EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Consensus report from the 10th Global Forum for Liver Magnetic Resonance Imaging: developments in HCC management

The 10th Global Forum for Liver Magnetic Resonance Imaging (MRI) was held as a virtual 2-day meeting in October 2021, attended by delegates from North and South America, Asia, Australia, and Europe. Most delegates were radiologists with experience in liver MRI, with representation also from specialists in liver surgery, oncology, and hepatology. Presentations, discussions, and working groups at the Forum focused on the following themes: • Gadoxetic acid in clinical practice: Eastern and Western perspectives on current uses and challenges in hepatocellular carcinoma (HCC) screening/surveillance, diagnosis, and management • Economics and outcomes of HCC imaging • Radiomics, artificial intelligence (AI) and deep learning (DL) applications of MRI in HCC. These themes are the subject of the current manuscript. A second manuscript discusses multidisciplinary tumor board perspectives: how to approach early-, mid-, and late-stage HCC management from the perspectives of a liver surgeon, interventional radiologist, and oncologist (Taouli et al, 2023). Delegates voted on consensus statements that were developed by working groups on these meeting themes. A consensus was considered to be reached if at least 80% of the voting delegates agreed on the statements. CLINICAL RELEVANCE STATEMENT: This review highlights the clinical applications of gadoxetic acid-enhanced MRI for liver cancer screening and diagnosis, as well as its cost-effectiveness and the applications of radiomics and AI in patients with liver cancer. KEY POINTS: • Interpretation of gadoxetic acid-enhanced MRI differs slightly between Eastern and Western guidelines, reflecting different regional requirements for sensitivity vs specificity. • Emerging data are encouraging for the cost-effectiveness of gadoxetic acid-enhanced MRI in HCC screening and diagnosis, but more studies are required. • Radiomics and artificial intelligence are likely, in the future, to contribute to the detection, staging, assessment of treatment response and prediction of prognosis of HCC-reducing the burden on radiologists and other specialists and supporting timely and targeted treatment for patients.

Gadoxetate-Enhanced MRI as a Diagnostic Tool in the Management of Hepatocellular Carcinoma: Report from a 2020 Asia-Pacific Multidisciplinary Expert Meeting

Gadoxetate magnetic resonance imaging (MRI) is widely used in clinical practice for liver imaging. For optimal use, we must understand both its advantages and limitations. This article is the outcome of an online advisory board meeting and subsequent discussions by a multidisciplinary group of experts on liver diseases across the Asia-Pacific region, first held on September 28, 2020. Here, we review the technical considerations for the use of gadoxetate, its current role in the management of patients with hepatocellular carcinoma (HCC), and its relevance in consensus guidelines for HCC imaging diagnosis. In the latter part of this review, we examine recent evidence evaluating the impact of gadoxetate on clinical outcomes on a continuum from diagnosis to treatment decision-making and follow-up. In conclusion, we outline the potential future roles of gadoxetate MRI based on an evolving understanding of the clinical utility of this contrast agent in the management of patients at risk of, or with, HCC.

Compressed sensing for breath-hold high-resolution hepatobiliary phase imaging: image noise, artifact, biliary anatomy evaluation, and focal lesion detection in comparison with parallel imaging

PURPOSE

To assess image quality, performance for biliary anatomy diagnosis, and focal lesion detection rate of breath-hold high-resolution 3D T1-weighted hepatobiliary phase imaging using compressed sensing (CS HBP) compared to standard HBP using conventional parallel imaging.

METHODS

This retrospective study assessed consecutive 125 patients who underwent CS HBP and standard HBP between November 2019 and July 2020. Optimized resolution and scan time for CS HBP were 1 × 1.4 × 1 mm³ and 15 s, while those for standard HBP were 1.3 × 1.8 × 3 mm³ and 16 s. Two independent radiologists evaluated qualitative indices on the clarity of liver margin, visibility of the hepatic vessel and bile duct, image noise, and artifact on a 5-point scale. Biliary anatomy, confidence for biliary anatomy diagnosis, expected number of bile duct openings, and number of focal lesions were assessed. Wilcoxon signed-rank test, Pearson chi-square test, and sensitivity for focal lesion were used for statistical analysis. Intraclass correlation coefficient (ICC) and Cohen's kappa (κ) were used to determine inter-observer agreement.

RESULTS

CS HBP showed significantly better liver edge sharpness and bile duct visualization, but greater subjective image noise and non-respiratory artifacts compared to standard HBP. CS HBP showed higher number of concordantly assigned biliary anatomy across readers (86 vs. 80), indicating greater inter-observer agreement for biliary anatomy (κ, 0.67 vs. 0.45) and the number of bile duct openings (ICC, 0.860 vs. 0.579) with significantly higher diagnostic confidence (4.70-4.74 vs. 3.96-4.55; p = 0.002). Both readers identified more focal lesions in CS HBP than in standard HBP (88.2% and 84.5% vs. 66.3% and 73.4%).

CONCLUSION

Breath-hold high-resolution CS HBP was a feasible clinical sequence providing superior liver edge sharpness, bile duct visualization, and focal lesion detection rate compared to standard HBP despite higher noise and artifact. Due to improved spatial resolution, CS HBP yielded a higher inter-observer agreement and confidence for the biliary anatomy diagnosis.

Additional MRI for initial M-staging in pancreatic cancer: a cost-effectiveness analysis

OBJECTIVE

Pancreatic cancer is portrayed to become the second leading cause of cancer-related death within the next years. Potentially complicating surgical resection emphasizes the importance of an accurate TNM classification. In particular, the failure to detect features for non-resectability has profound consequences on patient outcomes and economic costs due to incorrect indication for resection. In the detection of liver metastases, contrast-enhanced MRI showed high sensitivity and specificity; however, the cost-effectiveness compared to the standard of care imaging remains unclear. The aim of this study was to analyze whether additional MRI of the liver is a cost-effective approach compared to routinely acquired contrast-enhanced computed tomography (CE-CT) in the initial staging of pancreatic cancer.

METHODS

A decision model based on Markov simulation was developed to estimate the quality-adjusted life-years (QALYs) and lifetime costs of the diagnostic modalities. Model input parameters were assessed based on evidence from recent literature. The willingness-to-pay (WTP) was set to $100,000/QALY. To evaluate model uncertainty, deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In the base-case analysis, the model yielded a total cost of $185,597 and an effectiveness of 2.347 QALYs for CE-MR/CT and $187,601 and 2.337 QALYs for CE-CT respectively. With a net monetary benefit (NMB) of $49,133, CE-MR/CT is shown to be dominant over CE-CT with a NMB of $46,117. Deterministic and probabilistic survival analysis showed model robustness for varying input parameters.

CONCLUSION

Based on our results, combined CE-MR/CT can be regarded as a cost-effective imaging strategy for the staging of pancreatic cancer.

KEY POINTS

• Additional MRI of the liver for initial staging of pancreatic cancer results in lower total costs and higher effectiveness. • The economic model showed high robustness for varying input parameters.

MR Imaging Contrast Agents: Role in Imaging of Chronic Liver Diseases

Contrast-enhanced MR imaging plays an important role in the evaluation of patients with chronic liver disease, particularly for detection and characterization of liver lesions. The two most commonly used contrast agents for liver MR imaging are extracellular agents (ECAs) and hepatobiliary agents (HBAs). In patients with liver disease, the main advantage of ECA-enhanced MR imaging is its high specificity for the diagnosis of progressed HCCs. Conversely, HBAs have an additional contrast mechanism, which results in high liver-to-lesion contrast and highest sensitivity for lesion detection in the hepatobiliary phase. Emerging data suggest that features depicted on contrast-enhanced MR imaging scans are related to tumor biology and are predictive of patients' prognosis, likely to further expand the role of contrast-enhanced MR imaging in the clinical care of patients with chronic liver disease.

Relationship between quantitative contrast-enhanced ultrasonography parameters and angiogenesis in primary small hepatocellular carcinoma: A retrospective study

To analyze the correlation between quantitative contrast-enhanced ultrasonography (CEUS) parameters and angiogenesis in primary small hepatocellular carcinoma (sHCC) with varying degrees of differentiation.According to varying degrees of differentiation, a total of 90 primary sHCC patients admitted to our hospital from July 2018 to January 2020 were selected and divided into poorly differentiated group (24 cases), moderately differentiated group (31 cases), and highly differentiated group (35 cases). All patients received real-time CEUS before surgery. The tumor diameter, microvascular morphology, grading of color blood flow, contrast-enhanced performance in different phases, quantitative CEUS parameters, expression of angiogenesis-related genes, and microvessel density (MVD) were compared among the 3 groups. The correlation between quantitative parameters of CEUS and angiogenesis indexes was analyzed by Spearman rank correlation analysis.Spearman rank correlation analysis showed that vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), epidermal growth factor receptor (EGFR), and angiopoietin-2 (Ang-2) expression and MVD were negatively correlated with the time to peak (TTP), wash-out time, and peak accelerating time (PAT) (r < 0, P < .05), and were positively correlated with enhancing slope rate (ESR) and peak intensity increasing rate (PIIR) (r > 0, P < .05).CEUS is able to identify varying degrees of differentiation in primary sHCC, and the quantitative CEUS parameters are closely related to angiogenesis.

Abbreviated MRI protocol for colorectal liver metastases: How the radiologist could work in pre surgical setting

Background

MRI is the most reliable imaging modality that allows to assess liver metastases. Our purpose is to compare the per-lesion and per-patient detection rate of gadoxetic acid-(Gd-EOB) enhanced liver MRI and fast MR protocol including Diffusion Weighted Imaging (DWI) and T2-W Fat Suppression sequence in the detection of liver metastasis in pre surgical setting.

Methods

One hundred and eight patients with pathologically proven liver metastases (756 liver metastases) underwent Gd-EOBMRI were enrolled in this study. Three radiologist independently graded the presence of liver lesions on a five-point confidence scale assessed only abbreviated protocol (DWI and sampling perfection with application-optimized contrasts using different flip angle evolution (SPACE) fat suppressed sequence) and after an interval of more than 2 weeks the conventional study (all acquired sequences). Per-lesion and per-patient detection rate of metastases were calculated. Weighted к values were used to evaluate inter-reader agreement of the confidence scale regarding the presence of the lesion.

Results

MRI detected 732 liver metastases. All lesions were identified both by conventional study as by abbreviated protocol. In terms of per-lesion detection rate of liver metastasis, all three readers had higher detection rate both with abbreviated protocol and with standard protocol with Gd-EOB (96.8% [732 of 756] vs. 96.5% [730 of 756] for reader 1; 95.8% [725 of 756] vs. 95.2% [720 of 756] for reader 2; 96.5% [730 of 756] vs. 96.5% [730 of 756] for reader 3). Inter-reader agreement of lesions detection rate between the three radiologists was excellent (k range, 0.86–0.98) both for Gd-EOB MRI and for Fast protocol (k range, 0.89–0.99).

Conclusion

Abbreviated protocol showed the same detection rate than conventional study in detection of liver metastases.

Detection of pancreatic ductal adenocarcinoma and liver metastases: comparison of Gd-EOB-DTPA-enhanced MR imaging vs. extracellular contrast materials

PURPOSE

To compare the detectability of pancreatic ductal adenocarcinoma (PDAC) and liver metastases between Gd-EOB-DTPA- and extracellular contrast materials (ECCMs) contrast-enhanced MR imaging contrast.

METHODS

Two hundred seventy-two patients with suspected pancreatic disease underwent Gd-EOB-DTPA-enhanced MR imaging (EOB group, n = 79) or ECCMs-enhanced MR imaging (ECCM group, n = 193). The ECCM group were administered the following contrast agents: Gd-DTPA (n = 158), Gd-BT-DO3A (n = 28), Gd-DOTA (n = 5), and Gd-DTPA-BMA (n = 2). Signal intensities of pancreatic parenchyma, paraspinal muscle, PDAC (if present), and background noise were measured. The signal intensity ratio (SIR) of the pancreas and tumor-to-pancreas contrast-to-noise ratio (CNR) were also calculated. If present, the conspicuity of PDAC was evaluated with the arterial dominant phase images. Liver metastases, if present, were also evaluated for all sequences. Qualitative and quantitative imaging parameters were compared between EOB and ECCM groups.

RESULTS

SIR of the pancreas (P < 0.001) and CNR (P = 0.0037) were significantly lower in EOB group when compared with the ECCM group. However, the sensitivity (97.1% vs. 93.5%, P = 0.42) and specificity (100.0% vs. 99.2%, P = 1.00) for detecting PDAC were not significant between EOB and ECCM groups. The EOB group showed a significantly greater sensitivity for detecting liver metastases compared with the ECCM group (95.0% vs 84.5%, P = 0.04) when evaluating on a lesion-by-lesion basis.

CONCLUSION

Gd-EOB-DTPA-enhanced MR imaging performed similarly to ECCMs-enhanced MR imaging in detecting PDAC but had better sensitivity in detecting liver metastases.

Use of Gadoxetic Acid-enhanced Liver MRI and Mortality in More than 30 000 Patients with Hepatocellular Carcinoma: A Nationwide Analysis

Background The impact on survival of gadoxetic acid-enhanced MRI in addition to multiphase contrast material-enhanced CT for initial staging in patients with hepatocellular carcinoma (HCC) is unknown. Purpose To compare all-cause mortality in patients with HCC who underwent CT only, CT plus non-gadoxetic acid-enhanced MRI, or CT plus gadoxetic acid-enhanced MRI as part of their initial diagnostic work-up. Materials and Methods The authors performed a nationwide retrospective cohort study of patients diagnosed with HCC in South Korea between January 2008 and December 2010. Follow-up extended through December 2014. The primary outcome was all-cause mortality. Cox proportional hazards regression model with adjustment of confounding factors was used to estimate hazard ratios (HRs) for all-cause mortality. Results Among 30 023 patients with HCC (mean age ± standard deviation, 58.5 years ± 10.7, 23 978 men), the proportions of patients in whom HCC was diagnosed using CT only, CT plus non-gadoxetic acid-enhanced MRI, and CT plus gadoxetic acid-enhanced MRI were 56.1%, 12.9%, and 31.0%, respectively. In adjusted analysis using CT only as the reference category, the HR for mortality for CT plus gadoxetic acid-enhanced MRI was 0.64 (95% confidence interval [CI]: 0.62, 0.67; P < .001), and the HR for CT plus non-gadoxetic acid-enhanced MRI was 0.71 (95% CI: 0.68, 0.75; P < .001). Use of CT plus gadoxetic acid-enhanced MRI was associated with lower mortality compared with CT plus non-gadoxetic acid-enhanced MRI (adjusted HR, 0.90; 95% CI: 0.85, 0.95; P < .001), but this survival advantage was restricted to patients with localized disease. Conclusion In patients with hepatocellular carcinoma, additional use of contrast-enhanced MRI was associated with lower mortality. Furthermore, CT plus gadoxetic acid-enhanced MRI was associated with better survival than CT plus non-gadoxetic acid-enhanced MRI but only in patients with localized disease. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kim in this issue.

Relationship between MRI delayed enhancement of primary hepatocellular carcinoma and distribution of different fibrous components in pathological tissues

BACKGROUND

Primary hepatocellular carcinoma (HCC) is one of common malignant tumors in China, and magnetic resonance imaging (MRI) has a big advantage in the diagnosis of tumor diseases due to its high resolution. However, tumors with different fibrous components may have different enhancement characteristics. This research aimed to explore the relationship between MRI delayed enhancement characteristics of primary HCC and the distribution of different fibrous components in tumor tissue.

AIM

To observe the relationship between MRI delayed enhancement and the distribution of different fibrous components in primary HCC.

METHODS

From April 2016 to May 2019, 56 patients diagnosed with primary HCC and treated at our hospital were included. All patients underwent routine and enhanced MRI examinations, and 2-min delay images were analyzed to assess the degree of enhancement of the edge and internal portion of lesions and measure the thickness of edge annular enhancement in the MRI delay phase. Surgical samples were collected for routine HE staining. Resorcin-fuchsin staining, Masson trichromic staining, and argento-ammonia hydroxide staining were used to observe the thickness and distribution characteristics of the three types of fibers in the capsule.

RESULTS

There was no significant difference between patients with different degrees of edge annular enhancement in MRI delay phase in terms of capsule thickness and the infiltration degree of inflammatory cells outside the capsule (P > 0.05), while there was a significant difference between the vessels inside the capsule (P < 0.05). Lesions with a complete capsule had full annular enhancement, while those with an incomplete capsule had discontinuous enhancement. The thickness of annular enhancement in the 44 lesions was significantly correlated with capsule thickness, degree of inflammatory cell infiltration outside the capsule, and the number of capsular vessels (P < 0.05). Inside the lesions, the tumor tissue was rich in blood vessels, had less fiber content, and showed various fibrous tissue distribution in different lesions. There were statistically significant differences in the infiltration degree of inflammatory cells and the contents of collagen fibers, elastic fibers, and reticular fibers in patients with different degrees of internal enhancement in the MRI delay phase (P < 0.05).

CONCLUSION

The peripheral and internal enhancement characteristics of primary HCC in the delay phase of MRI are related to the infiltration of inflammatory cells and fibrous tissue distribution.

Use of gadoxetate disodium in patients with chronic liver disease and its implications for liver imaging reporting and data system (LI-RADS)

Use of gadoxetate disodium, a hepatobiliary gadolinium-based agent, in patients with chronic parenchymal liver disease offers the advantage of improved sensitivity for detecting hepatocellular carcinoma (HCC). Imaging features of liver observations on gadoxetate-enhanced MRI may also serve as biomarkers of recurrence-free and overall survival following definitive treatment of HCC. A number of technical and interpretative pitfalls specific to gadoxetate exist, however, and needs to be recognized when protocoling and interpreting MRI exams with this agent. This article reviews the advantages and pitfalls of gadoxetate use in patients at risk for HCC, and the potential impact on Liver Imaging Reporting and Data System (LI-RADS) imaging feature assessment and categorization. Level of Evidence: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;49:1236-1252.