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Mendiratta-Lala M, Fetzer D, Kamaya A, Parikh ND, Singal AG. The Future Role of Abdominal US in Hepatocellular Carcinoma Surveillance. Radiology 2024; 311:e232624. [PMID: 38742973 PMCID: PMC11140528 DOI: 10.1148/radiol.232624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/16/2023] [Accepted: 12/26/2023] [Indexed: 05/16/2024]
Abstract
Abdominal US is currently the best-validated surveillance strategy for hepatocellular carcinoma (HCC) in at-risk patients. It is the only modality shown to have completed all five phases of validation and can achieve high sensitivity and specificity for HCC detection, especially when conducted by expert sonographers in high-volume centers. However, US also has limitations, including operator dependency and varying sensitivity in clinical practice. Further, the sensitivity of US for early-stage HCC detection is lower in patients with obesity or nonviral liver disease, increasingly common populations undergoing surveillance. Imaging-based and blood-based surveillance strategies, including abbreviated MRI and biomarker panels, may overcome some limitations of US-based surveillance. Both strategies have promising test performance in phase II and phase III biomarker studies and are undergoing prospective validation. Considering the variation in HCC risk and test performance between patients, there will likely be a shift away from a one-size-fits-all approach and toward precision screening, in which the "best" test is selected based on individual patient characteristics. In this upcoming era of precision HCC screening among patients with cirrhosis, US will likely continue to have an important, albeit reduced, surveillance role.
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Affiliation(s)
| | | | - Aya Kamaya
- From the Departments of Radiology (M.M.L.) and Internal Medicine
(N.D.P.), University of Michigan, Ann Arbor, Mich; Department of Radiology
(D.F.) and Department of Internal Medicine, Division of Digestive and Liver
Diseases (A.G.S.), University of Texas Southwestern Medical Center, 5959 Harry
Hines Blvd, Ste 420, POB 1, Dallas, TX 75390-8887; and Department of Radiology,
Stanford University School of Medicine, Stanford, Calif (A.K.)
| | - Neehar D. Parikh
- From the Departments of Radiology (M.M.L.) and Internal Medicine
(N.D.P.), University of Michigan, Ann Arbor, Mich; Department of Radiology
(D.F.) and Department of Internal Medicine, Division of Digestive and Liver
Diseases (A.G.S.), University of Texas Southwestern Medical Center, 5959 Harry
Hines Blvd, Ste 420, POB 1, Dallas, TX 75390-8887; and Department of Radiology,
Stanford University School of Medicine, Stanford, Calif (A.K.)
| | - Amit G. Singal
- From the Departments of Radiology (M.M.L.) and Internal Medicine
(N.D.P.), University of Michigan, Ann Arbor, Mich; Department of Radiology
(D.F.) and Department of Internal Medicine, Division of Digestive and Liver
Diseases (A.G.S.), University of Texas Southwestern Medical Center, 5959 Harry
Hines Blvd, Ste 420, POB 1, Dallas, TX 75390-8887; and Department of Radiology,
Stanford University School of Medicine, Stanford, Calif (A.K.)
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Kim YY, Cho SB, Lee JS, Lee HW, Choi JY, Kim SU. Utility of fusion imaging for the evaluation of ultrasound quality in hepatocellular carcinoma surveillance. Ultrasonography 2023; 42:580-588. [PMID: 37722723 PMCID: PMC10555691 DOI: 10.14366/usg.23106] [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: 05/31/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE This study evaluated the quality of surveillance ultrasound (US) for hepatocellular carcinoma (HCC) utilizing fusion imaging. METHODS This research involved a secondary analysis of a prospectively recruited cohort. Under institutional review board approval, participants referred for surveillance US who had undergone liver computed tomography (CT) or magnetic resonance imaging (MRI) within the past year were screened between August 2022 and January 2023. After patient consent was obtained, the US visualization score in the Liver Imaging Reporting and Data System was assessed with fusion imaging at the time of examination. This score was compared to that of conventional US using the extended McNemar test. Multivariable logistic regression analysis was used to identify factors independently associated with a US visualization score of B or C. Factors limiting visualization of focal lesions were recorded during fusion imaging. RESULTS Among the 105 participants (mean age, 59±11 years; 66 men), US visualization scores of B and C were assigned to 57 (54.3%) and 17 (16.2%) participants, respectively, by conventional US and 54 (51.4%) and 32 (30.5%) participants, respectively, by fusion imaging. The score distribution differed significantly between methods (P=0.010). Male sex was independently associated with US visualization scores of B or C (adjusted odds ratio, 3.73 [95% confidence interval, 1.30 to 10.76]; P=0.015). The most common reason (64.5%) for lesion nondetection was a limited sonic window. CONCLUSION Conventional US may underestimate the limitations of the sonic window relative to real-time fusion imaging with pre-acquired CT or MRI in the surveillance of HCC.
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Affiliation(s)
- Yeun-Yoon Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seo-Bum Cho
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Won Lee
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Young Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Kang JH, Kim NH, Kim DH, Choi Y, Choi JI. Ultrasound LI-RADS Visualization Scores on Surveillance Ultrasound for Hepatocellular Carcinoma: A Systematic Review With Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2205-2212. [PMID: 37517886 DOI: 10.1016/j.ultrasmedbio.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/18/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
We performed a systematic review and meta-analysis to determine the proportions of each surveillance ultrasound (US) visualization score for hepatocellular carcinoma based on the US Liver Imaging Reporting and Data System (LI-RADS) and to identify the factors associated with visualization score C. Original publications reporting US LI-RADS visualization scores were identified in MEDLINE and EMBASE from January 1, 2017, to November 25, 2022. The meta-analytic pooled proportion of each visualization score based on US examination was calculated using the DerSimonian‒Laird random-effects model. Subgroup meta-regression analyses were performed to explore study heterogeneity. US LI-RADS visualization scores were reported from a total of 25,698 US examinations across 12 studies. The pooled proportions of visualization scores A, B and C were 56.7% (95% confidence interval [CI]: 38.6-73.2%, I2 = 99.2%), 30.3% (95% CI: 21.5-40.7%, I2 = 98.8%) and 6.9% (95% CI: 3.9-11.7%, I2 = 97.7%), respectively. Significantly higher proportions of visualization score C were found in studies that exclusively enrolled cirrhosis patients and a study in which the disease etiology was non-alcoholic fatty liver disease (NAFLD) (p < 0.05). In addition, the pooled proportion of visualization score C was higher in studies with a mean or median body mass index >25 kg/m2 (10.7%, 95% CI: 4.3-24.3%). In conclusion, a substantial proportion of surveillance US examinations exhibited moderate to severe limitations on visualization. There was a tendency toward higher proportions of US LI-RADS visualization score C in patients with cirrhosis, NAFLD and obesity.
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Affiliation(s)
- Ji Hun Kang
- Department of Radiology, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Dong Hwan Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea.
| | - Yangsean Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joon-Il Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
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Quek J, Tan DJH, Chan KE, Lim WH, Ng CH, Ren YP, Koh TK, Teh R, Xiao J, Fu C, Syn N, Teng M, Muthiah M, Fowler KJ, Sirlin CB, Loomba R, Huang DQ. Quality Assessment of Ultrasound and Magnetic Resonance Imaging for Hepatocellular Carcinoma Surveillance: A Systematic Review and Meta-Analysis. Dig Dis 2023; 41:757-766. [PMID: 37231918 DOI: 10.1159/000531016] [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: 12/15/2022] [Accepted: 04/14/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION To achieve early detection and curative treatment options, surveillance imaging for hepatocellular carcinoma (HCC) must remain of quality and without substantial limitations in liver visualization. However, the prevalence of limited liver visualization during HCC surveillance imaging has not been systematically assessed. Utilizing a systematic review and meta-analytic approach, we aimed to determine the prevalence of limited liver visualization during HCC surveillance imaging. METHODS MEDLINE and Embase electronic databases were searched to identify published data on liver visualization limitations of HCC surveillance imaging. An analysis of proportions was pooled using a generalized linear mixed model with Clopper-Pearson intervals. Risk factors were analysed using a generalized mixed model with a logit link and inverse variance weightage. RESULTS Of 683 records, 10 studies (7,131 patients) met inclusion criteria. Seven studies provided data on liver visualization limitations on ultrasound (US) surveillance exams: prevalence of limited liver visualization was 48.9% (95% CI: 23.5-74.9%) in the overall analysis and 59.2% (95% CI: 24.2-86.9%) in a sensitivity analysis for cirrhotic patients. Meta-regression determined that non-alcoholic fatty liver disease was associated with limited liver visualization on US. Four studies provided data for liver visualization limitations in abbreviated magnetic resonance imaging (aMRI), with inadequate visualization ranging from 5.8% to 19.0%. One study provided data for complete MRI and none for computed tomography. CONCLUSION A substantial proportion of US exams performed for HCC surveillance provide limited liver visualization, especially in cirrhosis, which may hinder detection of small observations. Alternative surveillance strategies including aMRI may be appropriate for patients with limited US visualization.
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Affiliation(s)
- Jingxuan Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yi Ping Ren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Teng Kiat Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Readon Teh
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Clarissa Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Kathryn J Fowler
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Rohit Loomba
- Division of Gastroenterology, NAFLD Research Center, University of California at San Diego, La Jolla, California, USA
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
- Division of Gastroenterology, NAFLD Research Center, University of California at San Diego, La Jolla, California, USA
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Chernyak V, Fowler KJ, Do RKG, Kamaya A, Kono Y, Tang A, Mitchell DG, Weinreb J, Santillan CS, Sirlin CB. LI-RADS: Looking Back, Looking Forward. Radiology 2023; 307:e222801. [PMID: 36853182 PMCID: PMC10068888 DOI: 10.1148/radiol.222801] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/09/2023] [Accepted: 01/23/2023] [Indexed: 03/01/2023]
Abstract
Since its initial release in 2011, the Liver Imaging Reporting and Data System (LI-RADS) has evolved and expanded in scope. It started as a single algorithm for hepatocellular carcinoma (HCC) diagnosis with CT or MRI with extracellular contrast agents and has grown into a multialgorithm network covering all major liver imaging modalities and contexts of use. Furthermore, it has developed its own lexicon, report templates, and supplementary materials. This article highlights the major achievements of LI-RADS in the past 11 years, including adoption in clinical care and research across the globe, and complete unification of HCC diagnostic systems in the United States. Additionally, the authors discuss current gaps in knowledge, which include challenges in surveillance, diagnostic population definition, perceived complexity, limited sensitivity of LR-5 (definite HCC) category, management implications of indeterminate observations, challenges in reporting, and treatment response assessment following radiation-based therapies and systemic treatments. Finally, the authors discuss future directions, which will focus on mitigating the current challenges and incorporating advanced technologies. Tha authors envision that LI-RADS will ultimately transform into a probability-based system for diagnosis and prognostication of liver cancers that will integrate patient characteristics and quantitative imaging features, while accounting for imaging modality and contrast agent.
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Affiliation(s)
- Victoria Chernyak
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Kathryn J. Fowler
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Richard K. G. Do
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Aya Kamaya
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Yuko Kono
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - An Tang
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Donald G. Mitchell
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Jeffrey Weinreb
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Cynthia S. Santillan
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
| | - Claude B. Sirlin
- From the Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY (V.C., R.K.G.D.); Liver Imaging Group, Department of
Radiology, University of California, San Diego, San Diego, Calif (K.J.F.,
C.S.S., C.B.S.); Department of Radiology, Stanford University Medical Center,
Stanford, Calif (A.K.); Department of Medicine and Radiology, University of
California, San Diego, San Diego, Calif (Y.K.); Department of Radiology,
Radiation Oncology and Nuclear Medicine, Université de Montréal,
Montréal, Canada (A.T.); Department of Radiology, Thomas Jefferson
University Hospital, Philadelphia, Pa (D.G.M.); and Department of Radiology,
Yale Medical School, New Haven, Conn (J.W.)
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Nahon P, Ronot M. Repeating Ultrasound for Hepatocellular Carcinoma Detection in Case of Inadequate Liver Visualization: A Matter of Expertise. Clin Gastroenterol Hepatol 2022; 20:1454-1455. [PMID: 34358716 DOI: 10.1016/j.cgh.2021.07.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pierre Nahon
- AP-HP, Hôpital Avicenne, Service d'Hépatologie, Bobigny, France; Université Sorbonne Paris Nord, Paris, France; Inserm, UMR-1138 "Functional Genomics of Solid Tumors,", Université de Paris, Paris, France
| | - Maxime Ronot
- AP-HP.Nord, Hôpital Beaujon, Service de Radiologie, Clichy, France; Université de Paris, Paris, France
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Multicenter Study of ACR Ultrasound LI-RADS Visualization Scores on Serial Examinations: Implications for Changes in Surveillance Strategies. AJR Am J Roentgenol 2022; 219:445-452. [PMID: 35383486 DOI: 10.2214/ajr.22.27405] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: American College of Radiology Ultrasound LI-RADS includes the visualization score as a subjective measure of examination quality and expected level of sensitivity. Whether a single suboptimal visualization score warrants change in surveillance strategy is unknown. Objective: To determine the relative stability of visualization scores on serial surveillance ultrasound examinations in patients at risk for HCC. Methods: This retrospective study included patients at risk for HCC who underwent at least two HCC surveillance ultrasound examinations at one of three institutions between January 2017 and November 2020. Frequencies of score remaining unchanged after variable numbers of preceding examinations with the given score were determined. A mixed-effects logistic model was fitted to identify factors associated with a repeat score C (severe limitations) versus change to score A (no or minimal limitations) or score B (moderate limitations). Results: A total of 3169 patients underwent at least 2 ultrasound examinations, yielding a total of 9602 examinations. A total of 8030 (83.6%) examinations had score A, 1378 (14.4%) score B, and 194 (2.0%) score C. Frequency of score A was 88%, 91%, and 93% after 1, 2 and 3 consecutive prior examinations with score A. Frequency of score B was 45%, 48%, and 55% after 1, 2, and 3 consecutive prior examinations with score B. Frequency of score C was 42%, 67%, and 80% after 1, 2, and 3 consecutive prior examinations with score C. Among 109 examinations with score C in 91 patients with an available follow-up examination, no factor (including age, sex, severe steatosis, advanced cirrhosis, ascites, body mass index, and change in ultrasound machine, sonographer, or radiologist) was significantly associated with repeat score C (all p>.05). Although not statistically significant, presence of severe steatosis and advanced cirrhosis had the highest odds ratios (2.88 and 2.38, respectively) for repeat score C in multivariable analysis. Conclusion: Only 42% of patients with visualization score C on surveillances examination have score C on follow-up examination. Clinical Impact: The findings may inform decisions for alternative surveillance strategies in patients with visualization score C on ultrasound. This decision should consider the number of previous examinations with score C.
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Chong N, Schoenberger H, Yekkaluri S, Fetzer DT, Rich NE, Yokoo T, Gopal P, Manwaring C, Quirk L, Singal AG. Association between ultrasound quality and test performance for HCC surveillance in patients with cirrhosis: a retrospective cohort study. Aliment Pharmacol Ther 2022; 55:683-690. [PMID: 35170052 DOI: 10.1111/apt.16779] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/18/2021] [Accepted: 01/10/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ultrasound visualisation is limited in approximately 20% of patients with cirrhosis undergoing hepatocellular carcinoma (HCC) surveillance; however, it is unknown if impaired visualisation directly impacts test performance. We aimed to evaluate the association between ultrasound visualisation and surveillance test performance. METHODS We performed a retrospective cohort study among patients with cirrhosis, with or without HCC, who underwent ultrasound-based surveillance at two large health systems between July 2016 and July 2019. Ultrasound visualisation assessment was recorded by interpreting radiologists using the ultrasound LI-RADS Visualisation score. We performed logistic regression analyses to evaluate the association between ultrasound visualisation and diagnostic test performance. We assessed sensitivity for HCC detection among ultrasounds performed in the year prior to HCC diagnoses and specificity using ultrasounds in those without HCC. RESULTS Among 186 patients with HCC, severely limited visualisation (Vis Score C) on ultrasound prior to HCC diagnosis was associated with increased odds of false-negative results, that is lower sensitivity (OR 7.94, 95% CI 1.23-51.16) in multivariable analysis. Ultrasound sensitivity with visualisation scores A or B exceeded 75%, compared to only 27.3% with visualisation score C. Among 2052 cirrhosis patients without HCC, moderate visualisation limitations (Vis score B) were associated with increased odds of false-positive results (OR 1.60, 1.13-2.27), although specificity exceeded 95% across all visualisation scores. CONCLUSIONS Impaired ultrasound visualisation is associated with worse surveillance test performance. Alternative blood-based biomarkers and imaging strategies are needed for patients at risk for ultrasound-based surveillance failure.
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Affiliation(s)
- Nicolas Chong
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Parkland Health & Hospital System, Dallas, TX, USA
| | - Haley Schoenberger
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Parkland Health & Hospital System, Dallas, TX, USA
| | - Sruthi Yekkaluri
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - David T Fetzer
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Parkland Health & Hospital System, Dallas, TX, USA
| | - Takeshi Yokoo
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Carrie Manwaring
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lisa Quirk
- 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.,Parkland Health & Hospital System, Dallas, TX, USA
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Associations of Ultrasound LI-RADS Visualization Score With Examination-, Sonographer-, and Radiologist-Factors: Retrospective Assessment in Over 10,000 Examinations. AJR Am J Roentgenol 2021; 218:1010-1020. [PMID: 34910539 DOI: 10.2214/ajr.21.26735] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: When performing ultrasound (US) for hepatocellular carcinoma (HCC) screening, numerous factors may impair hepatic visualization, potentially lowering sensitivity. US LI-RADS includes a visualization score as a technical adequacy measure. Objective: To identify associations between examination-, sonographer-, and radiologist-level factors and the visualization score in liver US HCC screening. Methods: This retrospective study included 6598 patients (3979 men, 2619 women; mean age, 58 years) at risk for HCC who underwent a total of 10,589 liver US examinations performed by 91 sonographers and interpreted by 50 radiologists. Visualization scores (A: no or minimal limitations; B: moderate limitations; C: severe limitations) were extracted from clinical reports. Patient location [emergency department (ED), inpatient, outpatient], sonographer and radiologist liver US volumes during the study period (<50, 50-500, >500 examinations), and radiologist practice pattern (ultrasound, abdominal, community, interventional) were recorded. Associations with visualization scores were explored. Results: Frequencies of visualization scores were 71.5%, 24.2%, and 4.2% for A, B, and C, respectively. Scores varied significantly (p<.001) between examinations performed in ED patients (59.7%, 33.1%, and 7.2%), inpatients (59.7%, 33.1%, and 7.2%), and outpatients (76.9%, 20.3%, and 2.9%). Scores also varied significantly (p<.001) by sonographer volume (<50 examinations: 58.4%, 33.7%, and 7.9%; >500 examinations: 72.9%, 22.5%, and 4.6%); reader volume (<50 examinations: 62.9%, 29.9%, and 7.1%; >500 examinations: 67.3%, 28.0%, and 4.7%); and reader practice pattern (ultrasound: 74.5%, 21.3%, and 4.3%; abdominal: 67.0%, 28.1%, and 4.8%; community: 75.2%, 21.9%, and 2.9%; interventional: 68.5%, 24.1%, and 7.4%). In multivariable analysis, independent predictors of score C were patient location [ED/inpatient: odds ratio (OR)=2.62; p=<.001] and sonographer volume (<50: OR=0.1.55; p=.01). Among sonographers performing >50 examinations, the percentage of outpatient examinations with score C ranged from 0.8% to 5.4%; 9/33 were above the upper 95% CI (3.2%). Conclusion: The US LI-RADS visualization score may identify factors impacting quality of HCC screening examinations and identify outlier sonographers in terms of poor examination quality. The approach also highlights potential systematic biases among radiologists in their quality assessment process. Clinical Impact: These findings may be applied to guide targeted quality improvement efforts and establish best practices and performance standards for screening programs.
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