Liver disease severity predicts carcinogenesis of dysplastic liver nodules in cirrhosis

While dysplastic liver nodules in cirrhosis are pre-malignant, little is known about the predictors of hepatocarcinogenesis of these lesions. This was a retrospective observational study of subjects with cirrhosis who had at least one hypervascular, non-malignant intrahepatic nodule on imaging while undergoing outpatient management by a tertiary hepatology referral centre between Jan 2009 and Jan 2019. Clinical and biochemical parameters were collected. The primary endpoint was transformation to hepatocellular carcinoma (HCC) as determined by Liver Imaging Reporting and Data System. During the study period, 163 non-malignant hypervascular nodules were identified in 77 patients; 147 had at least 6 months of follow up imaging and 16 received upfront radiofrequency ablation upon detection. During a median follow up of 38.5 months (IQR 16.5-74.5), 25 (17%) of the 147 hypervascular nodules being monitored transformed to HCC. On multivariate analysis, Child-Pugh grade was found to be the only independent predictor of nodule transformation into HCC (p = 0.02). Those with Child-Pugh B and C liver disease had a 10.1 (95% CI 1.22-83.8; p = 0.03) and 32.6-fold (95% CI 2.3-467; p = 0.01) increased risk respectively for HCC transformation compared to Child-Pugh A subjects. This large, single centre study demonstrates that around 20% of dysplastic nodules in cirrhotic patients undergo hepatocarcinogenesis during follow up, and that Child Pugh grade is the only independent predictor of transformation to HCC. Additional prospective studies are warranted to better understand the risk profile of these nodules, and how best they should be managed.

Evolution of indeterminate hepatocellular nodules at Gd-EOB-DPTA-enhanced MRI in cirrhotic patients

PURPOSE

To retrospectively analyze the evolution of indeterminate hepatocellular nodules in cirrhotic patients on serial Gd-EOB-DPTA-enhanced MRI, and to identify predictors of HCC development.

MATERIALS AND METHODS

This IRB approved study included 33 cirrhotic patients with 69 indeterminate hepatocellular nodules (mean diameter 1.1 cm) at baseline Gd-EOB-DPTA-enhanced MRI and a Gd-EOB-DPTA-enhanced-MRI follow-up of at least 2 years. Two radiologists evaluated size and signal intensity of each nodule at baseline and follow-up. Age, cirrhosis etiology, and HCC history were recorded. Data were compared between nodules that became HCCs at follow-up (HCC) and those that did not (no-HCC).

RESULTS

On follow-up, 5/69 nodules became HCCs and 64/69 showed indeterminate characteristics. HCC history was more frequently found in HCCs than in no-HCCs. Age, sex, and cirrhosis etiology were not significantly different between HCCs and no-HCCs. HCCs had a significantly greater baseline diameter and increase in size than no-HCCs. Hepatobiliary phase hypointensity was significantly more common in HCCs than in no-HCCs. Multivariate regression analysis showed that increase in size (OR 10.48; sensitivity, 100%; specificity, 81.2%; p < 0.001) and hepatobiliary phase hypointensity (OR 1.02; sensitivity, 100%; specificity, 78.1%; p < 0.001) was associated with HCC development.

CONCLUSION

Indeterminate hepatocellular nodules at Gd-EOB-DPTA-enhanced MRI in cirrhotic patients rarely became HCCs. Hepatobiliary phase hypointensity had a weak association with HCC development.

How reader perception of capsule affects interpretation of washout in hypervascular liver nodules in patients at risk for hepatocellular carcinoma

PURPOSE

To determine whether reader perception of a capsule affects reader interpretation of washout in hypervascular liver nodules at dynamic magnetic resonance imaging (MRI) in patients at risk for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This retrospective study was Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant, with waiver of informed consent. MRI reports for 111 hypervascular liver nodules (median 2.0 cm, range 1.0-17.8 cm) in 62 patients were reviewed, and the presence/absence of capsule and washout were recorded for one reading. A second independent study reading was also performed. The signal intensity ratio (SIR) for each nodule and liver parenchyma was measured. An objective SIR threshold was identified for nodules without capsules that correctly classified the presence/absence of washout, then applied to nodules with capsules to classify them as having / not having objective washout. Nodules were categorized as definite / not definite HCC using subjective and objective washout, based on LI-RADS, OPTN, AASLD, and EASL criteria, and proportions compared using McNemar's test.

RESULTS

Agreement on nodule features was high for Readings 1 and 2 (κ = 0.70-0.82). For Reading 1, 71 nodules lacked capsules (43 with and 28 without subjective washout); an SIR threshold of 0.88 classified the presence/absence of washout correctly in 94% (67/71, P < 0.001). Forty nodules had capsules; although all had subjective washout (100%, 40/40), 75% (30/40) had objective washout (P < 0.05). Using objective washout caused 4.5% (3/66; LI-RADS, OPTN) and 12% (10/83; AASLD, EASL) of nodules to be recategorized from definite HCC to not definite HCC.

CONCLUSION

Reader perception of capsule affects interpretation of washout. This effect can influence nodule categorization using imaging-based diagnostic systems. J. Magn. Reson. Imaging 2016;43:1337-1345.

Advanced precancerous lesions in the liver

We will focus on precursors of the most common liver cancer, i.e. hepatocellular carcinoma (HCC), which takes place in 90% of cases in a hepatitis/cirrhotic setting. High grade dysplastic nodules (HG-DN) are small sizable nodules and the most advanced precancerous lesions of the liver, with a risk of malignant transformation of about 30-40% at 24 months. We will survey the diagnostic distinction between them and early HCC from a clinical, radiological and pathological point of view. The use of a diagnostic algorithm supported by international guidelines is the best practice to manage HG-DN and early HCC. There is no typical imaging for HG-DN, needing all of them to be biopsied for characterization. The natural history of HG-DN is not predictable in individual cases and additional markers should be validated to increase the diagnostic accuracy and predict the behaviour. The treatment of HG-DN is under investigation.

Contrast-enhanced computed tomography and ultrasound-guided liver biopsy to diagnose dysplastic liver nodules in cirrhosis

BACKGROUND

Dysplastic nodules in cirrhosis herald a very high risk of transition to hepatocellular carcinoma. A better understanding of the relationships between dysplastic nodules and hepatocellular carcinoma development may help refining strategies of enhanced follow-up.

METHODS

All consecutive cirrhotics with a histologically proven de novo dysplastic nodule, were retrospectively identified and underwent alternating abdominal ultrasound and contrast-computed tomography every 3 months. An ultrasound-guided liver biopsy was the diagnostic gold standard, whereas surveillance and recall policies were according to current guidelines.

RESULTS

Among 36 patients with dysplastic nodule (21 low-grade, 15 high-grade, 17.4 ± 2.6mm), 17 (47%) showed arterial wash-in, 15 (42%) portal/venous hypodensity whereas 4 (11%) had neither pattern. During 6-128 (median 36) months, 21 patients developed a hepatocellular carcinoma at a rate of 13.8% per year, intranodular=8.7% vs extranodular=7.1% per year. Hepatocellular carcinoma occurred more frequently in high-grade than low-grade dysplastic nodules (32.2% vs 9.3% per year, p=0.0039); the maximum time to hepatocellular carcinoma transformation was 27 months for intranodular vs 67 months for extranodular tumours (p=0.025). No contrast-computed tomography pattern predicted neoplastic transformation of dysplastic nodules.

CONCLUSION

The histological examination of liver nodules in cirrhosis lacking the imaging hallmark of hepatocellular carcinoma improves both prognostication and outcome of surveillance, since it dictates the intensity of the radiological follow-up.

Detectability of hepatocellular carcinoma by gadoxetate disodium-enhanced hepatic MRI: tumor-by-tumor analysis in explant livers

PURPOSE

To investigate the detectability of hepatocellular carcinoma (HCC) on Gd-EOB-enhanced MR images (Gd-EOB-MRI), we performed tumor-by-tumor analysis of pathologically confirmed tumors using explants from cirrhotic patients who had undergone liver transplantation.

MATERIALS AND METHODS

We studied 11 explanted livers and classified the tumor intensity during the arterial phase (AP) and the hepatobiliary phase (HBP) as low in HBP with early enhancement (EE) in AP (A), as high in HBP with EE in AP (B), as low in HBP without EE in AP (C), as high in HBP without EE in AP (D), and as iso-intense in HBP with EE in AP (E). The diagnostic criteria for HCC were (i) pattern A and C, (ii) pattern A and E, (iii) pattern C and E, and (iv) patterns A, C, and E.

RESULTS

Of the 71 HCCs, 22 were not detected at MRI; of these, 9 were moderately differentiated and 13 were well-differentiated HCCs. The sensitivity of Gd-EOB-MRI for diagnostic criteria 1, 2, 3, and 4 was 63.4%, 52.1%, 22.5%, and 69.0%.

CONCLUSION

The maximum sensitivity of Gd-EOB-MRI for HCC was only 69.0% even when diagnostic criteria that included all previously reported HCC patterns were adopted.

Hepatocellular carcinoma presenting at contrast-enhanced multi-detector-row computed tomography or gadolinium-enhanced magnetic resonance imaging as a small (≤2 cm), indeterminate nodule: growth rate and optimal interval time for imaging follow-up

OBJECTIVE

The objective of the study was to measure growth rate and to determine the optimal interval time for imaging follow-up of hepatocellular carcinomas (HCCs) presenting at multi-detector-row computed tomography (MDCT) or magnetic resonance imaging (MRI) as small, indeterminate lesions.

METHODS

We included patients with cirrhosis with HCC initially presenting as indeterminate lesion of 2 cm or less at MDCT or MRI August 2005 to August 2009 and with available imaging follow-up. Measures of tumor growth included tumor volume doubling time (TVDT), tumor percentual diameter increase, and tumor percentual volume increase.

RESULTS

We examined 48 patients (mean age, 64 years) with 69 HCCs. At index examination, mean (SD) maximum transverse diameter and volume of lesions were 1.2 (SD, 0.3) cm and 0.6 (SD, 0.7) cm, respectively. Median TVDT was 210 days. Tumors with follow-up longer than 365 days had significant increase in tumor percentual diameter increase and tumor percentual volume increase.

CONCLUSIONS

Median TVDT of 210 days suggests extended follow-up of 6 months for small, indeterminate liver nodules detected at MDCT or MRI.

Intraindividual comparison of gadoxetate disodium-enhanced MR imaging and 64-section multidetector CT in the Detection of hepatocellular carcinoma in patients with cirrhosis

PURPOSE

To prospectively compare gadoxetate disodium-enhanced magnetic resonance (MR) imaging with multiphasic 64-section multidetector computed tomography (CT) in the detection of hepatocellular carcinoma (HCC) in patients with cirrhosis.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were obtained for this prospective study. Fifty-eight patients (39 men, 19 women; mean age, 63 years; age range, 35-84 years) underwent gadoxetate disodium-enhanced MR imaging and multiphasic 64-section multidetector CT. The imaging examinations were performed within 30 days of each other. The two sets of images were qualitatively analyzed in random order by three independent readers in a blinded and retrospective fashion. Using strict diagnostic criteria for HCC, readers classified all detected lesions with use of a four-point confidence scale. The reference standard was a combination of pathologic proof, conclusive imaging findings, and substantial tumor growth at follow-up CT or MR imaging (range of follow-up, 90-370 days). The diagnostic accuracy, sensitivity, and positive predictive value were compared between the two image sets. Interreader variability was assessed. The accuracy of each imaging method was determined by using an adjusted modified chi(2) test.

RESULTS

Eighty-seven HCCs (mean size +/- standard deviation, 1.8 cm +/- 1.5; range, 0.3-7.0 cm) were confirmed in 42 of the 58 patients. Regardless of lesion size, the average diagnostic accuracy and sensitivity for all readers were significantly greater with gadoxetate disodium-enhanced MR imaging (average diagnostic accuracy: 0.88, 95% confidence interval [CI]: 0.80, 0.97; average sensitivity: 0.85, 95% CI: 0.74, 0.96) than with multidetector CT (average diagnostic accuracy: 0.74, 95% CI: 0.65, 0.82; average sensitivity: 0.69, 95% CI: 0.59, 0.79) (P < .001 for each). No significant difference in positive predictive value was observed between the two image sets for each reader. Interreader agreement was good to excellent.

CONCLUSION

Compared with multiphasic 64-section multidetector CT, gadoxetate disodium-enhanced MR imaging yields significantly higher diagnostic accuracy and sensitivity in the detection of HCC in patients with cirrhosis.