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Ren J, Lu Q, Fei X, Dong Y, D Onofrio M, Sidhu PS, Dietrich CF. Assessment of arterial-phase hyperenhancement and late-phase washout of hepatocellular carcinoma-a meta-analysis of contrast-enhanced ultrasound (CEUS) with SonoVue® and Sonazoid®. Eur Radiol 2024; 34:3795-3812. [PMID: 37989916 DOI: 10.1007/s00330-023-10371-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVES The recognition of arterial phase hyperenhancement (APHE) and washout during the late phase is key for correct diagnosis of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS). This meta-analysis was conducted to compare SonoVue®-enhanced and Sonazoid®-enhanced ultrasound in the assessment of HCC enhancement and diagnosis. METHODS Studies were included in the analysis if they reported data for HCC enhancement in the arterial phase and late phase for SonoVue® or in the arterial phase and Kupffer phase (KP) for Sonazoid®. Forty-two studies (7502 patients) with use of SonoVue® and 30 studies (2391 patients) with use of Sonazoid® were identified. In a pooled analysis, the comparison between SonoVue® and Sonazoid® CEUS was performed using chi-square test. An inverse variance weighted random-effect model was used to estimate proportion, sensitivity, and specificity along with 95% confidence interval (CI). RESULTS In the meta-analysis, the proportion of HCC showing APHE with SonoVue®, 93% (95% CI 91-95%), was significantly higher than the proportion of HCC showing APHE with Sonazoid®, 77% (71-83%) (p < 0.0001); similarly, the proportion of HCC showing washout at late phase/KP was significantly higher with SonoVue®, 86% (83-89%), than with Sonazoid®, 76% (70-82%) (p < 0.0001). The sensitivity and specificity for the detection of APHE plus late-phase/KP washout detection in HCC were also higher with SonoVue® than with Sonazoid® (sensitivity 80% vs 52%; specificity 80% vs 73% in studies within unselected patient populations). CONCLUSION APHE and late washout in HCC are more frequently observed with SonoVue® than with Sonazoid®. This may affect the diagnostic performance of CEUS in the diagnosis of HCCs. CLINICAL RELEVANCE STATEMENT Meta-analysis data show the presence of key enhancement features for diagnosis of hepatocellular carcinoma is different between ultrasound contrast agents, and arterial hyperenhancement and late washout are more frequently observed at contrast-enhanced ultrasound with SonoVue® than with Sonazoid®. KEY POINTS • Dynamic enhancement features are key for imaging-based diagnosis of HCC. • Arterial hyperenhancement and late washout are more often observed in HCCs using SonoVue®-enhanced US than with Sonazoid®. • The existing evidence for contrast-enhanced US may need to be considered being specific to the individual contrast agent.
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Affiliation(s)
- Jie Ren
- Department of Medical Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qiang Lu
- Department of Ultrasound, Laboratory of Ultrasound Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Xiang Fei
- Department of Ultrasound, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | | | - Paul S Sidhu
- King's College London, Radiology, London, United Kingdom
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland.
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Zhang YZ, Liu YC, Su T, Shi JN, Huang Y, Liang B. Current advances and future directions in combined hepatocellular and cholangiocarcinoma. Gastroenterol Rep (Oxf) 2024; 12:goae031. [PMID: 38628397 PMCID: PMC11018545 DOI: 10.1093/gastro/goae031] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/17/2024] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
The low incidence of combined hepatocellular cholangiocarcinoma (cHCC-CCA) is an important factor limiting research progression. Our study extensively included nearly three decades of relevant literature and assembled the most comprehensive database comprising 5,742 patients with cHCC-CCA. We summarized the characteristics, tumor markers, and clinical features of these patients. Additionally, we present the evolution of cHCC-CCA classification and explain the underlying rationale for these classification standards. We reviewed cHCC-CCA diagnostic advances using imaging features, tumor markers, and postoperative pathology, as well as treatment options such as surgical, adjuvant, and immune-targeted therapies. In addition, recent advances in more effective chemotherapeutic regimens and immune-targeted therapies were explored. Furthermore, we described the molecular mutation features and potential specific markers of cHCC-CCA. The prognostic value of Nestin has been proven, and we speculate that Nestin will also play a role in classification and diagnosis. However, further research is needed. Moreover, we believe that the possibility of using machine learning liquid biopsy for preoperative diagnosis and establishing a scoring system are directions for future research.
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Affiliation(s)
- Yu-Zhu Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Yu-Chen Liu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- Queen Mary School, Jiangxi Medical College of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Tong Su
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Jiang-Nan Shi
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Yi Huang
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
| | - Bo Liang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi, Nanchang, Jiangxi, P. R. China
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Yang J, Zhang Y, Bao WYG, Chen YD, Jiang H, Huang JY, Zeng KY, Song B, Huang ZX, Lu Q. Comparison contrast-enhanced CT with contrast-enhanced US in diagnosing combined hepatocellular-cholangiocarcinoma: a propensity score-matched study. Insights Imaging 2024; 15:44. [PMID: 38353807 PMCID: PMC10866845 DOI: 10.1186/s13244-023-01576-6] [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: 07/26/2023] [Accepted: 11/25/2023] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVES To develop and compare noninvasive models for differentiating between combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and HCC based on serum tumor markers, contrast-enhanced ultrasound (CEUS), and computed tomography (CECT). METHODS From January 2010 to December 2021, patients with pathologically confirmed cHCC-CCA or HCC who underwent both preoperative CEUS and CECT were retrospectively enrolled. Propensity scores were calculated to match cHCC-CCA and HCC patients with a near-neighbor ratio of 1:2. Two predicted models, a CEUS-predominant (CEUS features plus tumor markers) and a CECT-predominant model (CECT features plus tumor markers), were constructed using logistic regression analyses. Model performance was evaluated by the area under the curve (AUC), sensitivity, specificity, and accuracy. RESULTS A total of 135 patients (mean age, 51.3 years ± 10.9; 122 men) with 135 tumors (45 cHCC-CCA and 90 HCC) were included. By logistic regression analysis, unclear boundary in the intratumoral nonenhanced area, partial washout on CEUS, CA 19-9 > 100 U/mL, lack of cirrhosis, incomplete tumor capsule, and nonrim arterial phase hyperenhancement (APHE) volume < 50% on CECT were independent factors for a diagnosis of cHCC-CCA. The CECT-predominant model showed almost perfect sensitivity for cHCC-CCA, unlike the CEUS-predominant model (93.3% vs. 55.6%, p < 0.001). The CEUS-predominant model showed higher diagnostic specificity than the CECT-predominant model (80.0% vs. 63.3%; p = 0.020), especially in the ≤ 5 cm subgroup (92.0% vs. 70.0%; p = 0.013). CONCLUSIONS The CECT-predominant model provides higher diagnostic sensitivity than the CEUS-predominant model for CHCC-CCA. Combining CECT features with serum CA 19-9 > 100 U/mL shows excellent sensitivity. CRITICAL RELEVANCE STATEMENT Combining lack of cirrhosis, incomplete tumor capsule, and nonrim arterial phase hyperenhancement (APHE) volume < 50% on CECT with serum CA 19-9 > 100 U/mL shows excellent sensitivity in differentiating cHCC-CCA from HCC. KEY POINTS 1. Accurate differentiation between cHCC-CCA and HCC is essential for treatment decisions. 2. The CECT-predominant model provides higher accuracy than the CEUS-predominant model for CHCC-CCA. 3. Combining CECT features and CA 19-9 levels shows a sensitivity of 93.3% in diagnosing cHCC-CCA.
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Affiliation(s)
- Jie Yang
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yun Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wu-Yong-Ga Bao
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yi-di Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hanyu Jiang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jia-Yan Huang
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ke-Yu Zeng
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Department of Radiology, Sanya People's Hospital, Hainan, China
| | - Zi-Xing Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
- Department of Radiology, West China Tianfu hospital of Sichuan University, Sichuan, China.
| | - Qiang Lu
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Lv TR, Hu HJ, Ma WJ, Liu F, Jin YW, Li FY. Meta-analysis of prognostic factors for overall survival and disease-free survival among resected patients with combined hepatocellular carcinoma and cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107279. [PMID: 38000116 DOI: 10.1016/j.ejso.2023.107279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Combined hepatocellular carcinoma and cholangiocarcinoma (CHCC-CC) is a rare subtype of primary liver malignancy and has been treated equally as intra-hepatic cholangiocarcinoma (IHCC) according to the 8th AJCC staging system. Owing to its rarity, its prognostic factors have been rarely explored and defined. METHODS PubMed, EMBASE, the Cochrane Library and Web of Science were searched up till January 1st, 2023 and eligible studies were restricted to studies reported prognostic factors of resected CHCC-CC. Standard Parmar modifications were used to determine pooled univariable hazard ratios (HRs). RESULTS A total of eleven studies with 1286 patients with resected classical CHCC-CC were finally included. Pooled results indicated that serum tumor biomarkers, including AFP, CA199, and CEA, were prognostic factors for postoperative overall survival (OS) and disease-free survival (DFS). Moreover, liver cirrhosis (P = 0.010), HBV infection (P = 0.030), and HCV infection (P < 0.001) were prognostic factors for OS. Age (HR = 1.03, P = 0.005) was a prognostic factor for DFS. Tumor size (OS: HR = 2, P < 0.001, DFS: HR = 2.15, P < 0.001), tumor number (OS: HR = 2.05, P < 0.001; DFS: HR = 1.96, P = 0.006), surgical margin (OS: HR = 2.33, <0.001001; DFS: HR = 2.35, P < 0.001), node metastasis (OS: HR = 2.96, P < 0.001; DFS: HR = 2.1, P < 0.001), vascular invasion (OS: HR = 2.17, P < 0.001; DFS: HR = 2.64, P < 0.001), and postoperative prophylactic trans-arterial chemotherapy embolization (PPTACE) (OS: HR = 1.67, P = 0.04; DFS: HR = 2.31, P < 0.001) were common prognostic factors for OS and DFS. CONCLUSION Various risk factors unmentioned in the 8th AJCC staging system were identified. These promising findings would facilitate a more personalized predictive model and help clinicians to stratify patients with different survival outcomes.
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Affiliation(s)
- Tian-Run Lv
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Hai-Jie Hu
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Wen-Jie Ma
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Fei Liu
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Yan-Wen Jin
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Fu-Yu Li
- Department of Biliary Tract Surgery, General Surgrey, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
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Kang HJ, Lee JM, Kim SW. Sonazoid-enhanced ultrasonography for noninvasive imaging diagnosis of hepatocellular carcinoma: special emphasis on the 2022 KLCA-NCC guideline. Ultrasonography 2023; 42:479-489. [PMID: 37423603 PMCID: PMC10555687 DOI: 10.14366/usg.23051] [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: 03/21/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023] Open
Abstract
Contrast-enhanced ultrasonography (CEUS) is a noninvasive imaging modality used to diagnose hepatocellular carcinoma (HCC) based on specific imaging features, without the need for pathologic confirmation. Two types of ultrasound contrast agents are commercially available: pure intravascular agents (such as SonoVue) and Kupffer agents (such as Sonazoid). Major guidelines recognize CEUS as a reliable imaging method for HCC diagnosis, although they differ depending on the contrast agents used. The Korean Liver Cancer Association-National Cancer Center guideline includes CEUS with either SonoVue or Sonazoid as a second-line diagnostic technique. However, Sonazoid-enhanced ultrasound is associated with several unresolved issues. This review provides a comparative overview of these contrast agents regarding pharmacokinetic features, examination protocols, diagnostic criteria for HCC, and potential applications in the HCC diagnostic algorithm.
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Affiliation(s)
- Hyo-Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Se Woo Kim
- Department of Radiology, Armed Forces Daejeon Hospital, Daejeon, Korea
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Jeong WK, Kang HJ, Choi SH, Park MS, Yu MH, Kim B, You MW, Lim S, Cho YS, Lee MW, Hwang JA, Lee JY, Kim JH, Joo I, Bae JS, Kim SY, Chung YE, Kim DH, Lee JM. Diagnosing Hepatocellular Carcinoma Using Sonazoid Contrast-Enhanced Ultrasonography: 2023 Guidelines From the Korean Society of Radiology and the Korean Society of Abdominal Radiology. Korean J Radiol 2023; 24:482-497. [PMID: 37271203 DOI: 10.3348/kjr.2023.0324] [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: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 06/06/2023] Open
Abstract
Sonazoid, a second-generation ultrasound contrast agent, was introduced for the diagnosis of hepatic nodules. To clarify the issues with Sonazoid contrast-enhanced ultrasonography for the diagnosis of hepatocellular carcinoma (HCC), the Korean Society of Radiology and Korean Society of Abdominal Radiology collaborated on the guidelines. The guidelines are de novo, evidence-based, and selected using an electronic voting system for consensus. These include imaging protocols, diagnostic criteria for HCC, diagnostic value for lesions that are inconclusive on other imaging results, differentiation from non-HCC malignancies, surveillance of HCC, and treatment response after locoregional and systemic treatment for HCC.
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Affiliation(s)
- Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo-Jin Kang
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Suk Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Hospital, Konkuk University College of Medicine, Seoul, Korea
| | - Bohyun Kim
- Department of Radiology, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Won You
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sanghyeok Lim
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young Seo Cho
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Min Woo Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Ah Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Young Lee
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ijin Joo
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seok Bae
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University 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
| | - Yong Eun Chung
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hwan Kim
- Department of Radiology, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology and Research Institute of Radiological Science, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Shen YT, Yue WW, Xu HX. Non-invasive imaging in the diagnosis of combined hepatocellular carcinoma and cholangiocarcinoma. Abdom Radiol (NY) 2023; 48:2019-2037. [PMID: 36961531 DOI: 10.1007/s00261-023-03879-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/25/2023]
Abstract
Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare type of primary liver cancer. It is a complex "biphenotypic" tumor type consisting of bipotential hepatic progenitor cells that can differentiate into cholangiocytes subtype and hepatocytes subtype. The prognosis of patients with cHCC-CC is quite poor with its specific and more aggressive nature. Furthermore, there are no definite demographic or clinical features of cHCC-CC, thus a clear preoperative identification and accurate non-invasive imaging diagnostic analysis of cHCC-CC are of great value. In this review, we first summarized the epidemiological features, pathological findings, molecular biological information and serological indicators of cHCC-CC disease. Then we reviewed the important applications of non-invasive imaging modalities-particularly ultrasound (US)-in cHCC-CC, covering both diagnostic and prognostic assessment of patients with cHCC-CC. Finally, we presented the shortcomings and potential outlooks for imaging studies in cHCC-CC.
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Affiliation(s)
- Yu-Ting Shen
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, 200032, China
| | - Wen-Wen Yue
- Department of Medical Ultrasound, Center of Minimally Invasive Treatment for Tumor, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, 200072, China.
| | - Hui-Xiong Xu
- Department of Ultrasound, Zhongshan Hospital, Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, 200032, China.
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Gong W, Wu J, Wei H, Jiang Z, Wan M, Wu C, Xue W, Ma R, Zhou X, Zhou H. Combining serum AFP and CEUS LI-RADS for better diagnostic performance in Chinese high-risk patients. LA RADIOLOGIA MEDICA 2023; 128:393-401. [PMID: 36943653 DOI: 10.1007/s11547-023-01614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/28/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE To evaluate and compare the diagnostic performance of revised contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System version by combining LR-M category and serum alpha-fetoprotein (AFP) under different cut-off values. MATERIAL AND METHODS This retrospective study enrolled 152 high-risk patients with 152 histology-proven nodules. For revised LI-RADS, nodules in LR-M with different elevated AFP thresholds have been reclassified as the LR-5 category. The diagnostic performances of original and revised CEUS LI-RADS were evaluated and compared. RESULTS To compare with the original version, the sensitivity of revised LR-5 (adjusted with AFP value > 200 ng/ml or 400 ng/ml) for the diagnosis of hepatocellular carcinoma (HCC) improved from 52.5 to 69.2% or 65.0%, respectively (both p < 0.001) without compromising specificity (87.5% vs. 71.9% or 78.1%, respectively, both p > 0.05). For the diagnosis of non-HCC malignancy, the specificity of the LR-M after reclassification was improved (69.6% vs. 84.4% or 80.7%, respectively, both p < 0.001) with a non-significant sensitivity reduction (100.0 vs. 70.6% or 82.4%, respectively, both p > 0.05). After modification, the sensitivity of LR-5 also increased to 69.1% or 64.9% (both p < 0.001), while the specificity and PPV did not change (both p > 0.05) for larger nodules (> 20 mm). CONCLUSION The diagnostic performance of CEUS LI-RADS can be further improved by reclassifying LR-M nodules with elevated AFP thresholds to LR-5.
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Affiliation(s)
- Wushuang Gong
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Jiaqi Wu
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Hong Wei
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Zhaopeng Jiang
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Ming Wan
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Chengwei Wu
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Weili Xue
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Rao Ma
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China
| | - Xianli Zhou
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China.
| | - Hang Zhou
- In-Patient Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Surgeons' Hall, No. 246, Xuefu Road, Nangang District, Harbin City, Heilongjiang, China.
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Chen Y, Lu Q, Zhu Y, Huang B, Dong Y, Wang W. Prediction of Microvascular Invasion in Combined Hepatocellular-Cholangiocarcinoma Based on Pre-operative Clinical Data and Contrast-Enhanced Ultrasound Characteristics. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1190-1201. [PMID: 35397928 DOI: 10.1016/j.ultrasmedbio.2022.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/27/2022] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
The goal of the study described here was to define the predictive value of pre-operative clinical information and contrast-enhanced ultrasound (CEUS) imaging characteristics in combined hepatocellular-cholangiocarcinoma (CHC) patients with microvascular invasion (MVI). Seventy-six patients with pathologically confirmed CHC were enrolled in this study, comprising 18 patients with MVI-positive status and 58 with MVI-negative CHC nodules. The pre-operative clinical data and CEUS imaging features were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the potential predictors of MVI in CHC. Recurrence-free survival (RFS) after hepatectomy was compared between patients with different MVI status using the log-rank test and Kaplan-Meier survival curves. Univariate analysis indicated that the following parameters of patients with CHC significantly differed between the MVI-positive and MVI-negative groups (p<0.05): tumor size, α-fetoprotein ≥400 ng/mL, enhancement patterns in arterial phase and marked washout during the portal venous phase on CEUS. On multivariate logistic regression analysis, only the CEUS characteristics of heterogeneous enhancement (odds ratio = 6.807; 95% confidence interval [CI]: 1.099, 42.147; p = 0.039) and marked washout (odds ratio = 4.380; 95% CI: 1.050,18.270; p = 0.043) were identified as independent predictors of MVI in CHC. The combination of the two risk factors in predicting MVI achieved a better diagnostic performance than each parameter alone, with an area under the receiver operating characteristic curve of 0.736 (0.622, 0.830). After hepatectomy, CHC patients with MVI exhibited earlier recurrence compared with those without MVI (hazard ratio = 1.859; 95% CI: 0.8699-3.9722, p = 0.046). The CEUS imaging features of heterogeneous enhancement in the arterial phase and marked washout during the portal venous phase were the potential predictors of MVI in CHC. Aside from that, CHC patients with MVI had an earlier recurrence rate than those without MVI after surgery.
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Affiliation(s)
- Yanling Chen
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuli Zhu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Beijian Huang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Ultrasound Medicine and Engineering, Fudan University, Shanghai, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Institute of Medical Imaging, Shanghai, China
| | - Wenping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China; Institute of Ultrasound Medicine and Engineering, Fudan University, Shanghai, China; Shanghai Institute of Medical Imaging, Shanghai, China.
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10
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Gao L, Huang JY, Lu ZJ, Lu Q. Contrast-enhanced ultrasound manifestations of synchronous combined hepatocellular-cholangiocarcinoma and hepatocellular carcinoma: A case report. World J Clin Cases 2022; 10:3615-3623. [PMID: 35611203 PMCID: PMC9048564 DOI: 10.12998/wjcc.v10.i11.3615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Synchronous combined hepatocellular-cholangiocarcinoma (CHC) and hepatocellular carcinoma (HCC) is very rare, with few literature reports and poor clinical outcomes associated with the disorder. Surgical resection is the main treatment, which makes the preoperative diagnosis very important. However, due to imaging manifestations overlapping with HCC, diagnosis of this type of synchronous cancer is challenging and it tends to be misdiagnosed as multiple HCC. Herein, we report the contrast-enhanced ultrasound (CEUS) manifestations of a case of synchronous CHC and HCC, aiming at adding to the understanding of this disease. CEUS displayed exquisite vascularity and tissue perfusion in real time with good spatial and temporal resolution and more accurately reflect tumor washin and washout times than contrast-enhanced computed tomography (CT) in this case.
CASE SUMMARY The patient was a 69-year-old female with a 20-year history of chronic hepatitis B. Due to months of epigastric pain and anorexia, she reffered to our hospital for treatment. Five days before hospitalization, abdominal magnetic resonance imaging performed at another hospital detected a space-occupying lesion in the liver. After her hospitalization, laboratory tests showed elevated alpha-fetoprotein and carbohydrate antigen 19-9 level. Two suspicious liver lesions located in S4 and S6, respectively, were identified in a cirrhotic background by abdominal contrast-enhanced CT (CECT). Furthermore, the lesion in S4 and S6 were detected by CEUS and assigned to CEUS LI-RADS 5 and M categories, respectively. The patient underwent tumor radical resections. Post-operative pathology confirmed the S4 and S6 lesions to be HCC and CHC, respectively. A newly-found suspicious liver nodule with potential malignancy was detected in liver S1 by both CEUS and CECT 7 mo after operation.
CONCLUSION The CEUS characteristics of CHC and HCC are different. CEUS features in combination with clinical information could help in effective diagnosis, clinical decision-making and better prognosis.
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Affiliation(s)
- Ling Gao
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Ultrasound, Chengdu BOE hospital, Chengdu 610219, Sichuan Province, China
| | - Jia-Yan Huang
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Jian Lu
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qiang Lu
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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11
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Chen Y, Lu Q, Zhang W, Cao J, Dong Y, Wang W. Preoperative Differentiation of Combined Hepatocellular-Cholangiocarcinoma From Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma: A Nomogram Based on Ultrasonographic Features and Clinical Indicators. Front Oncol 2022; 12:757774. [PMID: 35242699 PMCID: PMC8885729 DOI: 10.3389/fonc.2022.757774] [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: 08/12/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To establish a predictive nomogram to distinguish combined hepatocellular-cholangiocarcinoma (CHC) from hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) based on preoperative clinical and ultrasound findings. METHODS A total of 261 patients with pathologically confirmed primary liver cancers (PLCs) were enrolled in this retrospective study, comprising 87 CHCs, 87 HCCs, and 87 ICCs matched by propensity score matching. Patients were randomly assigned to a training cohort and a validation one at the ratio of 7:3. A nomogram integrating ultrasound imaging characteristics and clinical features was established based on the independent risk factors selected by least absolute shrinkage and selection operator (LASSO) regression. The performance of the nomogram was evaluated in the training and validation cohorts in terms of discrimination, calibration, and clinical usefulness. RESULTS The nomogram, consisting of ultrasound imaging features (shape and margin on B-mode ultrasound, enhanced pattern on contrast-enhanced ultrasound) and clinical information [elevated alpha fetoprotein (AFP) level and serum protein electrophoresis (SPE) α1 level], showed promising performance in differentiating CHC from HCC and ICC, with the concordance index (C-index) of 0.8275 and 0.8530 in the training cohort and the validation cohort, respectively. Hosmer-Lemeshow test and the calibration curves suggested good consistency between predictions and observations. High clinical practicability was confirmed by the decision curve analysis. CONCLUSIONS The nomogram based on clinical and ultrasound imaging characteristics showed good performance in the discrimination of CHC from other subtypes of PLC and would be valuable in clinical decision-making.
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Affiliation(s)
- Yanling Chen
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weibin Zhang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaying Cao
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
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Kang HJ, Kim JH, Yoo J, Han JK. Diagnostic criteria of perfluorobutane-enhanced ultrasonography for diagnosing hepatocellular carcinoma in high-risk individuals: how is late washout determined? Ultrasonography 2021; 41:530-542. [PMID: 35144328 PMCID: PMC9262666 DOI: 10.14366/usg.21172] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the optimal washout criteria of perfluorobutane-enhanced ultrasonography (PFB-US) for the diagnosis of hepatocellular carcinoma (HCC) in high-risk individuals. METHODS Participants at risk of HCC with treatment-naïve solid hepatic observations (≥1 cm) who underwent PFB-US from March 2019 to September 2020 were prospectively recruited. Arterial phase hyperenhancement (APHE), washout time, and washout degree were evaluated. The diagnosis of HCC was made by non-rim APHE with late and mild washout. The per-lesion diagnostic performance for diagnosing HCC using different cutoffs for late washout (50, 55, 60, 65, and 70 seconds postcontrast) and the different time windows for determining washout (until 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes postcontrast) were compared using the McNemar test. RESULTS In total, 101 participants with 113 observations (mean size, 33.5±2.8 mm; HCCs [n=82], non-HCC malignancies [n=16], benign [n=15]) were evaluated. Non-rim APHE was observed in 86.6% (71/82) of HCCs. As the cutoff time for late washout increased, the specificity increased to 100% (95% confidence interval [CI], 88.8% to 100%) at the 60-second cutoff with 62.2% sensitivity (95% CI, 50.8% to 72.7%). When the time window for determining washout became wider, the sensitivity and accuracy increased until 6 minutes, with 100% specificity at all times. CONCLUSION Determining washout within 6 minutes after contrast injection with a 60-second cutoff for late washout showed the highest sensitivity without losing specificity for diagnosing HCC using PFB-US in individuals at high risk.
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Affiliation(s)
- Hyo-Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Jeongin Yoo
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
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Jiang Y, Zhang M, Zhu Y, Zhu D. Diagnostic role of contrast-enhanced ultrasonography versus conventional B-mode ultrasonography in cirrhotic patients with early hepatocellular carcinoma: a retrospective study. J Gastrointest Oncol 2021; 12:2403-2411. [PMID: 34790401 DOI: 10.21037/jgo-21-611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background Early diagnosis of hepatocellular carcinoma (HCC) is very important for the prognosis of patients. However, there are very few studies that compared the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) and B-mode ultrasonography for early HCC in cirrhotic patients. Methods This retrospective study included cirrhotic patients, who were suspected of early HCC between January 2020 and June 2021. The diagnosis of patients was based on the pathology results of surgery or biopsy. Demographic and clinical characteristics of included patients were recorded. The diagnoses of suspected lesions using both types of ultrasonography were recorded, and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of early HCC in cirrhotic patients were calculated. Results Eventually, 137 patients with solitary lesions in the liver were included in this study, including 89 patients diagnosed with HCC and 48 patients diagnosed with non-HCC. The median diameter of suspected lesions was 26 mm, and the median level of alpha fetoprotein (AFP) was 37.2 ng/mL. When comparing the demographic and clinical characteristics of cirrhotic patients with HCC and non-HCC, it was found that patients with HCC had significantly higher levels of AFP than those with non-HCC (P=0.03). The sensitivity, specificity, PPV, NPV, and accuracy of CEUS in early HCC were 73%, 93.8%, 95.6%, 65.2% and 80.3%, respectively. In CEUS, all of these parameters were much higher than those in B-mode ultrasonography, i.e., 64%, 75%, 82.6%, 52.9%, and 67.9%. It was also found that the diagnostic accuracy of CEUS was much higher than that of B-mode ultrasonography especially regarding lesions <20 mm. To further improve the sensitivity of CEUS in early HCC, AFP was combined with CEUS for the diagnosis of early HCC. As a result, the sensitivity, specificity, PPV, NPV, and accuracy of CEUS combined with AFP level were 83.1%, 87.5%, 92.5%, 73.7%, and 84.7%, respectively. Conclusions Our study confirmed that CEUS' diagnostic accuracy for early HCC in cirrhotic patients was significantly higher than that of B-mode ultrasonography. However, the sensitivity of CEUS needs to be improved further, and the combination of CEUS and AFP level may be a potential solution.
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Affiliation(s)
- Yandong Jiang
- Department of Ultrasound, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Meng Zhang
- Department of Ultrasound, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yanting Zhu
- Department of Ultrasound, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Dongxiao Zhu
- Department of Ultrasound, Affiliated Hospital of Jiangnan University, Wuxi, China
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14
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Wang T, Wang W, Zhang J, Yang X, Shen S, Wang W. Development and Validation of a Nomogram for Differentiating Combined Hepatocellular Cholangiocarcinoma From Intrahepatic Cholangiocarcinoma. Front Oncol 2020; 10:598433. [PMID: 33363028 PMCID: PMC7756117 DOI: 10.3389/fonc.2020.598433] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/04/2020] [Indexed: 02/05/2023] Open
Abstract
Objectives To establish a nomogram based on preoperative laboratory study variables using least absolute shrinkage and selection operator (LASSO) regression for differentiating combined hepatocellular cholangiocarcinoma (cHCC) from intrahepatic cholangiocarcinoma (iCCA). Methods We performed a retrospective analysis of iCCA and cHCC patients who underwent liver resection. Blood signatures were established using LASSO regression, and then, the clinical risk factors based on the multivariate logistic regression and blood signatures were combined to establish a nomogram for a differential preoperative diagnosis between iCCA and cHCC. The differential accuracy ability of the nomogram was determined by Harrell’s index (C-index) and decision curve analysis, and the results were validated using a validation set. Furthermore, patients were categorized into two groups according to the optimal cut-off values of the nomogram-based scores, and their survival differences were assessed using Kaplan-Meier curves. Results A total of 587 patients who underwent curative liver resection for iCCA or cHCC between January 2008 and December 2017 at West China Hospital were enrolled in this study. The cHCC score was based on the personalized levels of the seven laboratory study variables. On multivariate logistic analysis, the independent factors for distinguishing cHCC were age, sex, biliary duct stones, and portal hypertension, all of which were incorporated into the nomogram combined with the cHCC-score. The nomogram had a good discriminating capability, with a C-index of 0.796 (95% CI, 0.752–0.840). The calibration plot for distinguishing cHCC from iCCA showed optimal agreement between the nomogram prediction and actual observation in the training and validation sets. The decision curves indicated significant clinical usefulness. Conclusion The nomogram showed good accuracy for the differential diagnosis between iCCA and cHCC preoperatively, and therapeutic decisions would improve if it was applied in clinical practice.
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Affiliation(s)
- Tao Wang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Wanxiang Wang
- Department of Hepatobiliary, Pancreatic, and Splenic Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jinfu Zhang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Xianwei Yang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Shu Shen
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
| | - Wentao Wang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China
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