Guidelines for imaging focal lesions in liver cirrhosis

RECIST 1.1 versus mRECIST for assessment of tumour response to molecular targeted therapies and disease outcomes in patients with hepatocellular carcinoma: a systematic review and meta-analysis

OBJECTIVES

Response Evaluation Criteria in Solid Tumours version 1.1 (RECIST 1.1) and modified RECIST (mRECIST) are commonly used to assess tumour response. Which one is better to evaluate efficacy after molecular targeted therapies in hepatocellular carcinoma (HCC) patients is still controversial. A systemic review was performed to compare the objective response rate (ORR) and disease control rate (DCR) and a meta-analysis was conducted to compare the correlation between objective response and overall survival (OS).

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation approach.

DATA SOURCES

EMBASE, PubMed, Web of Science and Cochrane Library were searched through 31 December 2021.

ELIGIBILITY CRITERIA

We included studies assessing the efficacy of molecular targeted therapy for HCC according to both RECIST 1.1 and mRECIST.

DATA EXTRACTION AND SYNTHESIS

Two investigators extracted data independently. The consistency between RECIST 1.1 vs mRECIST is measured by the k coefficient. HRs with corresponding 95% CIs were used for meta-analysis.

RESULTS

23 studies comprising 2574 patients were included in systematic review. The ORR according to mRECIST is higher than RECIST1.1 (15.9% vs 7.8%, p<0.001). The DCR is similar (68.4% vs 67.2%, p=0.5). The agreement of tumour response is moderate for objective response (k=0.499) and perfect for progressive disease (k=0.901), calculated from 8 studies including 372 patients. OS was significantly longer in response group than non-response group according to mRECIST (HR 0.56, 95% CI 0.41 to 0.78, p=0.0004) calculated from 7 studies including 566 patients, however, the RECIST1.1 could not distinguish the OS well (HR 0.68, 95% CI 0.44 to 1.05, p=0.08). Subgroup analusis by type of treatment was conducted.

CONCLUSIONS

mRECIST may be more accurate than RECIST 1.1 in assessing ORR after molecular targeted therapies in HCC patients and can better assess the prognosis. However, the performance of both criteria in assessing disease progression is identical.

PROSPERO REGISTRATION NUMBER

CRD42020200895.

ETHICS APPROVAL

Ethics approval is not required in this meta-analysis.

mRECIST for HCC: Performance and novel refinements

In 2010, modified RECIST (mRECIST) criteria were proposed as a way of adapting the RECIST criteria to the particularities of hepatocellular carcinoma (HCC). We intended to overcome some limitations of RECIST in measuring tumour shrinkage with local and systemic therapies, and also to refine the assessment of progression that could be misinterpreted with conventional RECIST 1.1, due to clinical events related to the natural progression of chronic liver disease (development of ascites, enlargement of lymph nodes, etc.). mRECIST has served its purpose since being adopted or included in clinical practice guidelines (European, American and Asian) for the management of HCC; it has also been instrumental for assessing response and time-to-event endpoints in several phase II and III investigations. Nowadays, mRECIST has become the standard tool for measurement of radiological endpoints at early/intermediate stages of HCC. At advanced stages, guidelines recommend both methods. mRECIST has been proven to capture higher objective response rates in tumours treated with molecular therapies and those responses have shown to be independently associated with better survival. With the advent of novel treatment approaches (i.e. immunotherapy) and combination therapies there is a need to further refine and clarify some concepts around the performance of mRECIST. Similarly, changes in the landscape of standard of care at advanced stages of the disease are pointing towards progression-free survival as a potential primary endpoint in some phase III investigations, as effective therapies applied beyond progression might mask overall survival results. Strict recommendations for adopting this endpoint have been reported. Overall, we review the performance of mRECIST during the last decade, incorporating novel clarifications and refinements in light of emerging challenges in the study and management of HCC.

Incidence and risk factors associated with hepatocellular carcinoma surveillance failure

BACKGROUND AND AIM

Surveillance for hepatocellular carcinoma (HCC) intends to detect tumors at an early stage to improve survival. The study aims were to assess the frequency and risk factors associated with HCC surveillance failure.

METHODS

The study analyzed data from 188 consecutive patients diagnosed with HCC within a surveillance program conducted among 1,242 cirrhotic patients and based on ultrasonography and alpha-fetoprotein (AFP) testing every 3 or 6 months. Program failure was defined as the detection of HCC exceeding the Milan criteria. Variables recorded at entry into the program, during follow-up and at HCC diagnosis, were analyzed.

RESULTS

At diagnosis, 50 (26.6%) HCC tumors were beyond the Milan criteria. In univariate analysis, Child-Pugh B at entry (P = 0.03), development of complications of portal hypertension before tumor diagnosis (P = 0.03), and failure to complete the prior screening round (P = 0.02), Child-Pugh B/C (P = 0.001) and AFP ≥ 100 ng/mL (P = 0.03) at diagnosis, were associated with failure. In multivariate analysis, only Child-Pugh B/C (hazard ratio, 3.18; 95% confidence interval, 1.66-6.10, P < 0.001) and AFP ≥ 100 ng/mL, both at diagnosis (hazard ratio, 2.80; 95% confidence interval, 1.37-5.71, P = 0.005), were independently associated with failure. Survival was higher among patients with tumors within the Milan criteria than those with program failure (33.9 vs 7.6 months, P < 0.001).

CONCLUSIONS

Approximately 25% of HCC cases diagnosed among patients included in a surveillance program were beyond the Milan criteria. Child-Pugh B/C and AFP ≥ 100 ng/mL at diagnosis were associated with program failure. However, Child-Pugh B at entry and development of liver-related complications during follow-up can be early predictors of failure.

Comprehensive Comparison of Multiple-Detector Computed Tomography and Dynamic Magnetic Resonance Imaging in the Diagnosis of Hepatocellular Carcinoma with Varying Degrees of Fibrosis

Background & Aims

Liver computed tomography and dynamic magnetic resonance imaging play an important role in the early detection of hepatocellular carcinoma. However, the American Association for the Study of Liver Diseases (AASLD) recommend the use of applied imaging studies for HCC diagnosis only in cirrhotic patients. This study aimed to comprehensively compare liver CT and dynamic MRI for HCC diagnosis before surgical resection over years in clinical practice, and also to compare the diagnostic differences between liver CT and dynamic MRI in HCCs with varying degrees of fibrosis.

Methods

841 patients with liver tumor who had liver CT or dynamic MRI examinations followed by surgical resection were included in the study. We defined typical HCC imaging characteristics as early enhancement in the artery phase and early washout in the venous phase. The tumor size was recorded based on pathological examination after surgery. The pathologic fibrosis score was verified by the METAVIR scoring classification.

Results

Among the 841 patients, 756 underwent liver CT and 204 underwent dynamic liver MRI before surgery. The etiologies of chronic liver disease included hepatitis B virus, hepatitis C virus, hepatitis B and C virus, and non-hepatitis B or C virus. The sensitivity and accuracy of liver CT or MRI for HCC diagnosis was approximately 80%~90%. Liver CT had a diagnostic accuracy for HCC similar to that of dynamic MRI, and liver fibrosis stage did not influence their diagnostic efficacies.

Conclusions

The application of 4-phase dynamic CT and MRI exhibit similar diagnostic accuracy for hepatocellular carcinoma, in tumors of sizes 1 to 2 cm and >2 cm. Liver fibrosis status did not affect the diagnostic accuracy of liver CT or MRI for HCC. The AASLD and EASL restrictions of dynamic imaging studies for HCC diagnosis to cirrhotic patients alone are unnecessary.

Gd-EOB-DTPA-enhanced MR guidance in thermal ablation of liver malignancies

OBJECTIVE

To evaluate the potency of Gd-EOB-DTPA to support hepatic catheter placement in laser ablation procedures by quantifying time-dependent delineation effects for instrumentation and target tumor within liver parenchyma. Monitoring potential influence on online MR thermometry during the ablation procedure is a secondary aim.

MATERIALS AND METHODS

30 cases of MR-guided laser ablation were performed after i.v. bolus injection of gadoxetic acid (0.025 mmol/Kg Gd-EOB-DTPA; Bayer Healthcare, Berlin, Germany). T1-weighted GRE sequences were used for applicator guidance (FLASH 3D) in the catheter placement phase and for therapy monitoring (FLASH 2D) in the therapy phase. SNR and consecutive CNR values were measured for elements of interest plotted over time both for catheter placement and therapy phase and compared with a non-contrast control group of 19 earlier cases. Statistical analysis was realized using the paired Wilcoxon test.

RESULTS

Sustainable signal elevation of liver parenchyma in the contrast-enhanced group was sufficient to silhouette both target tumor and applicator against the liver. Differences in time dependent CNR alteration were highly significant between contrast-enhanced and non-contrast interventions for parenchyma and target on the one hand (p = 0.020) and parenchyma and instrument on the other hand (p = 0.002). Effects lasted for the whole procedure (monitoring up to 60 min) and were specific for the contrast-enhanced group. Contrasting maxima were seen after median 30 (applicator) and 38 (tumor) minutes, in the potential core time of a multineedle procedure. Contrast influence on T1 thermometry for real-time monitoring of thermal impact was not significant (p = 0.068-0.715).

CONCLUSION

Results strongly support anticipated promotive effects of Gd-EOB-DTPA for MR-guided percutaneous liver interventions by proving and quantifying the delineating effects for therapy-relevant elements in the procedure. Time benefit, cost effectiveness and oncologic outcome of the described beneficiary effects will have to be part of further investigations.

Factors that affect efficacy of ultrasound surveillance for early stage hepatocellular carcinoma in patients with cirrhosis

BACKGROUND & AIMS

Ultrasound surveillance does not detect early stage hepatocellular carcinomas (HCCs) in some patients with cirrhosis, although the reasons for this have not been well studied. We assessed the rate at which ultrasound fails to detect early stage HCCs and factors that affect its performance.

METHODS

We collected information on 1170 consecutive patients included in the Italian Liver Cancer (ITA.LI.CA) database who had Child-Pugh A or B cirrhosis and were diagnosed with HCC during semiannual or annual ultrasound surveillance, from January 1987 through December 2008. Etiologies included hepatitis C virus infection (59.3%), alcohol abuse (11.3%), hepatitis B virus infection (9%), a combination of factors (15.6%), and other factors (4.7%). Surveillance was considered to be a failure when patients were diagnosed with HCC at a stage beyond the Milan criteria (1 nodule ≤5 cm or ≤3 nodules each ≤3 cm).

RESULTS

HCC was found beyond Milan criteria in 34.3% of surveilled patients (32.2% during semi-annual surveillance and 41.3% during annual surveillance; P < .01). Nearly half of surveillance failures were associated with at least one indicator of aggressive HCC (levels of AFP >1000 ng/mL, infiltrating tumors, or vascular invasion and metastases). Semiannual surveillance, female sex, Child-Pugh class A, and α-fetoprotein levels of 200 ng/mL or less were associated independently with successful ultrasound screening for HCC.

CONCLUSIONS

Based on our analysis of surveillance for HCC in patients with cirrhosis, the efficacy of ultrasound-based screening is acceptable. Ultrasound was least effective in identifying aggressive HCC, and at surveillance intervals of more than 6 months.

Transarterial chemoembolization vs. conservative treatment for unresectable infiltrating hepatocellular carcinoma: A retrospective comparative study

This study was conducted to compare long-term survival between patients with unresectable infiltrating hepatocellular carcinoma (HCC) who were treated with transarterial chemoembolization (TACE) and those who received conservative treatment (best supportive care). Between January, 2007 and January, 2012, a total of 131 consecutive patients with unresectable infiltrating HCC underwent TACE in a cancer center (TACE group), while 156 similar consecutive HCC patients received conservative treatment in another cancer center (conservative treatment group). The diagnosis of unresectable infiltrating HCC was established by agreement between two radiologists coming from the two centers, who performed an independent review of all the cross-sectional imagings of the patients. The two groups were comparable regarding patient characteristics, preoperative liver function, tumor burden and general condition. In the TACE group, 52 patients received one session and 79 patients received more than one session of TACE (mean, 1.5 and range, 1-4 sessions). There was no reported TACE-related mortality. The 1-month mortality rate was 0.8 and 3.8% in the TACE and the conservative groups, respectively (P=0.134). The median survival for the TACE and conservative treatment groups was 7.0 and 3.0 months, respectively. The 6-, 12- and 24-month overall survival rates for the TACE and conservative treatment groups were 61.7, 18.5 and 2.3% vs. 22.7, 12.1 and 0%, respectively (P<0.001). On multivariate analysis, treatment allocation [odds ratio (OR)=1.777; 95% confidence interval (CI): 1.499-2.107; P<0.001] and portal vein tumor thrombosis (OR=1.721; 95% CI: 1.504-1.907; P<0.001) were independent predictors of overall survival. In conclusion, TACE was found to be a safe and feasible treatment option for patients with unresectable infiltrating HCC and it conferred survival benefit over conservative treatment.

Factors associated with outcomes and response to therapy in patients with infiltrative hepatocellular carcinoma

BACKGROUND & AIMS

Infiltrative hepatocellular carcinoma (iHCC) is characterized by its indistinct borders and lack of a typical pattern of contrast enhancement. There are few published data on iHCC. We assessed outcomes, effects of treatment, and prognostic factors in a large cohort of patients with iHCC.

METHODS

We analyzed data from 155 patients (median age, 60 years; 79% male; median level of α-fetoprotein, 347 ng/mL; median Model for End-Stage Liver Disease score, 13) with iHCC, on the basis of contrast-enhanced computed tomography or magnetic resonance imaging, from 2002-2010 at the University of California, San Francisco Medical Center. All imaging study results were independently reviewed by 2 investigators.

RESULTS

Most of the patients had tumors of Barcelona Clinic Liver Cancer stage C (70%) or D (22%). The median maximum tumor diameter was 11.3 cm; 41% of lesions were hypovascular, 82% had macrovascular invasion, and 52% had extrahepatic metastases. Median survival was 4.0 months, and rates of survival at 6 and 12 months were 30% and 10%, respectively. On multivariate analysis, predictors of 6-month mortality were Child-Pugh class B or C cirrhosis; lack of tumor-directed therapy with chemoembolization (transarterial chemoembolization), radiofrequency ablation, or sorafenib; α-fetoprotein level >1000 ng/mL; female sex; Model for End-Stage Liver Disease score; and maximum tumor diameter. The percentages of patients surviving 6 and 12 months were 17% and 2% for those who received no therapy (n = 109), 73% and 36% for those who received sorafenib (n = 11), and 45% and 17% for those who received transarterial chemoembolization (n = 18) (all P values <.01).

CONCLUSIONS

Infiltrative HCC is a radiographically distinct and advanced form of hepatocellular carcinoma with a poor prognosis. Therapy with transarterial chemoembolization or sorafenib appears to prolong survival and requires further investigation.

MRI of Focal Liver Lesions

Magnetic resonance imaging, MRI has more advantages than ultrasound, computed tomography, CT, positron emission tomography, PET, or any other imaging modality in diagnosing focal hepatic masses. With a combination of basic T1 and T2 weighted sequences, diffusion weighted imaging, DWI, and hepatobiliary gadolinium contrast agents, that is gadobenate dimeglumine (Gd-BOPTA) and gadoxetic acid (Gd-EOB), most liver lesions can be adequately diagnosed. Benign lesions, as cyst, hemangioma, focal nodular hyperplasia, FNH or adenoma, can be distinguished from malignant lesions. In a non-cirrhotic liver, the most common malignant lesions are metastases which may be hypovascular or hypervascular. In the cirrhotic liver hepatocellular carcinoma, HCC, is of considerable importance. Besides, intrahepatic cholangiocarcinoma and other less common malignancies has to be assessed. In this review, the techniques and typical MRI features are presented as well as the new algorithm issued by American Association for the Study of the Liver Diseases (AASLD).

[Epidemiology, natural history and pathogenesis of hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) is the main type of primary liver cancers and the third most common cause of cancer mortality worldwide. In France, rising number between 5000 and 6000 cases are diagnosed each year. The major risk factor for hepatocellular carcinoma is chronic hepatitis: viral hepatitis B, viral hepatitis C, consumption of alcohol, hemochromatosis. Hepatocellular carcinoma is closely associated to liver cirrhosis, which is a true precancerous state. Because hepatocarcinogenesis is a long and heterogeneous process, there is still much to understand. Many genetic and epigenetic alterations are described leading to changes in cellular signalling cascades involved in regulation of growth, differentiation, apoptosis, motility. Hepatitis viruses play a direct oncogenic role through the interaction between viral and cellular proteins, which control cell homeostasis, or by the integration of hepatitis B virus genome into the host genome. Furthermore, hepatitis viruses play an indirect oncogenic role by causing chronic inflammation and hepatocyte regeneration related to viral hepatopathy. In expectation of a better understanding of hepatocarcinogenesis and new treatments, prevention from risk factors and ultrasonographic screening of patients with cirrhosis should increase prognosis.

Surveillance and early diagnosis of hepatocellular carcinoma

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

[Imaging techniques in hepatocellular carcinoma: diagnosis, extension and evaluation of therapeutic response]

Hepatocellular carcinoma (HCC) has a poor prognosis when diagnosed in advanced stages. Patients with cirrhosis of any etiology are a clear risk group. Thus, to improve prognosis, these patients should be included in surveillance programs to detect HCC in the early phases. Ultrasonographic examination is recommended for this purpose. The imaging techniques currently available for characterization of focal liver lesions are dynamic ultrasound, magnetic resonance imaging (MRI) and computed tomography (CT). MRI and CT are also suitable to determine tumoral extension. This article reviews the role of imaging techniques in the diagnosis and study of extension of HCC and in assessment of tumoral response after treatment, according to tumoral stage at diagnosis and the clinical status of the patient.

The radiological diagnosis of hepatocellular carcinoma

The American Association for the Study of Liver Diseases (AASLD) guidelines on the management of hepatocellular carcinoma (HCC) includes an algorithm to assist in the diagnosis of small liver nodules found on surveillance. The algorithm was developed on the basis of expert opinion. The two authors of the guidelines have since validated the algorithm. In this issue, the first external validation of the diagnostic algorithm is presented.