dominant strategy was CT every 3 months during an initial 2 years, followed by semiannual CT, and then switch to biannual the combination of US screening and AFP testing after 5 years (m3_CT-m6_CT-m6_USAFP), with an ICER of $68,570.92 compared with the "not followed" strategy. One-way sensitivity analysis showed the ICER consistently remained below the willingness-to-pay threshold of $100,000.00. In a probabilistic sensitivity analysis, m3_CT-m6_CT-m6_USAFP was the most cost-effective approach in 95.6% of simulated scenarios at a willingness-to-pay threshold. DISCUSSION For small HCC after RFA, the recommended follow-up strategy is CT, with scans scheduled every 3 months for the first 2 years, every 6 months thereafter, and transition to biannual the combination of US screening and AFP testing after 5 years.
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Affiliation(s)
- Qi-Feng Chen
- Department of Minimally Invasive Interventional Therapy, Liver Cancer Study and Service Group, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
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Kim DH, Yoon JH, Choi MH, Lee CH, Kang TW, Kim HA, Ku YM, Lee JM, Kim SH, Kim KA, Lee SL, Choi JI. Comparison of non-contrast abbreviated MRI and ultrasound as surveillance modalities for HCC. J Hepatol 2024:S0168-8278(24)00272-1. [PMID: 38636849 DOI: 10.1016/j.jhep.2024.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/23/2024] [Accepted: 03/31/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND & AIMS Ultrasonography (US) is recommended for HCC surveillance in high-risk patients but has limited performance in detecting early-stage HCC. We aimed to compare the diagnostic performance of biannual US and annual non-contrast abbreviated magnetic resonance imaging (NC-AMRI) as HCC surveillance modalities in high-risk patients. METHODS This prospective, multicenter cohort study enrolled participants with an estimated annual risk of HCC greater than 5% between October 2015 and April 2017. Participants underwent six rounds of HCC surveillance at 6-month intervals, with both US and NC-AMRI at rounds 1, 3, and 5, and only US at rounds 2, 4, and 6. The sensitivity, diagnostic yield (DY), and false referral rate (FRR) for HCC detection by US and NC-AMRI were compared. RESULTS In total, 208 participants underwent 980 US and 516 NC-AMRI examinations during 30 months of follow-up. Among them, 34 HCCs were diagnosed in 31 participants, with 20 (64.5%) classified as very early-stage and 11 (35.5%) as early-stage HCC. The sensitivity of annual NC-AMRI (71.0%, 22/31) was marginally higher than that of biannual US (45.2%, 14/31; p = 0.077). NC-AMRI showed a significantly higher DY than US (4.26% vs. 1.43%, p <0.001), with a similar FRR (2.91% vs. 3.06%, p = 0.885). A simulation of alternating US and NC-AMRI at 6-month intervals yielded a sensitivity of 83.9% (26/31), significantly exceeding that of biannual US (p = 0.006). CONCLUSIONS Annual NC-AMRI showed a marginally higher sensitivity than biannual US for HCC detection in high-risk patients. The DY of annual NC-AMRI was significantly higher than that of biannual US, without increasing the FRR. Thus, alternating US and NC-AMRI at 6-month intervals could be an optimal surveillance strategy for high-risk patients. IMPACT AND IMPLICATIONS Current guidelines permit the use of magnetic resonance imaging (MRI) as a surveillance tool for hepatocellular carcinoma in patients in whom ultrasonography (US) is inadequate. However, the specific indications, imaging sequences, and intervals for MRI surveillance remain unclear. In our study, we found that annual non-contrast abbreviated MRI exhibited marginally higher sensitivity and significantly better diagnostic yield than biannual US in patients at high risk of hepatocellular carcinoma. Alternating US and non-contrast abbreviated MRI at 6-month intervals led to significantly improved sensitivity compared to biannual US, making it a potentially optimal surveillance strategy for high-risk patients. CLINICALTRIALS GOV IDENTIFIER NCT02551250.
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Affiliation(s)
- Dong Hwan Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea; Current address: Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 05505, Republic of Korea
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital and College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Moon Hyung Choi
- Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Tae Wook Kang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun A Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Mi Ku
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital and College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Seong Hyun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung Ah Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Su Lim Lee
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joon-Il Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea.
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Nahon P, Layese R, Ganne-Carrié N, Moins C, N'Kontchou G, Chaffaut C, Ronot M, Audureau E, Durand-Zaleski I, Natella PA. The clinical and financial burden of nonhepatocellular carcinoma focal lesions detected during the surveillance of patients with cirrhosis. Hepatology 2024; 79:813-828. [PMID: 37774387 DOI: 10.1097/hep.0000000000000615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND AND AIMS HCC surveillance is challenged by the detection of hepatic focal lesions (HFLs) of other types. This study aimed to describe the incidence, characteristics, outcomes, and costs of non-HCC HFL detected during surveillance. APPROACH AND RESULTS We retrospectively analyzed nonstandardized workup performed in French patients included in HCC surveillance programs recruited in 57 French tertiary centers (ANRS CirVir and CIRRAL cohorts, HCC 2000 trial). The overall cost of workup was evaluated, with an estimation of an average cost per patient for the entire population and per lesion detected. A total of 3295 patients were followed up for 59.8 months, 391 (11.9%) patients developed HCCs (5-year incidence: 12.1%), and 633 (19.2%) developed non-HCC HFLs (5-year incidence: 21.8%). Characterization of non-HCC HFL required a median additional of 0.7 exams per year. A total of 11.8% of non-HCC HFLs were not confirmed on recall procedures, and 19.6% of non-HCC HFLs remained undetermined. A definite diagnosis of benign liver lesions was made in 65.1%, and malignant tumors were diagnosed in 3.5%. The survival of patients with benign or undetermined non-HCC HFL was similar to that of patients who never developed any HFL (5-year survival 92% vs. 88%, p = 0.07). The average cost of the diagnostic workup was 1087€ for non-HCC HFL and €1572 for HCC. CONCLUSIONS Non-HCC HFLs are frequently detected in patients with cirrhosis, and do not impact prognosis, but trigger substantial costs. This burden must be considered in cost-effectiveness analyses of future personalized surveillance strategies.
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Affiliation(s)
- Pierre Nahon
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Department, Bobigny; Université Sorbonne Paris Nord, Bobigny, France
- Inserm, UMR-1138 Functional Genomics of Solid Tumors department, Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Richard Layese
- Univ Paris Est Créteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Unité de Recherche Clinique (URC Mondor), Public health department, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Nathalie Ganne-Carrié
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Department, Bobigny; Université Sorbonne Paris Nord, Bobigny, France
- Inserm, UMR-1138 Functional Genomics of Solid Tumors department, Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Cécile Moins
- Clinical Research Department, ANRS | Emerging Infectious Diseases, Paris, France
| | - Gisèle N'Kontchou
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Department, Bobigny; Université Sorbonne Paris Nord, Bobigny, France
- Inserm, UMR-1138 Functional Genomics of Solid Tumors department, Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Cendrine Chaffaut
- SBIM, APHP, Hôpital Saint-Louis, Paris, Inserm, UMR-1153, ECSTRA department, Paris, France
| | - Maxime Ronot
- APHP, Hôpital Beaujon, Radiology department, Hôpital Beaujon, APHP. Nord, Clichy-Sous-Bois, & Université Paris Cité, Paris, France
| | - Etienne Audureau
- Univ Paris Est Créteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Unité de Recherche Clinique (URC Mondor), Public health department, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCECo department, AP-HP, Hôpital de l'Hôtel Dieu, Paris, France
| | - Pierre-André Natella
- Univ Paris Est Créteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Unité de Recherche Clinique (URC Mondor), Public health department, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
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Nikzad N, Fuentes DT, Roach M, Chowdhury T, Cagley M, Badawy M, Elkhesen A, Hassan M, Elsayes KM, Beretta L, Koay EJ, Jalal PK. Enhancement Pattern Mapping for Early Detection of Hepatocellular Carcinoma in Patients with Cirrhosis. J Hepatocell Carcinoma 2024; 11:595-606. [PMID: 38525156 PMCID: PMC10961013 DOI: 10.2147/jhc.s449996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Background and Aims Limited methods exist to accurately characterize the risk of malignant progression of liver lesions. Enhancement pattern mapping (EPM) measures voxel-based root mean square deviation (RMSD) of parenchyma and the contrast-to-noise (CNR) ratio enhances in malignant lesions. This study investigates the utilization of EPM to differentiate between HCC versus cirrhotic parenchyma with and without benign lesions. Methods Patients with cirrhosis undergoing MRI surveillance were studied prospectively. Cases (n=48) were defined as patients with LI-RADS 3 and 4 lesions who developed HCC during surveillance. Controls (n=99) were patients with and without LI-RADS 3 and 4 lesions who did not develop HCC. Manual and automated EPM signals of liver parenchyma between cases and controls were quantitatively validated on an independent patient set using cross validation with manual methods avoiding parenchyma with artifacts or blood vessels. Results With manual EPM, RMSD of 0.37 was identified as a cutoff for distinguishing lesions that progress to HCC from background parenchyma with and without lesions on pre-diagnostic scans (median time interval 6.8 months) with an area under the curve (AUC) of 0.83 (CI: 0.73-0.94) and a sensitivity, specificity, and accuracy of 0.65, 0.97, and 0.89, respectively. At the time of diagnostic scans, a sensitivity, specificity, and accuracy of 0.79, 0.93, and 0.88 were achieved with manual EPM with an AUC of 0.89 (CI: 0.82-0.96). EPM RMSD signals of background parenchyma that did not progress to HCC in cases and controls were similar (case EPM: 0.22 ± 0.08, control EPM: 0.22 ± 0.09, p=0.8). Automated EPM produced similar quantitative results and performance. Conclusion With manual EPM, a cutoff of 0.37 identifies quantifiable differences between HCC cases and controls approximately six months prior to diagnosis of HCC with an accuracy of 89%.
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Affiliation(s)
- Newsha Nikzad
- Department of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Internal Medicine, The University of Chicago Medical Center, Chicago, IL, USA
| | - David Thomas Fuentes
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Millicent Roach
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tasadduk Chowdhury
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Cagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamed Badawy
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed Elkhesen
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Manal Hassan
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Khaled M Elsayes
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Beretta
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene Jon Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prasun Kumar Jalal
- Department of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
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10
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Nahon P, Ronot M, Sutter O, Natella PA, Baloul S, Durand-Zaleski I, Audureau E. Study protocol for FASTRAK: a randomised controlled trial evaluating the cost impact and effectiveness of FAST-MRI for HCC suRveillance in pAtients with high risK of liver cancer. BMJ Open 2024; 14:e083701. [PMID: 38367972 PMCID: PMC10875554 DOI: 10.1136/bmjopen-2023-083701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/23/2024] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION The surveillance of hepatocellular carcinoma (HCC) using semi-annual liver ultrasound (US) is justified in patients with cirrhosis. In this context, US has a low sensitivity (<30%) for the detection of HCC at the very early stage (ie, Barcelona clinic liver cancer (BCLC) 0, uninodular tumour <2 cm). The sensitivity of abbreviated liver MRI (AMRI) is reported to exceed 80%, but its use is hampered by costs and availability. Our hypothesis is that AMRI used as a screening examination in patients at high risk of HCC (>3% per year) could increase the rates of patients with a tumour detected at an early stage accessible to curative-intent treatment, and demonstrate its cost-effectiveness in this population. METHODS AND ANALYSIS The FASTRAK trial is a multicentre, randomised controlled trial with two parallel arms, aiming for superiority and conducted on patients at high risk for HCC (yearly HCC incidence >3%). Randomisation will be conducted on an individual basis with a centralised approach and stratification by centre. After inclusion in the trial, each patient will be randomly assigned to the experimental group (semi-annual US and AMRI) or the control group (semi-annual US alone). The main objective is to assess the cost/quality-adjusted life year and cost/patient detected with a BCLC 0 HCC in both arms. A total of 944 patients will be recruited in 37 tertiary French centres during a 36-month period and will be followed-up during 36 months. ETHICS AND DISSEMINATION The FASTRAK trial received ethical approval on 4 April 2022. Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER Clinical trial number (ClinicaTrials.gov) NCT05095714.
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Affiliation(s)
| | | | | | - Pierre-André Natella
- Clinical Epidemiology and Ageing, Hôpitaux Universitaires Henri Mondor, Creteil, France
| | - Samia Baloul
- Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Isabelle Durand-Zaleski
- University of Paris, Paris, France
- URCEco, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Etienne Audureau
- CEPIA EA7376, Universite Paris-Est Creteil Val de Marne, Creteil, France
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11
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Heo S, Choi WM. Non-Contrast Abbreviated Magnetic Resonance Imaging: A Cost-Effective Rookie in Hepatocellular Carcinoma Surveillance for Cirrhotic Patients. Gut Liver 2024; 18:7-9. [PMID: 38221817 PMCID: PMC10791505 DOI: 10.5009/gnl230537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Affiliation(s)
- Subin Heo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Decharatanachart P, Pan-ngum W, Peeraphatdit T, Tanpowpong N, Tangkijvanich P, Treeprasertsuk S, Rerknimitr R, Chaiteerakij R. Cost-Utility Analysis of Non-Contrast Abbreviated Magnetic Resonance Imaging for Hepatocellular Carcinoma Surveillance in Cirrhosis. Gut Liver 2024; 18:135-146. [PMID: 37560799 PMCID: PMC10791494 DOI: 10.5009/gnl230089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/01/2023] [Accepted: 05/23/2023] [Indexed: 08/11/2023] Open
Abstract
Background/Aims Ultrasonography has a low sensitivity for detecting early-stage hepatocellular carcinoma (HCC) in cirrhotic patients. Non-contrast abbreviated magnetic resonance imaging (aMRI) demonstrated a comparable performance to that of magnetic resonance imaging without the risk of contrast media exposure and at a lower cost than that of full diagnostic MRI. We aimed to investigate the cost-effectiveness of non-contrast aMRI for HCC surveillance in cirrhotic patients, using ultrasonography with alpha-fetoprotein (AFP) as a reference. Methods Cost-utility analysis was performed using a Markov model in Thailand and the United States. Incremental cost-effectiveness ratios were calculated using the total costs and quality-adjusted life years (QALYs) gained in each strategy. Surveillance protocols were considered cost-effective based on a willingness-to-pay value of $4,665 (160,000 Thai Baht) in Thailand and $50,000 in the United States. Results aMRI was cost-effective in both countries with incremental cost-effectiveness ratios of $3,667/QALY in Thailand and $37,062/QALY in the United States. Patient-level microsimulations showed consistent findings that aMRI was cost-effective in both countries. By probabilistic sensitivity analysis, aMRI was found to be more cost-effective than combined ultrasonography and AFP with a probability of 0.77 in Thailand and 0.98 in the United States. By sensitivity analyses, annual HCC incidence was revealed as the most influential factor affecting cost-effectiveness. The cost-effectiveness of aMRI increased in settings with a higher HCC incidence. At a higher HCC incidence, aMRI would remain cost-effective at a higher aMRI-to-ultrasonography with AFP cost ratio. Conclusions Compared to ultrasonography with AFP, non-contrast aMRI is a cost-effective strategy for HCC surveillance and may be useful for such surveillance in cirrhotic patients, especially in those with high HCC risks.
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Affiliation(s)
| | - Wirichada Pan-ngum
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thoetchai Peeraphatdit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Natthaporn Tanpowpong
- Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pisit Tangkijvanich
- Center of Excellence in Hepatitis and Liver Cancer, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Roongruedee Chaiteerakij
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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13
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 269] [Impact Index Per Article: 269.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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14
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Thörn R, Hemmingsson O, Danielsson Borssén Å, Werner M, Karling P, Wixner J. Improved Survival in At-Risk Patients Undergoing Surveillance for Hepatocellular Carcinoma - A Nationwide Swedish Register-Based Study. J Hepatocell Carcinoma 2023; 10:1573-1586. [PMID: 37753268 PMCID: PMC10518262 DOI: 10.2147/jhc.s420130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Purpose Surveillance for hepatocellular carcinoma (HCC) is recommended in at-risk patients, but its effectiveness in Western populations has been questioned. The purpose was to evaluate the effect of surveillance in patients with HCC in a Northern European setting. Patients and Methods Data on patients diagnosed with HCC between 2009 and 2019 were collected from the nationwide Swedish National Registry for Tumors of the Liver and Bile Ducts (SweLiv). Patients who had undergone HCC surveillance were compared to those who had not (but had an obvious indication for surveillance, ie, liver cirrhosis or hepatic porphyria and an age of ≥50 years) regarding etiology, tumor burden, presence of extrahepatic spread, treatment and lead-time adjusted overall survival. Results A total of 4979 patients with index HCC were identified and information regarding surveillance was available in 4116 patients. Among these, 1078 had got their HCC diagnosis during surveillance, whereas 1647 had been diagnosed without surveillance despite a presumed indication. The most common underlying etiologies for HCC were hepatitis C (28.2%) and alcoholic liver disease (26.9%), and 94.8% had cirrhosis. The surveillance cohort more frequently met the University of California San Francisco-criteria (79% vs 53%, p <0.001), more often received a potentially curative treatment (62% vs 28%, p <0.001) and had less extrahepatic spread (7.6% vs 22.4% p <0.001). After adjustment for lead-time bias (sojourn time of 270 days), the surveillance group had a significantly longer estimated median survival time than the non-surveillance group (34 months vs 11 months, p <0.001). A multivariable cox regression analysis showed an adjusted hazard ratio of 0.59 (95% CI 0.51-0.67) in favor of surveillance. Conclusion Surveillance for HCC in at-risk patients is associated with diagnosis at an earlier tumor stage, treatment with curative intent and with improved lead-time adjusted overall survival. These findings encourage HCC surveillance of at-risk patients also in a Western population.
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Affiliation(s)
- Richard Thörn
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | | | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Pontus Karling
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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15
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Ronot M, Nahon P, Rimola J. Screening of liver cancer with abbreviated MRI. Hepatology 2023; 78:670-686. [PMID: 36896975 DOI: 10.1097/hep.0000000000000339] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/02/2022] [Indexed: 03/11/2023]
Abstract
Current recommendations for the surveillance of HCC are based on the semiannual liver ultrasound (with or without serum alpha-fetoprotein) in patients with cirrhosis and in subgroups with chronic hepatitis B infection. However, the sensitivity of this strategy is suboptimal for the detection of early-stage tumors, especially in obese patients, due to interoperator variability and poor adherence. The detection rate of focal liver lesions is excellent with MRI, making it the best alternative candidate for surveillance. However, performing a full contrast-enhanced MRI is unrealistic because of limited availability and health economics. Abbreviated MRI (AMRI) corresponds to the acquisition of a limited number of sequences with a high detection rate. The theoretical benefits of AMRI are a reduced acquisition time (≤10 min) with improved time-effectiveness and cost-effectiveness compared with conventional MRI, and greater accuracy than ultrasound. Numerous protocols may be performed, including T1-weighted, T2-weighted, and DWI sequences, with or without contrast administration. Although published studies report promising per-patient results, they should be interpreted with caution. Indeed, most studies were simulated, retrospectively reviewing a subset of sequences in relatively small populations who underwent a full MRI. They also included groups that were not representative of screening populations. In addition, most were published by Asian groups, with at-risk populations that were different from Western populations. There are no existing longitudinal studies that directly compare the different AMRI approaches or AMRI to ultrasound. Finally, it is possible that 1 approach will not fit all patients and that strategies should be tailored to the risk of HCC, in particular in relation to the cost and availability of AMRI. Several trials are ongoing to evaluate these questions.
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Affiliation(s)
- Maxime Ronot
- Department of Radiology, Hopital Beaujon, APHP.Nord, Clichy, France
- Université Paris Paris, CRI, INSERM, Paris, France
| | - Pierre Nahon
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, APHP, Liver Unit, Bobigny
- Université Sorbonne Paris Nord, F-93000 Bobigny
- Inserm, UMR-1138 « Functional Genomics of solid tumors », Centre de recherche des Cordeliers, Université de Paris, Paris
| | - Jordi Rimola
- BCLC group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Spain
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16
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Lee YT, Fujiwara N, Yang JD, Hoshida Y. Risk stratification and early detection biomarkers for precision HCC screening. Hepatology 2023; 78:319-362. [PMID: 36082510 PMCID: PMC9995677 DOI: 10.1002/hep.32779] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 12/08/2022]
Abstract
Hepatocellular carcinoma (HCC) mortality remains high primarily due to late diagnosis as a consequence of failed early detection. Professional societies recommend semi-annual HCC screening in at-risk patients with chronic liver disease to increase the likelihood of curative treatment receipt and improve survival. However, recent dynamic shift of HCC etiologies from viral to metabolic liver diseases has significantly increased the potential target population for the screening, whereas annual incidence rate has become substantially lower. Thus, with the contemporary HCC etiologies, the traditional screening approach might not be practical and cost-effective. HCC screening consists of (i) definition of rational at-risk population, and subsequent (ii) repeated application of early detection tests to the population at regular intervals. The suboptimal performance of the currently available HCC screening tests highlights an urgent need for new modalities and strategies to improve early HCC detection. In this review, we overview recent developments of clinical, molecular, and imaging-based tools to address the current challenge, and discuss conceptual framework and approaches of their clinical translation and implementation. These encouraging progresses are expected to transform the current "one-size-fits-all" HCC screening into individualized precision approaches to early HCC detection and ultimately improve the poor HCC prognosis in the foreseeable future.
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Affiliation(s)
- Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, California
| | - Naoto Fujiwara
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California; Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, Los Angeles, California; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Yan YW, Liu XK, Zhang SX, Tian QF. Real-world 10-year retrospective study of the guidelines for diagnosis and treatment of primary liver cancer in China. World J Gastrointest Oncol 2023; 15:858-877. [DOI: 10.4251/wjgo.v15.i5.858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a common malignant tumor worldwide. Many regions across the world have issued various HCC diagnosis and treatment protocols to improve the diagnosis and targeted treatment of patients with HCC. However, real-world studies analysing the practice, application value, and existing problems of the China Liver Cancer (CNLC) staging system are scarce.
AIM To analyze the current situation and problems associated with the Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China.
METHODS We collected the medical records of all patients with HCC admitted to the First Affiliated Hospital of Zhengzhou University from January 1, 2011 to December 31, 2019, and recorded the hospitalization information of those patients until December 31, 2020. All information on the diagnosis and treatment of the target patients was recorded, and their demographic and sociological characteristics, CNLC stages, screening situations, and treatment methods and effects were analyzed. The survival status of the patients was obtained from follow-up data.
RESULTS This study included the medical records of 3022 patients with HCC. Among these cases, 304 patients were screened before HCC diagnosis; their early-stage diagnosis rate was 69.08%, which was significantly higher than that of patients with HCC who were diagnosed without screening and early detection (33.74%). Herein, patients with no clinical outcome at discharge were followed up, and the survival information of 1128 patients was obtained. A Cox model was used to analyse independent risk factors affecting overall survival, which were revealed as age > 50 years, no screening, alpha-fetoprotein > 400 ng/mL, Child–Pugh grade B, and middle and late CNLC stages. Based on the Cox model survival analysis, in our study, patients with HCC identified via screening had significant advantages in overall and tumor-free survival after hepatectomy.
CONCLUSION Early diagnosis and treatment can be achieved by screening groups at high risk for HCC based on the guidelines; however, real-world compliance is poor.
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Affiliation(s)
- Yun-Wei Yan
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Xin-Kui Liu
- Department of Medical Records Management, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Shun-Xiang Zhang
- Department of Epidemiology and Health Statistics and Henan Key Laboratory for Tumour Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Qing-Feng Tian
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
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18
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Yan YW, Liu XK, Zhang SX, Tian QF. Real-world 10-year retrospective study of the guidelines for diagnosis and treatment of primary liver cancer in China. World J Gastrointest Oncol 2023; 15:859-877. [PMID: 37275443 PMCID: PMC10237028 DOI: 10.4251/wjgo.v15.i5.859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/06/2023] [Accepted: 04/04/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a common malignant tumor worldwide. Many regions across the world have issued various HCC diagnosis and treatment protocols to improve the diagnosis and targeted treatment of patients with HCC. However, real-world studies analysing the practice, application value, and existing problems of the China Liver Cancer (CNLC) staging system are scarce.
AIM To analyze the current situation and problems associated with the Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China.
METHODS We collected the medical records of all patients with HCC admitted to the First Affiliated Hospital of Zhengzhou University from January 1, 2011 to December 31, 2019, and recorded the hospitalization information of those patients until December 31, 2020. All information on the diagnosis and treatment of the target patients was recorded, and their demographic and sociological characteristics, CNLC stages, screening situations, and treatment methods and effects were analyzed. The survival status of the patients was obtained from follow-up data.
RESULTS This study included the medical records of 3022 patients with HCC. Among these cases, 304 patients were screened before HCC diagnosis; their early-stage diagnosis rate was 69.08%, which was significantly higher than that of patients with HCC who were diagnosed without screening and early detection (33.74%). Herein, patients with no clinical outcome at discharge were followed up, and the survival information of 1128 patients was obtained. A Cox model was used to analyse independent risk factors affecting overall survival, which were revealed as age > 50 years, no screening, alpha-fetoprotein > 400 ng/mL, Child–Pugh grade B, and middle and late CNLC stages. Based on the Cox model survival analysis, in our study, patients with HCC identified via screening had significant advantages in overall and tumor-free survival after hepatectomy.
CONCLUSION Early diagnosis and treatment can be achieved by screening groups at high risk for HCC based on the guidelines; however, real-world compliance is poor.
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Affiliation(s)
- Yun-Wei Yan
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Xin-Kui Liu
- Department of Medical Records Management, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Shun-Xiang Zhang
- Department of Epidemiology and Health Statistics and Henan Key Laboratory for Tumour Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
| | - Qing-Feng Tian
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, Zhengzhou 450001, Henan Province, China
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Karim MA, Singal AG, Kum HC, Lee YT, Park S, Rich NE, Noureddin M, Yang JD. Prediagnostic CT or MRI Utilization and Outcomes in Hepatocellular Carcinoma: SEER-Medicare Database Analysis. CANCER RESEARCH COMMUNICATIONS 2023; 3:874-883. [PMID: 37377892 PMCID: PMC10187587 DOI: 10.1158/2767-9764.crc-23-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023]
Abstract
Ultrasound-based surveillance has suboptimal sensitivity for early hepatocellular carcinoma (HCC) detection, generating interest in alternative surveillance modalities. We aim to investigate the association between prediagnostic CT or MRI and overall survival in a contemporary cohort of patients with HCC. Using the Surveillance Epidemiology and End Results (SEER)-Medicare database, we analyzed Medicare beneficiaries diagnosed with HCC between 2011 and 2015. Proportion of time covered (PTC) was defined as the proportion of the 36-month period prior to HCC diagnosis in which patients had received abdominal imaging (ultrasound, CT, MRI). Cox proportional hazards regression was used to investigate the association between PTC and overall survival. Among 5,098 patients with HCC, 3,293 (65%) patients had abdominal imaging prior to HCC diagnosis, of whom 67% had CT/MRI. Median PTC by any abdominal imaging was 5.6% [interquartile range (IQR): 0%-36%], with few patients having PTC >50%. Compared with no abdominal images, ultrasound [adjusted HR (aHR): 0.87, 95% confidence interval (CI): 0.79-0.95] and CT/MRI group (aHR: 0.68, 95% CI: 0.63-0.74) were associated with improved survival. Lead-time adjusted analysis showed improved survival continued to be observed with CT/MRI (aHR: 0.80, 95% CI: 0.74-0.87) but not ultrasound (aHR: 1.00, 95% CI: 0.91-1.10). Increased PTC was associated with improved survival, with a larger effect size observed with CT/MRI (aHR per 10%: 0.93, 95% CI: 0.91-0.95) than ultrasound (aHR per 10%: 0.96, 95% CI: 0.95-0.98). In conclusion, PTC by abdominal images was associated with improved survival in patients with HCC, with potential greater benefit using CT/MRI. Regular utilization of CT/MRI before cancer diagnosis may have potential survival benefit compared to ultrasound in patients with HCC. Significance Our population-based study using SEER-Medicare database demonstrated that proportion of time covered by abdominal imaging was associated with improved survival in patients with HCC, with potential greater benefit using CT/MRI. The results suggest that CT/MRI surveillance may have potential survival benefit compared with ultrasound surveillance in high-risk patients for HCC. A larger prospective study should be conducted for external validation.
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Affiliation(s)
- Mohammad A. Karim
- Population Informatics Lab, School of Public Health, Texas A&M University, College Station, Texas
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hye Chung Kum
- Population Informatics Lab, School of Public Health, Texas A&M University, College Station, Texas
| | - Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, California
| | - Sulki Park
- Population Informatics Lab, School of Public Health, Texas A&M University, College Station, Texas
| | - Nicole E. Rich
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
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20
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Chen S, Shen B, Wu Y, Shen L, Qi H, Cao F, Huang T, Tan H, Wen C, Fan W. The relationship between the efficacy of thermal ablation and inflammatory response and immune status in early hepatocellular carcinoma and the progress of postoperative adjuvant therapy. Int Immunopharmacol 2023; 119:110228. [PMID: 37121111 DOI: 10.1016/j.intimp.2023.110228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
Hepatocellular carcinoma (HCC) is a highly heterogeneous disease. Thermal ablation has the advantages of being equivalent to surgical resection, minimally invasive, low cost and significantly reducing hospital stay. Therefore, it is recommended as one of the first-line radical treatment for early HCC. However, with the deepening of research on early HCC, more and more studies have found that not all patients with early HCC can obtain similar efficacy after radical thermal ablation, which may be related to the heterogeneity of HCC. Previous studies have shown that inflammation and immunity play an extremely important role in the prognostic heterogeneity of patients with HCC. Therefore, the inflammatory response and immune status of patients may be closely related to the efficacy of early HCC after curative thermal ablation. This article elaborates the mechanism of high inflammatory response and poor immune status in the poor prognosis after radical thermal ablation of early HCC, and clarifies the population who may benefit from adjuvant therapy after radical thermal ablation in patients with early HCC, which provides a new idea for the precise adjuvant treatment after radical ablation of early HCC in the future.
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Affiliation(s)
- Shuanggang Chen
- Department of Oncology, Yuebei People's Hospital, Shantou University Medical College, Shaoguan 512025, Guangdong, People's Republic of China; Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China.
| | - Binyan Shen
- Department of Nursing, Medical College of Shaoguan University, Shaoguan 512026, People's Republic of China
| | - Ying Wu
- Department of Interventional Therapy, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen 518035, China
| | - Lujun Shen
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Han Qi
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Fei Cao
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Tao Huang
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Hongtong Tan
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Chunyong Wen
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China
| | - Weijun Fan
- Department of Minimally Invasive Interventional Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, People's Republic of China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University, Guangzhou 510060, People's Republic of China.
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21
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Nguyen ALT, Si L, Lubel JS, Shackel N, Yee KC, Wilson M, Bradshaw J, Hardy K, Palmer AJ, Blizzard CL, de Graaff B. Hepatocellular carcinoma surveillance based on the Australian Consensus Guidelines: a health economic modelling study. BMC Health Serv Res 2023; 23:378. [PMID: 37076870 PMCID: PMC10116722 DOI: 10.1186/s12913-023-09360-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/31/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the fastest increasing cause of cancer death in Australia. A recent Australian consensus guidelines recommended HCC surveillance for cirrhotic patients and non-cirrhotic chronic hepatitis B (CHB) patients at gender and age specific cut-offs. A cost-effectiveness model was then developed to assess surveillance strategies in Australia. METHODS A microsimulation model was used to evaluate three strategies: biannual ultrasound, biannual ultrasound with alpha-fetoprotein (AFP) and no formal surveillance for patients having one of the conditions: non-cirrhotic CHB, compensated cirrhosis or decompensated cirrhosis. One-way and probabilistic sensitivity analyses as well as scenario and threshold analyses were conducted to account for uncertainties: including exclusive surveillance of CHB, compensated cirrhosis or decompensated cirrhosis populations; impact of obesity on ultrasound sensitivity; real-world adherence rate; and different cohort's ranges of ages. RESULTS Sixty HCC surveillance scenarios were considered for the baseline population. The ultrasound + AFP strategy was the most cost-effective with incremental cost-effectiveness ratios (ICER) compared to no surveillance falling below the willingness-to-pay threshold of A$50,000 per quality-adjusted life year (QALY) at all age ranges. Ultrasound alone was also cost-effective, but the strategy was dominated by ultrasound + AFP. Surveillance was cost-effective in the compensated and decompensated cirrhosis populations alone (ICERs < $30,000), but not cost-effective in the CHB population (ICERs > $100,000). Obesity could decrease the diagnostic performance of ultrasound, which in turn, reduce the cost-effectiveness of ultrasound ± AFP, but the strategies remained cost-effective. CONCLUSIONS HCC surveillance based on Australian recommendations using biannual ultrasound ± AFP was cost-effective.
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Affiliation(s)
- Anh Le Tuan Nguyen
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
| | - Lei Si
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, Australia
| | - John S Lubel
- Alfred Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | | | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
| | - Mark Wilson
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
| | | | - Kerry Hardy
- Royal Hobart Hospital, Hobart, TAS, Australia
| | - Andrew John Palmer
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
| | - Christopher Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
| | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
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22
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Cao L, Wang Q, Hong J, Han Y, Zhang W, Zhong X, Che Y, Ma Y, Du K, Wu D, Pang T, Wu J, Liang K. MVI-TR: A Transformer-Based Deep Learning Model with Contrast-Enhanced CT for Preoperative Prediction of Microvascular Invasion in Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:cancers15051538. [PMID: 36900327 PMCID: PMC10001339 DOI: 10.3390/cancers15051538] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
In this study, we considered preoperative prediction of microvascular invasion (MVI) status with deep learning (DL) models for patients with early-stage hepatocellular carcinoma (HCC) (tumor size ≤ 5 cm). Two types of DL models based only on venous phase (VP) of contrast-enhanced computed tomography (CECT) were constructed and validated. From our hospital (First Affiliated Hospital of Zhejiang University, Zhejiang, P.R. China), 559 patients, who had histopathological confirmed MVI status, participated in this study. All preoperative CECT were collected, and the patients were randomly divided into training and validation cohorts at a ratio of 4:1. We proposed a novel transformer-based end-to-end DL model, named MVI-TR, which is a supervised learning method. MVI-TR can capture features automatically from radiomics and perform MVI preoperative assessments. In addition, a popular self-supervised learning method, the contrastive learning model, and the widely used residual networks (ResNets family) were constructed for fair comparisons. With an accuracy of 99.1%, a precision of 99.3%, an area under the curve (AUC) of 0.98, a recalling rate of 98.8%, and an F1-score of 99.1% in the training cohort, MVI-TR achieved superior outcomes. Additionally, the validation cohort's MVI status prediction had the best accuracy (97.2%), precision (97.3%), AUC (0.935), recalling rate (93.1%), and F1-score (95.2%). MVI-TR outperformed other models for predicting MVI status, and showed great preoperative predictive value for early-stage HCC patients.
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Affiliation(s)
- Linping Cao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Qing Wang
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jiawei Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Yuzhe Han
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Weichen Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Xun Zhong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Yongqian Che
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Yaqi Ma
- Department of Pathology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Keyi Du
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Dongyan Wu
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
| | - Tianxiao Pang
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou 310003, China
- Correspondence: (J.W.); (K.L.)
| | - Kewei Liang
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310058, China
- Correspondence: (J.W.); (K.L.)
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23
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Seif El Dahan K, Daher D, Singal AG. Hepatocellular carcinoma surveillance in patients with non-alcoholic fatty liver disease. Clin Mol Hepatol 2023; 29:S207-S219. [PMID: 36103899 PMCID: PMC10029960 DOI: 10.3350/cmh.2022.0247] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/05/2022] [Indexed: 11/05/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) may progress to cirrhotic or non-cirrhotic hepatocellular carcinoma (HCC), and is currently recognized as the fastest growing cause of HCC worldwide. Accordingly, professional society guidelines recommend HCC surveillance in patients with cirrhosis from any etiology, and some may consider it beneficial in subgroups with non-cirrhotic NAFLD at higher risk for HCC. Notably, patients with NAFLD-related HCC are more likely to have HCC diagnosed at more advanced stages and have poorer outcomes when compared to other etiologies, and suboptimal effectiveness of HCC surveillance programs is a major culprit. In this review, we summarize the current guidelines for HCC surveillance and discuss its benefits versus potential harms for NAFLD patients. We also address the unique challenges of HCC surveillance in NAFLD, including higher proportion of NAFLD-related HCC without cirrhosis, poor recognition of at-risk patients, lack of consensus regarding the value of surveillance in non-cirrhotic NAFLD, subpar effectiveness of surveillance tools related to NAFLD phenotype, and preponderant surveillance underuse among NAFLD patients. Finally, we examine the effectiveness of currently used surveillance tools (i.e., ultrasound and alpha fetoprotein) and outline future perspectives including emerging risk stratification tools, imaging surveillance strategies (e.g., abbreviated magnetic resonance imaging protocols), blood-based biomarkers (e.g., GALAD and circulating tumor DNA panels), and interventions to improve surveillance adherence.
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Affiliation(s)
- Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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24
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Adding MRI as a Surveillance Test for Hepatocellular Carcinoma in Patients with Liver Cirrhosis Can Improve Prognosis. Biomedicines 2023; 11:biomedicines11020382. [PMID: 36830919 PMCID: PMC9953123 DOI: 10.3390/biomedicines11020382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/01/2023] Open
Abstract
Gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) can detect early stages of hepatocellular carcinoma (HCC). However, the survival benefit of Gd-EOB-DTPA-enhanced MRI in the surveillance of patients with cirrhosis has not yet been determined. We explored whether the intermittent replacement of ultrasonography (USG) with Gd-EOB-DTPA-enhanced MRI during HCC surveillance improved the clinical outcomes of patients with cirrhosis. We performed a retrospective cohort study of 421 HCC patients who were newly diagnosed during surveillance. Of these patients, 126 (29.9%) underwent surveillance based on Gd-EOB-DTPA-enhanced MRI and USG (USG+MRI group). The patients (295, 70.1%) who did not undergo MRI during surveillance were referred to as the USG group. In the USG+MRI group, 120 (95.2%) of 126 patients were diagnosed with early-stage HCC, whereas 247 (83.7%) of 295 patients were diagnosed with early-stage HCC in the USG group (P = 0.009). The significantly longer overall survival and time to progression in patients in the USG+MRI group compared to the unmatched cohort USG group was consistently observed by inverse probability weighting and propensity score-matched analysis. Gd-EOB-DTPA-enhanced MRI combined surveillance improved the detection of early-stage HCC and clinical outcomes such as overall survival and the time to progression in patients with cirrhosis.
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25
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Park SH, Han K, Jang HY, Park JE, Lee JG, Kim DW, Choi J. Methods for Clinical Evaluation of Artificial Intelligence Algorithms for Medical Diagnosis. Radiology 2023; 306:20-31. [PMID: 36346314 DOI: 10.1148/radiol.220182] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Adequate clinical evaluation of artificial intelligence (AI) algorithms before adoption in practice is critical. Clinical evaluation aims to confirm acceptable AI performance through adequate external testing and confirm the benefits of AI-assisted care compared with conventional care through appropriately designed and conducted studies, for which prospective studies are desirable. This article explains some of the fundamental methodological points that should be considered when designing and appraising the clinical evaluation of AI algorithms for medical diagnosis. The specific topics addressed include the following: (a) the importance of external testing of AI algorithms and strategies for conducting the external testing effectively, (b) the various metrics and graphical methods for evaluating the AI performance as well as essential methodological points to note in using and interpreting them, (c) paired study designs primarily for comparative performance evaluation of conventional and AI-assisted diagnoses, (d) parallel study designs primarily for evaluating the effect of AI intervention with an emphasis on randomized clinical trials, and (e) up-to-date guidelines for reporting clinical studies on AI, with an emphasis on guidelines registered in the EQUATOR Network library. Sound methodological knowledge of these topics will aid the design, execution, reporting, and appraisal of clinical evaluation of AI.
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Affiliation(s)
- Seong Ho Park
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - Kyunghwa Han
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - Hye Young Jang
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - Ji Eun Park
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - June-Goo Lee
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - Dong Wook Kim
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
| | - Jaesoon Choi
- From the Department of Radiology and Research Institute of Radiology (S.H.P., J.E.P., D.W.K.) and Department of Biomedical Engineering (J.C.), Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.); Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.); and Biomedical Engineering Research Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea (J.G.L.)
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26
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Heo S, Lee SS, Kim SY, Lim YS, Park HJ, Yoon JS, Suk HI, Sung YS, Park B, Lee JS. Prediction of Decompensation and Death in Advanced Chronic Liver Disease Using Deep Learning Analysis of Gadoxetic Acid-Enhanced MRI. Korean J Radiol 2022; 23:1269-1280. [PMID: 36447415 PMCID: PMC9747270 DOI: 10.3348/kjr.2022.0494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/12/2022] [Accepted: 10/11/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the usefulness of quantitative indices obtained from deep learning analysis of gadoxetic acid-enhanced hepatobiliary phase (HBP) MRI and their longitudinal changes in predicting decompensation and death in patients with advanced chronic liver disease (ACLD). MATERIALS AND METHODS We included patients who underwent baseline and 1-year follow-up MRI from a prospective cohort that underwent gadoxetic acid-enhanced MRI for hepatocellular carcinoma surveillance between November 2011 and August 2012 at a tertiary medical center. Baseline liver condition was categorized as non-ACLD, compensated ACLD, and decompensated ACLD. The liver-to-spleen signal intensity ratio (LS-SIR) and liver-to-spleen volume ratio (LS-VR) were automatically measured on the HBP images using a deep learning algorithm, and their percentage changes at the 1-year follow-up (ΔLS-SIR and ΔLS-VR) were calculated. The associations of the MRI indices with hepatic decompensation and a composite endpoint of liver-related death or transplantation were evaluated using a competing risk analysis with multivariable Fine and Gray regression models, including baseline parameters alone and both baseline and follow-up parameters. RESULTS Our study included 280 patients (153 male; mean age ± standard deviation, 57 ± 7.95 years) with non-ACLD, compensated ACLD, and decompensated ACLD in 32, 186, and 62 patients, respectively. Patients were followed for 11-117 months (median, 104 months). In patients with compensated ACLD, baseline LS-SIR (sub-distribution hazard ratio [sHR], 0.81; p = 0.034) and LS-VR (sHR, 0.71; p = 0.01) were independently associated with hepatic decompensation. The ΔLS-VR (sHR, 0.54; p = 0.002) was predictive of hepatic decompensation after adjusting for baseline variables. ΔLS-VR was an independent predictor of liver-related death or transplantation in patients with compensated ACLD (sHR, 0.46; p = 0.026) and decompensated ACLD (sHR, 0.61; p = 0.023). CONCLUSION MRI indices automatically derived from the deep learning analysis of gadoxetic acid-enhanced HBP MRI can be used as prognostic markers in patients with ACLD.
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Affiliation(s)
- Subin Heo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jee Seok Yoon
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
| | - Heung-Il Suk
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea.,Department of Artificial Intelligence, Korea University, Seoul, Korea
| | - Yu Sub Sung
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Bumwoo Park
- Health Innovation Big Data Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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27
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Kim BH, Cho Y, Park JW. Surveillance for hepatocellular carcinoma: It is time to move forward. Clin Mol Hepatol 2022; 28:810-813. [PMID: 36064304 PMCID: PMC9597219 DOI: 10.3350/cmh.2022.0257] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 01/05/2023] Open
Affiliation(s)
- Bo Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Joong-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea,Corresponding author : Joong-Won Park Division of Gastroenterology, Department of Internal Medicine, Center for Liver and Pancreatobiliary Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang 10408, Korea Tel: +82-31-920-1605, Fax: +82-31-920-1520, E-mail:
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28
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Park HJ, Kim SY, Singal AG, Lee SJ, Won HJ, Byun JH, Choi SH, Yokoo T, Kim MJ, Lim YS. Abbreviated magnetic resonance imaging vs ultrasound for surveillance of hepatocellular carcinoma in high-risk patients. Liver Int 2022; 42:2080-2092. [PMID: 34817921 DOI: 10.1111/liv.15110] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/30/2021] [Accepted: 11/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We aimed to compare the performance of gadoxetic acid-enhanced abbreviated MRI (AMRI)-based surveillance and ultrasound-only surveillance in high-risk patients for hepatocellular carcinoma (HCC). METHODS Prospectively recruited high-risk patients (>5% annual risk of HCC) who underwent one to three rounds of complete gadoxetic acid-enhanced MRI (CMRI) and ultrasound at 6-months intervals were retrospectively analysed. AMRI consisted of diffusion-weighted, T2-weighted, and hepatobiliary phase imaging. The sensitivity, specificity, and accuracy of CMRI followed by AMRI (CAA), AMRI-only (AAA), and ultrasound-only (US) were compared using generalized estimating equations. Image quality was assessed. RESULTS In 382 patients, HCC was diagnosed in 43 (11.3%), including 42 with early-stage HCCs. The sensitivities of CAA (90.7%, 39/43) and AAA (86.0%, 37/43) were higher than US (27.9% [12/43]; P < 0.001), whereas the sensitivities of the two MRI approaches did not significantly differ (P = 0.56). The specificity of CAA (97.1%, 983/1012) was higher than AAA (95.6% [967/1012]; P = 0.01) and not significantly different from US (96.3% [975/1012]; P = 0.59). The CAA approach had the best accuracy of 96.9% (1022/1055), higher than the AAA approach (95.2% [1004/1055]; P = 0.01) and the US approach (93.6% [987/1055]; P = 0.01). Image quality was inadequate in 33.7% (356/1055) of US examinations but in only 10.0% (105/1055) of the AAA and 11.1% (117/1055) of the CAA approach. CONCLUSIONS In high-risk patients, AMRI-based surveillance approaches had higher sensitivities than ultrasound-only surveillance for early-stage HCC. A sequential MRI approach of CMRI followed by AMRIs showed superior accuracy than the AMRI-only or ultrasound-only approach.
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Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - So Jung Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Hyung Jin Won
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Takeshi Yokoo
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Suk Lim
- Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea.,Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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29
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Esteban JPG, Asgharpour A. Evaluation of liver transplant candidates with non-alcoholic steatohepatitis. Transl Gastroenterol Hepatol 2022; 7:24. [PMID: 35892057 PMCID: PMC9257540 DOI: 10.21037/tgh.2020.03.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/03/2020] [Indexed: 11/07/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.
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Affiliation(s)
- James Philip G Esteban
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amon Asgharpour
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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30
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Cortés P, Ghoz HM, Stancampiano F, Omer M, Malviya B, Bowman AW, Palmer WC. Incidentalomas are associated with an increase in liver transplantation in patients with cirrhosis: a single-center retrospective study. BMC Gastroenterol 2022; 22:336. [PMID: 35818022 PMCID: PMC9275240 DOI: 10.1186/s12876-022-02379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Incidentalomas, defined as incidental findings on imaging, are a growing concern. Our aim was to determine the impact and outcomes of extrahepatic incidentalomas on liver transplantation.
Methods Patients at a large liver transplant center, who had an initial MRI for hepatocellular carcinoma screening between January 2004 and March 2020 were identified. Clinical data were collected retrospectively. Survival analysis, utilizing Kaplan Meier estimates and Cox proportional hazards regression analysis, was utilized to determine factors associated with liver transplantation. Results 720 patients were included. NASH (24.9%), HCV (22.1%) and alcohol (20.6%) were the most common causes of cirrhosis. 79.7% of patients had an extrahepatic incidentaloma. Older age and having received a liver transplant by the end of the study were associated with an incidentaloma. MELD was not associated with the presence of an incidentaloma. On univariate Cox proportional hazards regression, male sex, history of moderate alcohol use, smoking history, MELD, and incidentalomas were predictors of liver transplantation. On multivariate analysis, only MELD and the presence of an incidentaloma were found to be significant. Discovery of an incidentaloma was associated with a 30% increase in the risk of liver transplantation. Median time to transplantation did not differ based on the presence on an incidentaloma. Patients with cirrhosis from alcohol or HCV had a significantly shorter median time to transplantation than those with NASH. Renal and pancreatic lesions comprised 91% of all incidentalomas. Conclusions In this single-center retrospective study, extrahepatic incidentalomas were common in patients with cirrhosis. The finding of an incidentaloma was associated with a higher risk of liver transplantation despite a similar median time to transplantation if no incidentaloma was discovered.
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Affiliation(s)
- Pedro Cortés
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - Hassan M Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Fernando Stancampiano
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - Mohamed Omer
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Balkishan Malviya
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrew W Bowman
- Division of Hospital and Emergency Radiology, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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31
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Tan CH, Chou SC, Inmutto N, Ma K, Sheng R, Shi Y, Zhou Z, Yamada A, Tateishi R. Gadoxetate-Enhanced MRI as a Diagnostic Tool in the Management of Hepatocellular Carcinoma: Report from a 2020 Asia-Pacific Multidisciplinary Expert Meeting. Korean J Radiol 2022; 23:697-719. [PMID: 35555884 PMCID: PMC9240294 DOI: 10.3348/kjr.2021.0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 02/21/2022] [Accepted: 03/17/2022] [Indexed: 12/04/2022] Open
Abstract
Gadoxetate magnetic resonance imaging (MRI) is widely used in clinical practice for liver imaging. For optimal use, we must understand both its advantages and limitations. This article is the outcome of an online advisory board meeting and subsequent discussions by a multidisciplinary group of experts on liver diseases across the Asia-Pacific region, first held on September 28, 2020. Here, we review the technical considerations for the use of gadoxetate, its current role in the management of patients with hepatocellular carcinoma (HCC), and its relevance in consensus guidelines for HCC imaging diagnosis. In the latter part of this review, we examine recent evidence evaluating the impact of gadoxetate on clinical outcomes on a continuum from diagnosis to treatment decision-making and follow-up. In conclusion, we outline the potential future roles of gadoxetate MRI based on an evolving understanding of the clinical utility of this contrast agent in the management of patients at risk of, or with, HCC.
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Affiliation(s)
- Cher Heng Tan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - Shu-Cheng Chou
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei City & Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Nakarin Inmutto
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ke Ma
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - RuoFan Sheng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - YingHong Shi
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhongguo Zhou
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Akira Yamada
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, The University of Tokyo Hospital, Tokyo, Japan
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32
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Lee H, Jang S, Ahn SH, Kim BK. Cost-effectiveness of antiviral therapy in untreated compensated cirrhosis patient with serum HBV-DNA level < 2000 IU/mL. Hepatol Int 2022; 16:294-305. [PMID: 35322374 DOI: 10.1007/s12072-022-10310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to stringent reimbursement criteria, significant numbers of patients with compensated cirrhosis (CC) and low-level viremia [LLV; serum hepatitis B virus (HBV)-DNA levels of 20-2000 IU/mL] remain untreated especially in the East Asian countries, despite potential risk of disease progression. We analyzed cost-effectiveness to assess rationales for antiviral therapy (AVT) for this population. METHODS We compared cost and effectiveness (quality-adjusted life years, QALYs) in a virtual cohort including 10,000 54-year-old CC-LLV patients receiving AVT (Scenario I) versus no treatment (Scenario II). A Markov model, including seven HBV-related conditions, was used. Values for transition probabilities and costs were mostly obtained from recent real-world South Korean data. RESULTS As per a simulation of a base-case analysis, AVT reduced costs by $639 USD and yielded 0.108 QALYs per patient for 5 years among CC-LLV patients compared to no treatment. Thus, AVT is a cost-saving option with lower costs and better effectiveness than no treatment. If 10,000 patients received AVT, 815 incident cases of hepatocellular carcinoma (HCC) and 630 HBV-related deaths could be averted in 5 years compared to no treatment. In case of 10-year observation, AVT was consistently dominant. Even when the transition probabilities from CC-LLV vs. maintained virological response to HCC were same, fluctuation of results also lied within willingness-to-pay in South Korea. In the probabilistic sensitivity analysis with the willingness-to-pay threshold, the probability of AVT cost-effectiveness was 100%. CONCLUSION The extended application of AVT in CC-LLV patients may contribute positively to individual clinical benefits and national healthcare budgets.
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Affiliation(s)
- Hankil Lee
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do, Republic of Korea
| | - Sungin Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
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33
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Park HJ, Lee TY, Kim SY, Kim MJ, Singal AG, Lee SJ, Won HJ, Byun JH, Lim YS. Hypervascular transformation of hepatobiliary phase hypointense nodules without arterial phase hyperenhancement on gadoxetic acid-enhanced MRI: long-term follow-up in a surveillance cohort. Eur Radiol 2022; 32:5064-5074. [PMID: 35229195 DOI: 10.1007/s00330-022-08623-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES With the increasing use of gadoxetic acid-enhanced MRI for HCC surveillance, hepatobiliary phase (HBP) hypointense nodules without arterial phase hyperenhancement (APHE) are frequently encountered. We investigated the rate of these nodules with hypervascular transformation, which suggests hepatocarcinogenesis, by using a prospectively collected longitudinal surveillance cohort data. METHODS This study included 382 prospectively enrolled patients at high risk for developing HCC who underwent 1-3 rounds of bi-annual surveillance gadoxetic acid-enhanced MRI. MRI was analyzed to detect HBP hypointense nodules without APHE. Follow-up dynamic CTs and MRIs were evaluated to detect hypervascular transformation of the nodules. Cox proportional hazards regression analyses were used to find predictors for hypervascular transformation. RESULTS A total of 76 HBP hypointense nodules without APHE were found in 48 patients, giving a prevalence of 12.6% (48/382). The mean nodule size was 10.8 mm, with 43.4% (33/76) being ≥ 10 mm. Over a median follow-up of 78.6 months, 19 nodules (25.0%) showed hypervascular transformation, all of which demonstrated typical imaging features of HCC. On multivariable Cox-regression analysis, size (≥ 10 mm) was the only independent predictor of hypervascular transformation (hazard ratio, 3.31; 95% confidence interval, 1.21-9.05). The cumulative incidence of hypervascular transformation at 12 and 60 months of nodules ≥ 10 mm was 12.3% and 50.4%, respectively, while that of nodules < 10 mm was 2.5% and 13.9%, respectively. CONCLUSIONS About half of the HBP hypointense nodules ≥ 10 mm without APHE transformed to HCC at 5 years of follow-up, indicating the necessity for cautious monitoring with an augmented and extended follow-up schedule for these nodules. KEY POINTS • The prevalence of HBP hypointense nodules without APHE was 12.6% in a prospectively recruited population at high risk of developing HCC. • Nodule size ≥ 10 mm was significantly associated with hypervascular transformation, and approximately half of the HBP hypointense nodules ≥ 10 mm without APHE transformed to HCC during 5 years of follow-up. • Given the risk of malignant transformation, HBP hypointense nodules ≥ 10 mm without APHE should be closely monitored.
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Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Tae Young Lee
- Department of Radiology, Ulsan University Hospital, Ulsan, Republic of Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea. .,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea.
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - So Jung Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Hyung Jin Won
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea
| | - Young-Suk Lim
- Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea.,Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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34
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Nahon P, Najean M, Layese R, Zarca K, Segar LB, Cagnot C, Ganne-Carrié N, N'Kontchou G, Pol S, Chaffaut C, Carrat F, Ronot M, Audureau E, Durand-Zaleski I. Early hepatocellular carcinoma detection using magnetic resonance imaging is cost-effective in high-risk patients with cirrhosis. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100390. [PMID: 34977518 PMCID: PMC8683591 DOI: 10.1016/j.jhepr.2021.100390] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/02/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022]
Abstract
Background & Aims Reinforced hepatocellular carcinoma (HCC) surveillance using magnetic resonance imaging (MRI) could increase early tumour detection but faces cost-effectiveness issues. In this study, we aimed to evaluate the cost-effectiveness of MRI for the detection of very early HCC (Barcelona Clinic Liver Cancer [BCLC] 0) in patients with an annual HCC risk >3%. Methods French patients with compensated cirrhosis included in 4 multicentre prospective cohorts were considered. A scoring system was constructed to identify patients with an annual risk >3%. Using a Markov model, the economic evaluation estimated the costs and life years (LYs) gained with MRI vs. ultrasound (US) monitoring over a 20-year period. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the incremental costs by the incremental LYs. Results Among 2,513 patients with non-viral causes of cirrhosis (n = 840) and/or cured HCV (n = 1,489)/controlled HBV infection (n = 184), 206 cases of HCC were detected after a 37-month follow-up. When applied to training (n = 1,658) and validation (n = 855) sets, the construction of a scoring system identified 33.4% and 37.5% of patients with an annual HCC risk >3% (3-year C-Indexes 75 and 76, respectively). In patients with a 3% annual risk, the incremental LY gained with MRI was 0.4 for an additional cost of €6,134, resulting in an ICER of €15,447 per LY. Compared to US monitoring, MRI detected 5x more BCLC 0 HCC. The deterministic sensitivity analysis confirmed the impact of HCC incidence. At a willingness to pay of €50,000/LY, MRI screening had a 100% probability of being cost-effective. Conclusions In the era of HCV eradication/HBV control, patients with annual HCC risk >3% represent one-third of French patients with cirrhosis. MRI is cost-effective in this population and could favour early HCC detection. Lay summary The early identification of hepatocellular carcinoma in patients with cirrhosis is important to improve patient outcomes. Magnetic resonance imaging could increase early tumour detection but is more expensive and less accessible than ultrasound (the standard modality for surveillance). Herein, using a simple score, we identified a subgroup of patients with cirrhosis (accounting for >one-third), who were at increased risk of hepatocellular carcinoma and for whom the increased expense of magnetic resonance imaging would be justified by the potential improvement in outcomes.
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Key Words
- AFP, alpha-fetoprotein
- AMRI, abbreviated magnetic resonance imaging
- BCLC, Barcelona Clinic Liver Cancer
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- ICER, incremental cost-effectiveness ratio
- LY, life years
- LYG, life years gained
- MRI
- MRI, magnetic resonance imaging
- NAFLD, non-alcoholic fatty liver disease
- QALY, quality-adjusted life year
- RFA, radiofrequency ablation
- SHR, subdistribution hazard ratio
- TACE, transarterial chemoembolization
- US, ultrasound
- cirrhosis
- cost-effectiveness
- liver cancer risk
- surveillance
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Affiliation(s)
- Pierre Nahon
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Unit, Bobigny, France.,Université Sorbonne Paris Nord, F-93000 Bobigny, France.,Inserm, UMR-1138 "Functional Genomics of Solid Tumors", Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Marie Najean
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, F-75004, Paris, France
| | - Richard Layese
- Univ Paris Est Créteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Unité de Recherche Clinique (URC Mondor), Service de Santé Publique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94000, Créteil, France
| | - Kevin Zarca
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, F-75004, Paris, France
| | - Laeticia Blampain Segar
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, F-75004, Paris, France
| | - Carole Cagnot
- Clinical Research Department, ANRS
- Emerging Infectious Diseases, Paris, France
| | - Nathalie Ganne-Carrié
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Unit, Bobigny, France.,Université Sorbonne Paris Nord, F-93000 Bobigny, France.,Inserm, UMR-1138 "Functional Genomics of Solid Tumors", Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Gisèle N'Kontchou
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Unit, Bobigny, France.,Université Sorbonne Paris Nord, F-93000 Bobigny, France.,Inserm, UMR-1138 "Functional Genomics of Solid Tumors", Centre de recherche des Cordeliers, Université de Paris, Paris, France
| | - Stanislas Pol
- Université de Paris, département d'hépatologie/Addictologie, Hôpital Cochin, APHP, Paris, France
| | - Cendrine Chaffaut
- SBIM, APHP, Hôpital Saint-Louis, Paris, France.,Inserm, UMR-1153, ECSTRA Team, Paris, France
| | - Fabrice Carrat
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Unité de Santé Publique, Paris, France
| | - Maxime Ronot
- AP-HP, Hôpital Beaujon, Service de Radiologie, Clichy, France
| | - Etienne Audureau
- Univ Paris Est Créteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Unité de Recherche Clinique (URC Mondor), Service de Santé Publique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94000, Créteil, France
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, F-75004, Paris, France
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35
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Singal AG, El-Serag HB. Rational HCC screening approaches for patients with NAFLD. J Hepatol 2022; 76:195-201. [PMID: 34508791 PMCID: PMC8688224 DOI: 10.1016/j.jhep.2021.08.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of developing hepatocellular carcinoma (HCC), especially among those who have cirrhosis or advanced fibrosis, but 20-30% of cases of NAFLD-related HCC occur in the absence of advanced fibrosis. The prevalence of NAFLD-related HCC is increasing in most countries worldwide. There are few direct data to support or refute the efficacy or effectiveness of HCC surveillance in NAFLD or to guide its application. We use evidence on surveillance in other conditions and studies on the clinical course of patients with NAFLD to arrive at recommendations for rational approaches to HCC surveillance in this growing cohort of patients. We also outline gaps in research and practice, including opportunities to advance the field.
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Affiliation(s)
- Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Hashem B El-Serag
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
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Provider Attitudes Toward Risk-Based Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis in the United States. Clin Gastroenterol Hepatol 2022; 20:183-193. [PMID: 32927050 PMCID: PMC8657369 DOI: 10.1016/j.cgh.2020.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers' opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient's HCC risk on the choice of surveillance modality. METHODS We conducted a web-based survey among gastroenterology and hepatology providers (40% faculty physicians, 21% advanced practice providers, 39% fellow-trainees) from 26 US medical centers in 17 states. RESULTS Of 654 eligible providers, 305 (47%) completed the survey. Nearly all (98.4%) of the providers endorsed semi-annual HCC surveillance in patients with cirrhosis, with 84.2% recommending ultrasound ± alpha fetoprotein (AFP) and 15.4% recommending computed tomography (CT) or magnetic resonance imaging (MRI). Barriers to surveillance included limited HCC treatment options, screening test effectiveness to reduce mortality, access to transportation, and high out-of-pocket costs. Facilitators of surveillance included professional society guidelines. Most providers (72.1%) would perform surveillance even if HCC risk was low (≤0.5% per year), while 98.7% would perform surveillance if HCC risk was ≥1% per year. As a patient's HCC risk increased from 1% to 3% to 5% per year, providers reported they would be less likely to order ultrasound ± AFP (83.6% to 68.9% to 57.4%; P < .001) and more likely to order CT or MRI ± AFP (3.9% to 26.2% to 36.1%; P < .001). CONCLUSIONS Providers recommend HCC surveillance even when HCC risk is much lower than the threshold suggested by professional societies. Many appear receptive to risk-based HCC surveillance strategies that depend on patients' estimated HCC risk, instead of our current "one-size-fits all" strategy.
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Park HJ, Seo N, Kim SY. Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance. Korean J Radiol 2022; 23:598-614. [PMID: 35434979 PMCID: PMC9174497 DOI: 10.3348/kjr.2021.0896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 11/15/2022] Open
Abstract
While ultrasound (US) is considered an important tool for hepatocellular carcinoma (HCC) surveillance, it has limited sensitivity for detecting early-stage HCC. Abbreviated MRI (AMRI) has recently gained popularity owing to better sensitivity in its detection of early-stage HCC than US, while also minimizing the time and cost in comparison to complete contrast-enhanced MRI, as AMRI includes only a few essential sequences tailored for detecting HCC. Currently, three AMRI protocols exist, namely gadoxetic acid-enhanced hepatobiliary-phase AMRI, dynamic contrast-enhanced AMRI, and non-enhanced AMRI. In this study, we discussed the rationale and technical details of AMRI techniques for achieving optimal surveillance performance. The strengths, weaknesses, and current issues of each AMRI protocol were also elucidated. Moreover, we scrutinized previously performed AMRI studies regarding clinical and technical factors. Reporting and recall strategies were discussed while considering the differences in AMRI protocols. A risk-stratified approach for the target population should be taken to maximize the benefits of AMRI and the cost-effectiveness should be considered. In the era of multiple HCC surveillance tools, patients need to be fully informed about their choices for better adherence to a surveillance program.
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Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Nieun Seo
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kim SY, Lim YS. Towards a New Horizon for Individualized Surveillance Tools in Hepatocellular Carcinoma. Clin Gastroenterol Hepatol 2022; 20:25-27. [PMID: 33940226 DOI: 10.1016/j.cgh.2021.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 02/07/2023]
Affiliation(s)
- So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, The Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, The Republic of Korea
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Isfordink CJ, Maan R, de Man RA, van Erpecum KJ, van der Meer AJ. Should we continue surveillance for hepatocellular carcinoma and gastroesophageal varices in patients with cirrhosis and cured HCV infection? Eur J Intern Med 2021; 94:6-14. [PMID: 34563447 DOI: 10.1016/j.ejim.2021.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/27/2021] [Indexed: 12/13/2022]
Abstract
Hepatocellular carcinoma (HCC) and variceal bleeding are among the most common causes of liver-related mortality in patients with hepatitis C virus (HCV)-induced cirrhosis. Current guidelines recommend HCC and gastroesophageal varices (GEV) surveillance in patients with HCV infection and cirrhosis. However, since the recent introduction of direct-acting antivirals, most patients with cirrhosis are now cured of their chronic HCV infection. As virological cure is considered to substantially reduce the risk of cirrhosis-related complications, this review discusses the current literature concerning the surveillance of HCC and GEV in patients with HCV-induced cirrhosis with a focus on the setting following sustained virological response.
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Affiliation(s)
- Cas J Isfordink
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands; Division of Infectious Diseases, Amsterdam Infection & Immunity Institute Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.
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40
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An J. [Current Status and Future Directions of Hepatocellular Carcinoma Surveillance Test Based on Cost-effective Analysis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 78:255-260. [PMID: 34824183 DOI: 10.4166/kjg.2021.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 12/25/2022]
Abstract
Detection of hepatocellular carcinoma (HCC) at an early stage enables patients to receive curative treatment with survival gains. Current international liver society guidelines recommend the enrollment of patients at high risk for HCC in surveillance programs. In Korea, surveillance for HCC advocated for patients with chronic hepatitis B, chronic hepatitis C, and liver cirrhosis. The established surveillance tool for HCC is liver ultrasonography plus serum alpha-fetoprotein measurement every 6 months. However, there would be obstacles to the improvement of efficacy and cost-effectiveness of the HCC surveillance test. Assessing who is at risk of developing HCC remains incompletely validated. Also, which surveillance tools to use according to patients' characteristics are controversial. The present paper reviews the latest knowledge regarding the strategies and cost-effectiveness of HCC surveillance.
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Affiliation(s)
- Jihyun An
- Department of Gastroenterology and Hepatology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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41
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Kim HL, Kim GA, Park JA, Kang HR, Lee EK, Lim YS. Cost-effectiveness of antiviral treatment in adult patients with immune-tolerant phase chronic hepatitis B. Gut 2021; 70:2172-2182. [PMID: 33239344 DOI: 10.1136/gutjnl-2020-321309] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/15/2020] [Accepted: 11/07/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The cost-effectiveness of antiviral treatment in adult immune-tolerant (IT) phase chronic hepatitis B (CHB) patients is uncertain. DESIGN We designed a Markov model to compare expected costs and quality-adjusted life-years (QALYs) of starting antiviral treatment at IT-phase ('treat-IT') vs delaying the therapy until active hepatitis phase ('untreat-IT') in CHB patients over a 20-year horizon. A cohort of 10 000 non-cirrhotic 35-year-old patients in IT-phase CHB (hepatitis B e antigen-positive, mean serum hepatitis B virus (HBV) DNA levels 7.6 log10 IU/mL, and normal alanine aminotransferase levels) was simulated. Input parameters were obtained from previous studies at Asan Medical Center, Korea. The incremental cost-effectiveness ratio (ICER) between the treat-IT and untreat-IT strategies was calculated. RESULTS From a healthcare system perspective, the treat-IT strategy with entecavir or tenofovir had an ICER of US$16 516/QALY, with an annual hepatocellular carcinoma (HCC) incidence of 0.73% in the untreat-IT group. With the annual HCC risk ≥0.54%, the treat-IT strategy was cost-effective at a willingness-to-pay threshold of US$20 000/QALY. From a societal perspective considering productivity loss by premature death, the treat-IT strategy was extremely cost-effective, and was dominant (ICER <0) if the HCC risk was ≥0.43%, suggesting that the treat-IT strategy incurs less costs than the untreat-IT strategy. The most influential parameters on cost-effectiveness of the treat-IT strategy were those related with HCC risk (HBV DNA levels, platelet counts and age) and drug cost. CONCLUSION Starting antiviral therapy in IT phase is cost-effective compared with delaying the treatment until the active hepatitis phase in CHB patients, especially with increasing HCC risk, decreasing drug costs and consideration of productivity loss.
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Affiliation(s)
- Hye-Lin Kim
- College of Pharmacy, Sahmyook University, Seoul, Republic of Korea
| | - Gi-Ae Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Jae-A Park
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Hye-Rim Kang
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Eui-Kyung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Adeniji N, Dhanasekaran R. Current and Emerging Tools for Hepatocellular Carcinoma Surveillance. Hepatol Commun 2021; 5:1972-1986. [PMID: 34533885 PMCID: PMC8631096 DOI: 10.1002/hep4.1823] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/04/2021] [Accepted: 08/30/2021] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer‐related mortality worldwide. Early detection of HCC enables patients to avail curative therapies that can improve patient survival. Current international guidelines advocate for the enrollment of patients at high risk for HCC, like those with cirrhosis, in surveillance programs that perform ultrasound every 6 months. In recent years, many studies have further characterized the utility of established screening strategies and have introduced new promising tools for HCC surveillance. In this review, we provide an overview of the most promising new imaging modalities and biomarkers for the detection of HCC. We discuss the role of imaging tools like ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) in the early detection of HCC, and describe recent innovations which can potentially enhance their applicability, including contrast enhanced ultrasound, low‐dose CT scans, and abbreviated MRI. Next, we outline the data supporting the use of three circulating biomarkers (i.e., alpha‐fetoprotein [AFP], AFP lens culinaris agglutinin‐reactive fraction, and des‐gamma‐carboxy prothrombin) in HCC surveillance, and expand on multiple emerging liquid biopsy biomarkers, including methylated cell‐free DNA (cfDNA), cfDNA mutations, extracellular vesicles, and circulating tumor cells. These promising new imaging modalities and biomarkers have the potential to improve early detection, and thus improve survival, in patients with HCC.
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Affiliation(s)
- Nia Adeniji
- Stanford School of Medicine, Stanford, CA, USA
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43
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Kim DH, Choi SH, Shim JH, Kim SY, Lee SS, Byun JH, Choi JI. Meta-Analysis of the Accuracy of Abbreviated Magnetic Resonance Imaging for Hepatocellular Carcinoma Surveillance: Non-Contrast versus Hepatobiliary Phase-Abbreviated Magnetic Resonance Imaging. Cancers (Basel) 2021; 13:cancers13122975. [PMID: 34198589 PMCID: PMC8231787 DOI: 10.3390/cancers13122975] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Ultrasonography is recommended as a standard surveillance modality, but the performance of surveillance ultrasound for detecting early-stage hepatocellular carcinoma (HCC) is limited. Motivated to provide a more sensitive method, abbreviated magnetic resonance imaging (AMRI) protocols have been introduced for HCC surveillance. We aimed to systematically determine the diagnostic performance of surveillance AMRI for detecting HCC. This meta-analysis of 10 studies comprising 1547 patients found that the pooled sensitivity and specificity of surveillance AMRI for detecting HCC were 86% and 96%, respectively. Hepatobiliary phase contrast-enhanced AMRI showed significantly higher sensitivities for detecting HCC than non-contrast AMRI (87% vs. 82%), but significantly lower specificities (93% vs. 98%). Therefore, surveillance AMRI had overall good diagnostic performance for detecting HCC and might be clinically useful for HCC surveillance. In addition, AMRI protocol should be selected with consideration of the advantages and disadvantages of each protocol. Abstract We aimed to determine the performance of surveillance abbreviated magnetic resonance imaging (AMRI) for detecting hepatocellular carcinoma (HCC), and to compare the performance of surveillance AMRI according to different protocols. Original research studies reporting the performance of surveillance AMRI for the detection of HCC were identified in MEDLINE, EMBASE, and Cochrane databases. The pooled sensitivity and specificity of surveillance AMRI were calculated using a hierarchical model. The pooled sensitivity and specificity of contrast-enhanced hepatobiliary phase (HBP)-AMRI and non-contrast (NC)-AMRI were calculated and compared using bivariate meta-regression. Ten studies, including 1547 patients, reported the accuracy of surveillance AMRI. The pooled sensitivity and specificity of surveillance AMRI for detecting any-stage HCC were 86% (95% confidence interval (CI), 80–90%; I2 = 0%) and 96% (95% CI, 93–98%; I2 = 80.5%), respectively. HBP-AMRI showed a significantly higher sensitivity for detecting HCC than NC-AMRI (87% vs. 82%), but significantly lower specificity (93% vs. 98%) (p = 0.03). Study quality and MRI magnet field strength were factors significantly associated with study heterogeneity (p ≤ 0.01). In conclusion, surveillance AMRI showed good overall diagnostic performance for detecting HCC. HBP-AMRI had significantly higher sensitivity for detecting HCC than NC-AMRI, but lower specificity.
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Affiliation(s)
- Dong Hwan Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (D.H.K.); (J.-I.C.)
| | - Sang Hyun Choi
- Asan Medical Center, Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.Y.K.); (S.S.L.); (J.H.B.)
- Correspondence: ; Tel.: +8-223-010-1797; Fax: +8-22-476-4719
| | - Ju Hyun Shim
- Asan Medical Center, Department of Gastroenterology, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - So Yeon Kim
- Asan Medical Center, Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.Y.K.); (S.S.L.); (J.H.B.)
| | - Seung Soo Lee
- Asan Medical Center, Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.Y.K.); (S.S.L.); (J.H.B.)
| | - Jae Ho Byun
- Asan Medical Center, Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.Y.K.); (S.S.L.); (J.H.B.)
| | - Joon-Il Choi
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (D.H.K.); (J.-I.C.)
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Costentin CE, Nahon P. HCC risk prediction using biomarkers in non-cirrhotic patients following HCV eradication: Reassuring the patient or the doctor? JHEP Rep 2021; 3:100320. [PMID: 34308325 PMCID: PMC8283026 DOI: 10.1016/j.jhepr.2021.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Charlotte E. Costentin
- Université Grenoble Alpes, 38000 Grenoble, France
- Institute for Advanced Biosciences, Research Center UGA/Inserm U 1209/CNRS 5309, 38700 La Tronche, France
- Service d’hépato-gastroentérologie, Pôle Digidune, CHU Grenoble Alpes, 38700 La Tronche, France
- Corresponding authors: Addresses: Centre Hospitalier Universitaire Grenoble Alpes, Avenue Maquis du Grésivaudan, 38700 La Tronche, France; Tel.: +33 4 76 76 75 75.
| | - Pierre Nahon
- Centre de Recherche des Cordeliers, Sorbonne Universités, Université Paris Descartes, Université Paris Diderot, Université Paris, Paris, France
- Functional Genomics of Solid Tumors, USPC, Université Paris Descartes, Université Paris Diderot, Université Paris, Paris, France
- Service d'hépatologie, Hôpital Avicenne, Assistance-Publique Hôpitaux de Paris, 125 Route de Stalingrad 93000 Bobigny, France
- Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Paris 13, Communauté d'Universités et Etablissements Sorbonne Paris Cité, Paris, France
- Service d’hépatologie, Hôpital Avicenne, Assistance-Publique Hôpitaux de Paris, 125 Route de Stalingrad 93000 Bobigny, France; Tel.: +33 148026294.
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Nguyen ALT, Nguyen HTT, Yee KC, Palmer AJ, Blizzard CL, de Graaff B. A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:733-743. [PMID: 33933243 DOI: 10.1016/j.jval.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/24/2020] [Accepted: 11/17/2020] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data. METHODS We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies. RESULTS The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial. CONCLUSIONS Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.
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Affiliation(s)
- Anh Le Tuan Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoa Thi Thu Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
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Ballard DH, Burton KR, Lakomkin N, Kim S, Rajiah P, Patel MJ, Mazaheri P, Whitman GJ. The Role of Imaging in Health Screening: Screening for Specific Conditions. Acad Radiol 2021; 28:548-563. [PMID: 32404272 PMCID: PMC7655640 DOI: 10.1016/j.acra.2020.03.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
There are well-established and emerging screening examinations aimed at identifying malignant and nonmalignant conditions at early, treatable stages. The Radiology Research Alliance's "Role of Imaging in Health Screening" Task Force provides a comprehensive review of specific imaging-based screening examinations. This work reviews and serves as a reference for screening examinations for breast and colon cancer in a healthy population along with screening for lung cancer, hepatocellular carcinoma, and the use of whole body magnetic resonance imaging in at-risk individuals. American College of Radiology scoring systems, along with case-based examples, are included to illustrate the different disease entities. The future of screening is discussed, particularly in the context of artificial intelligence.
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Affiliation(s)
- David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO 63110.
| | - Kirsteen R Burton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario
| | | | - Shannon Kim
- Department of Radiology, Eastern Virginia Medical School Norfolk, Virginia
| | | | | | - Parisa Mazaheri
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO 63110
| | - Gary J Whitman
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center; Houston, Texas
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Chon HY, Lee HA, Suh SJ, Lee JI, Kim BS, Kim IH, Lee CH, Jang BK, Lee HW, Hwang JS, Lee CH, Lee JW, Yu JH, Seo YS, Yim HJ, Kim SU. Addition of liver stiffness enhances the predictive accuracy of the PAGE-B model for hepatitis B-related hepatocellular carcinoma. Aliment Pharmacol Ther 2021; 53:919-927. [PMID: 33465253 DOI: 10.1111/apt.16267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/12/2020] [Accepted: 01/04/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The modified PAGE-B (mPAGE-B) and PAGE-B models reliably predict the risk of developing chronic hepatitis B (CHB)-related hepatocellular carcinoma (HCC). AIM(S) To investigate whether the addition of liver stiffness (LS) value, assessed using transient elastography, enhanced the predictive accuracies of these models METHODS: Patients with CHB who started anti-viral therapy (AVT) between 2007 and 2017 were enrolled. The training (Yonsei University Hospital) and validation (seven Korean referral institutes) cohorts contained 1211 and 973 patients, respectively. RESULTS Based on multivariate analysis, older age (hazard ratio [HR] = 1.051, 95% confidence interval [CI] = 1.031-1.071), male sex (HR = 2.265, 95% CI = 1.463-3.506), lower platelet count (HR = 0.993, 95% CI = 0.989-0.997) and greater LS values (HR = 1.015, 95% CI = 1.002-1.028) were independently associated with an increased risk of HCC development (all P < 0.05). Thus, we developed a modified PAGELS -B model (maximum score 34) that included age, male sex, platelet count and LS value. The integrated area under the curve of the modified PAGELS model was greater than those of the PAGE-B and mPAGE-B models (0.760 vs 0.714 and 0.716, respectively) in the derivation dataset. The cumulative HCC incidence was significantly higher in the high-risk (modified PAGE-BLS score ≥ 24) group than in the intermediate-risk (modified PAGELS -B score 12-24) or low-risk (modified PAGELS -B score < 12) group (all P < 0.001). Similar results were observed in the validation cohort. CONCLUSIONS The predictive accuracies of the PAGE-B and mPAGE-B models were validated in Korean patients with CHB receiving AVT. However, the modified PAGELS -B model featuring the addition of LS value showed higher predictability than the PAGE-B and mPAGE-B models.
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Affiliation(s)
- Hye Yeon Chon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Han Ah Lee
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Jun Suh
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Il Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Seok Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Woong Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Seok Hwang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chang Hun Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jin-Woo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jung Hwan Yu
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Yeon Seok Seo
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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48
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Lee H, Kim BK, Jang S, Ahn SH. Cost-Effectiveness Analysis of Antiviral Therapy for Untreated Minimally Active Chronic Hepatitis B to Prevent Liver Disease Progression. Clin Transl Gastroenterol 2021; 12:e00299. [PMID: 33600103 PMCID: PMC7889372 DOI: 10.14309/ctg.0000000000000299] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/07/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Antiviral therapy (AVT) for chronic hepatitis B (CHB) can prevent liver disease progression. Because of its stringent reimbursement criteria, significant numbers of patients with untreated minimally active (UMA)-CHB exist, although they are still subject to disease progression. We thus performed a cost-effectiveness analysis to assess the rationale for AVT for UMA-CHB. METHODS We compared cost and effectiveness (quality-adjusted life years, QALYs) in virtual UMA-CHB cohorts of 10,000 50-year-olds receiving AVT (scenario 1) vs no treatment (scenario 2) for 10 years. A Markov model, including 7 health states of CHB-related disease progression, was used. Values for transition probabilities and costs were mostly obtained from recent South Korean data. RESULTS The simulation of AVT vs no treatment predicted $2,201 incremental costs and 0.175 incremental QALYs per patient for 10 years, with an incremental cost-effectiveness ratio (ICER) of $12,607/QALY, suggesting cost-effectiveness of AVT. In sum, if 10,000 patients received AVT, 720 incident hepatocellular carcinoma and 465 CHB-related more deaths could be averted in 10 years relative to no treatment. When the simulated analysis period was extended to 20 years, AVT was also highly cost-effective with an ICER of $2,036/QALY. Although hepatocellular carcinoma-related mortality was a major factor influencing ICER, its fluctuation can be accepted within willingness to pay of $33,000 in South Korea. According to probabilistic sensitivity analysis with the threshold of willingness to pay, the probability of AVT cost-effectiveness was 83.3%. DISCUSSION Long-term AVT for patients with UMA-CHB may contribute positively toward individual clinical benefit and national health care budget.
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Affiliation(s)
- Hankil Lee
- Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Sungin Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
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Stratification of Hepatocellular Carcinoma Risk Following HCV Eradication or HBV Control. J Clin Med 2021; 10:jcm10020353. [PMID: 33477752 PMCID: PMC7832303 DOI: 10.3390/jcm10020353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 12/18/2022] Open
Abstract
Hepatocellular carcinoma (HCC) incidence has dramatically decreased in patients infected with HCV and HBV due to the widespread use of highly effective antiviral agents. Nevertheless, a substantial proportion of patients with advanced fibrosis or cirrhosis following HCV clearance of in case of HBV control whatever the stage of fibrosis remains at risk of liver cancer development. Cancer predictors in these virus-free patients include routine parameters estimating coexisting comorbidities, persisting liver inflammation or function impairment, and results of non-invasive tests which can be easily combined into HCC risk scoring systems. The latter enables stratification according to various liver cancer incidences and allocation of patients into low, intermediate or high HCC risk probability groups. All international guidelines endorse lifelong surveillance of these patients using semi-annual ultrasound, with known sensibility issues. Refining HCC prediction in this growing population ultimately will trigger personalized management using more effective surveillance tools such as contrast-enhanced imaging techniques or circulating biomarkers while taking into account cost-effectiveness parameters.
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50
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Chang Y, Lee J. Optimal Modalities for HCC Surveillance in a High-Incidence Region. Clin Liver Dis (Hoboken) 2021; 16:236-239. [PMID: 33489094 PMCID: PMC7805297 DOI: 10.1002/cld.923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/08/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Young Chang
- Institute for Digestive ResearchDigestive Disease CenterDepartment of Internal MedicineSoonchunhyang University College of MedicineSeoulKorea
| | - Jeong‐Hoon Lee
- Department of Internal Medicine and Liver Research InstituteSeoul National University College of MedicineSeoulKorea
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