Correlations between the time-intensity parameters of contrast-enhanced ultrasound and clinical prognosis of hepatocellular carcinoma

Ultrasound Patterns of Hepatocellular Carcinoma and Their Prognostic Impact: A Retrospective Study

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death. Abdominal ultrasound (US) is by far the most widely used first-level exam for the diagnosis of HCC. We aimed to assess whether different ultrasound patterns were related to tumor prognosis.

METHODS

We retrospectively reviewed all patients with a new diagnosis of HCC (single nodule) and undergoing radiofrequency thermal ablation (RFTA) at our clinic between January 2009 and December 2021. Patients were classified according to four HCC ultrasound patterns: 1A, single capsulated nodule; 1B, well capsulated intra-node nodule; 1C, cluster consisting of capsulated nodules; and 2, non-capsulated nodule.

RESULTS

149 patients were analysed; median follow-up time was 43 months. US patterns 1A (32.9%) and 1B (61.1%) were the most commonly seen. Median overall survival (OS) and recurrence-free survival (RFS) from RFTA were 54 months (95% CI, 42-66) and 22 months (95% CI, 12-32), respectively. Pattern 1A showed the best OS. Compared to pattern 1A, 1B was independently associated with worse OS (51 months (95% CI, 34-68) vs. 46 months (95% CI, 18-62)) and RFS (34 months (95% CI, 27-41) vs. 18 months (95% CI, 12-24)). Patterns 1C and 2 were associated with worse RFS compared to 1A, while no difference was seen for OS. Among baseline clinical variables, pattern 1B exhibited higher histological grade (p = 0.048) and tumor dimension (p = 0.034) compared to pattern 1A.

CONCLUSIONS

Our findings demonstrate that different US patterns correlate with different survival outcomes and tumor behavior in patients with HCC. Prospective studies are needed to confirm these results.

Contrast-enhanced ultrasound liver imaging reporting and data system v2017: patient outcomes after treatment for early-stage hepatocellular carcinoma nodules with category 3-5 and category M

OBJECTIVE

To evaluate correlation between contrast-enhanced ultrasonography Liver Imaging Reporting and Data System (CEUS LI-RADS; v. 2017) categories (LR 3-5 vs LR-M) and outcomes in patients with early-stage hepatocellular carcinoma (HCC) after initial therapy.

METHODS

In this retrospective study, 272 patients with high risks for HCC and solitary clinically or pathologically confirmed HCC were identified between January 2010 and December 2015. Patients were initially treated by resection and radiofrequency ablation (RFA) according to the Barcelona Clinic Liver Cancer staging system and were followed up until December 31, 2018. Recurrence-free survival (RFS) and overall survival (OS) were compared between nodules assigned as LR 3-5 or LR M according to CEUS LI-RADS v. 2017 by using the Kaplan-Meier curve, log-rank test, and Cox proportional hazard model.

RESULTS

Early washout is the key determinating whether a nodule is classed as LR-M. Treatment procedures and LI-RADS category showed an independent correlation with OS and RFS (p < 0.05). LR 3-5 category were more correlated with better OS (88.6 months and 74.2 months, respectively; p = 0.017) compared with LR-M. Surgical resection demonstrated longer OS and RFS than RFA in LR-M patients and longer OS in LR 3-5 patients (p < 0.05). Besides, there was no significantly difference in OS and RFS between two categories in resection (p > 0.05), while for patients treated with RFA, LR 3-5 patients showed significant longer OS and RFS than LR-M patients (p < 0.05).

CONCLUSION

Patients with HCC assigned as LR-M showed worse RFS and OS and surgical resection tended to be a more effective treatment for these patients.

ADVANCES IN KNOWLEDGE

Putting forward a theory that CEUS LI-RADS categories could independently predict the outcome for patients with solitary HCC at early-stage after initial treatment.

Prognostic value of enhancement rate by enhanced ultrasound in hepatitis B virus-positive hepatocellular carcinoma undergoing radiofrequency ablation

AIM

To assess the prognostic significance of enhancement rate (ER) measured by contrast-enhanced ultrasonography (CEUS) in patients with hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA).

MATERIALS AND METHODS

A total of 253 patients with single primary HCC undergoing preoperative CEUS and RFA were enrolled in this study. The ER were evaluated though pretreatment CEUS. After a mean follow-up of 36.8 ± 10.2 months, the correlation of ER measured by CEUS and survival after RFA was analyzed by univariate and multivariate analysis. The optimal cutoff ER value to predict survival was determined using receiver-operating characteristic analysis.

RESULTS

Mean follow-up period for all 253 patients was 36.8 ± 10.2 months, 31.2% of patients had died at endpoint. The optimal cutoff ER value predicting survival was 2.2 dB/s. Univariate analysis demonstrated that patients with a high ER level had poorer OS (62.8 months vs 48.8 months, P = 0.02) and recurrence-free survival (RFS = 60.2 months vs 47.4 months, P = 0.03) than patients with a low ER level. ER measured by CEUS also been confirmed as independent risk factor for overall survival (hazard ratio [HR], 1.87; 95% confidence interval [95% CI], 1.21-7.25; P < 0.01) and RFS (HR, 1.67; 95% CI, 1.08-6.21; P < 0.01) in multivariate analysis enrolling gender, BMI, tumor size, antiviral therapy, HBV DNA, histological differentiation, Child-Pugh score and tumor node metastasis (TNM) stage.

CONCLUSIONS

ER measured by CEUS was a significant predictive factor for survival after RFA for HCC.

Evaluation of Hepatocellular Carcinoma Transarterial Chemoembolization using Quantitative Analysis of 2D and 3D Real-time Contrast Enhanced Ultrasound

Quantitative 2D and 3D contrast-enhanced ultrasound (CEUS) was assessed to evaluate early transarterial chemoembolization (TACE) treatment response. Seventeen patients scheduled for TACE for the treatment of hepatocellular carcinoma participated in the study. 2D and 3D CEUS were performed for each patient at three time points: prior to TACE, 1-2 weeks post TACE, and 1 month post TACE. Peak-intensities of the tumor and surrounding liver tissue were calculated from 2D and 3D data before and after TACE and used to evaluate tumor treatment response. Residual tumor percentages were calculated from 2D and 3D CEUS acquired 1-2 weeks and 1 month post TACE and compared with results from MRI 1 month post TACE. Nine subjects had complete response while 8 had incomplete response. Peak-intensities of the tumor from 3D CEUS prior to TACE were similar between the complete and incomplete treatment groups (p=0.70), while 1-2 weeks (p<0.01) and 1 month post treatment (p<0.01) were significantly lower in the complete treatment group than in the incomplete treatment group. For 2D CEUS, only the peak-intensity values of the tumor from1 month post TACE were significantly different (p<0.01). The correlation coefficients between 2D and 3D residual tumor estimates 1-2 weeks post TACE and the estimates from MRI were 0.73 and 0.94, respectively, while those from 2D and 3D CEUS 1 month post TACE were 0.66 and 0.91, respectively. Quantitative analysis on 2D and 3D CEUS shows potential to differentiate patients with complete vs. incomplete response to TACE as early as 1-2 weeks post treatment.

Utility of quantitative contrast-enhanced ultrasound for the prediction of extracapsular extension in papillary thyroid carcinoma

The aim of this study was to find an accurate method for the detection of extracapsular extension (ECE) in papillary thyroid carcinoma (PTC). A total of 102 patients with 109 PTC nodules were retrospectively enrolled. Contrast-enhanced ultrasound (CEUS) characteristics were evaluated. The diagnostic efficacy of quantitative CEUS and tumor size was analyzed. The qualitative CEUS features did not differ significantly between the ECE and non-ECE groups (P > 0.05). All of the quantitative CEUS parameters with the exception of peak intensity and tumor size were found to differ significantly between the ECE and non-ECE groups (P < 0.05). Multivariate stepwise logistic regression analysis demonstrated that time from peak to one half (TPH), tumor size and wash-in slope (WIS) were the significantly different parameters between the ECE and non-ECE groups (P = 0.000, P = 0.005 and P = 0.030, respectively).The sensitivity and specificity in the diagnosis of ECE were: TPH, 75.4% (43/57) and 78.9% (41/52), respectively; WIS, 87.7% (50/57) and 42.3% (22/52), respectively; and tumor size, 71.9% (41/57) and 65.4% (34/52), respectively. Quantitative CEUS analysis and tumor size are essential for the prediction of ECE in PTC; in particular TPH has good diagnostic value in detecting ECE. Our study provides important insights into the prediction of ECE in PTC.

Correlations of microvascular blood flow of contrast-enhanced ultrasound and HGF/c-Met signaling pathway with clinicopathological features and prognosis of patients with hepatocellular carcinoma

The study is designed to explore the correlations of microvascular blood flow of contrast-enhanced ultrasound (CEUS) and hepatocyte growth factor (HGF)/c-Met signaling pathway with clinicopathological features and prognosis of patients with hepatocellular carcinoma (HCC). One hundred and eighteen patients pathologically diagnosed as primary HCC were selected. All HCC patients underwent CEUS examination before operation. HCC tissues and adjacent normal tissue specimens were obtained to detect the protein rates of HGF and c-Met expressions by immunohistochemistry. The mRNA expressions of HGF and c-Met were detected by quantitative real-time polymerase chase reaction assay. The microvessel density (MVD) was tested by CD34 immunohistochemistry. Compared with liver parenchyma, the HCC lesions had higher MVD, preoperative peak intensity (PI), area under the curve (AUC), lower preoperative time to peak (TTP), and washout time (WOT). Compared with adjacent normal tissues, the protein and mRNA expressions of HGF were reduced in HCC tissues, but the protein and mRNA expressions of c-Met and MVD were increased. The protein expressions of HGF and c-Met exhibited evident correlations with TNM stage, tumor size, vascular invasion, liver cirrhosis, and hepatitis B virus and hepatitis C virus infection of HCC patients. The tumor size and number, vascular invasion, the protein expressions of HGF and c-Met, and MVD were associated with the TTP, PI, WOT, and AUC of CEUS in HCC patients. The protein expressions of HGF and c-Met, MVD and preoperative PI revealed negative associations with the prognosis of HCC patients. In conclusion, quantitative parameters of CEUS and HGF/c-Met signaling pathway-related proteins may be helpful for early diagnosis and prognosis prediction of HCC patients.

Mathematical Models of Contrast Transport Kinetics for Cancer Diagnostic Imaging: A Review

Angiogenesis plays a fundamental role in cancer growth and the formation of metastasis. Novel cancer therapies aimed at inhibiting angiogenic processes and/or disrupting angiogenic tumor vasculature are currently being developed and clinically tested. The need for earlier and improved cancer diagnosis, and for early evaluation and monitoring of therapeutic response to angiogenic treatment, have led to the development of several imaging methods for in vivo noninvasive assessment of angiogenesis. The combination of dynamic contrast-enhanced imaging with mathematical modeling of the contrast agent kinetics enables quantitative assessment of the structural and functional changes in the microvasculature that are associated with tumor angiogenesis. In this paper, we review quantitative imaging of angiogenesis with dynamic contrast-enhanced magnetic resonance imaging, computed tomography, and ultrasound.

Usefulness of contrast enhanced ultrasound in monitoring therapeutic response after hepatocellular carcinoma treatment

In the last years, the development in the oncology field has been huge and rapid. In particular, the evaluation of response to anti-tumour treatments has been being object of intense research, producing significant changes. Response assessment after therapy in solid neoplasias has always used radiological imaging techniques, with tumour size reduction representing a presumed therapeutic efficacy. However, with the introduction of anti-angiogenetic drugs the evaluation of tumour size has become unsuitable because some tumours, under treatment, show only tumour perfusion changes rather than lesion shrinkage. Between different imaging techniques with contrast-enhancement, contrast-enhanced ultrasound (CEUS) and, in particular, dynamic CEUS have arisen as a promising and non-invasive device for monitoring cancer treatments. Moreover, the introduction of perfusion software has even more refined the technique since it is able to provide quantitative parameters related to blood flow and blood volume that can be associated with tumour response and clinical outcome such as the progression free survival and the overall survival. Here, we give an overview of the current status of CEUS in monitoring hepatocellular carcinoma response to different kind of treatments.

Contrast-enhanced ultrasonography: advance and current status in abdominal imaging

In the field of contrast-enhanced ultrasonography (US), contrast agents are classified as either first- or second-generation agents depending on the gas within the microbubbles. In the case of first-generation contrast agents, a high-mechanical-index technique is used and only intermittent scanning is possible due to the early destruction of the microbubbles during the scanning. The use of second-generation contrast agents in a low-mechanical-index technique enables continuous scanning. Besides the detection and characterization of focal liver lesions, contrastenhanced US is helpful in the monitoring of radiofrequency ablation therapy and in the targeting step of an US-guided biopsy. Recently, there has been a demand for new criteria to evaluate the treatment response obtained using anti-angiogenic agents because morphologic criteria alone may not reflect the treatment response of the tumor and contrast-enhanced US can provide quantitative markers of tissue perfusion. In spite of the concerns related to its cost-effectiveness, contrast-enhanced US has the potential to be more widely used as a complimentary tool or to substitute the current imaging modalities in some occasions.

Value of wash-in and wash-out time in the diagnosis between hepatocellular carcinoma and other hepatic nodules with similar vascular pattern on contrast-enhanced ultrasound

BACKGROUND AND AIM

The study aims to demonstrate whether the wash-in and wash-out time can be reliable as a criterion in the differential diagnosis between hepatocellular carcinoma (HCC) and other hepatic nodules with vascular pattern similar to HCC on contrast-enhanced ultrasound (CEUS).

METHODS

From February 2012 to February 2013, 214 patients with hepatic nodules displayed rapid hyperenhancement and quick wash-out on CEUS were included in this study. Before performing CEUS, all nodules were examined by grayscale ultrasonography and color Doppler techniques. CEUS was performed with SonoVue and low mechanical index technique. The initial time to enhancement, time to peak, time of the nodule being hypoenhanced were comparatively studied between HCCs and other hepatic nodules.

RESULTS

Of all the 214 nodules, 209 were malignant (164 HCCs, 31 metastases, 10 intrahepatic cholangiocarcinomas (ICCs), 3 combined hepatocellular-cholangiocarcinomas, 1 epithelioid hemangioendothelioma), and five were benign (two inflammatory pseudotumors, one focal nodular hyperplasia nodule, one hemangioma, and one hyperplastic nodule). Metastases and ICCs showed more rapid wash-out than HCCs (P < 0.05): 16 of 31 metastases and 7 of all ICCs showed wash-out by 40 s after injection.

CONCLUSIONS

Some focal liver lesions can show enhancement pattern similar to HCCs on CEUS. The wash-out time may be useful in the differential diagnosis.