Sonographic appearance of focal liver lesions and likelihood of hepatocellular carcinoma in adult Thais with chronic hepatitis B virus infection

PURPOSE

The objective of our study was to study and compare the sonographic findings of hepatocellular carcinoma (HCC) and benign liver lesions, and apply these to an HCC surveillance program in patient with chronic hepatitis B virus (HBV).

METHODS

Sonographic findings of HCC and benign liver lesions were retrospectively reviewed following diagnosis based on either computer tomography or magnetic resonance imaging from July 2010 to December 2020. Multiple sonographic features were analyzed, including internal echogenicity, rim characteristics, and posterior acoustic enhancement. Associations between sonographic characteristics and HCC were assessed using uni- and multi-variate logistic regression analyses.

RESULTS

Of the focal liver lesions in 337 chronic HBV patients, there were 25 HCC and 410 benign lesions, with median sizes of 1.6 and 1.0 cm, respectively. Three ultrasound patterns, homogeneous hypoechogenicity, heterogeneous echogenicity, and hypoechoic rims were more frequently found in HCC than in benign lesions. Moreover, the hypoechoic rim feature was the only sonographic pattern independently associated with HCC (Odds ratio, 68.05; 95% confidence interval, 7.37-628.10; p-values < 0.001). In a subgroup analysis of the lesions sized 2 cm or smaller, no sonographic findings were associated with HCC.

CONCLUSION

A hypoechoic rim was a sonographic feature independently associated with HCC. These findings may aid in improving HCC detection and guiding management during HCC screening and surveillance with ultrasound.

Cost-Effectiveness Analysis of Ultrasound Surveillance for Cholangiocarcinoma in an Endemic Area of Thailand

OBJECTIVE

This research aimed to analyze the cost-effectiveness of ultrasound surveillance for Cholangiocarcinoma (CCA) in a high-risk population residing in the northern region of Thailand and compare these results with the non-surveillance patients who presented with CCA.

METHODS

This was a retrospective descriptive study of two groups monitored and treated for CCA in the same institute, but differing as to whether ultrasound was included in the surveillance. The ultrasound surveillance group comprised those who participated in the cohort study of CCA at Chulabhorn Hospital from 2011 to 2017. Whereas, the non-ultrasound surveillance group consisted of patients treated for CCA at Chulabhorn Hospital from 2009 to 2015 (and not part of the first group). Historical data and societal perspectives were analyzed and interpreted using a decision tree model. The results of one-way sensitivity analyses of probability and cost parameters affecting the change in incremental cost-effectiveness ratio (ICER) were analyzed and presented using tornado diagrams.

RESULT

The ultrasound surveillance group had the quality-adjusted life years gained (QALY gained) of 0.117 years, resulting in the incremental cost-effectiveness ratio (ICER) of 152,985 Thai Baht (THB) or equal to 4,222.6 US-dollars (USD) /QALY gained which is about when compared to the non-ultrasound surveillance group. Moreover, the ICER value was within the willingness to pay (WTP) calculated for Thailand of 4,416.2 USD (160,000 THB) /QALY gained.  The probability of non-diagnostic CCA in non-ultrasound surveillance group and the cost of abdominal ultrasound were found to be major factors affecting the ICER.

CONCLUSION

Ultrasound surveillance of CCA was cost-effective in Thailand. This information can be helpful for national policy planning in regard to Thai populations at high risk of CCA. Further study is recommended to assess cost-effectiveness in other areas with lower incidences of CCA.

Improvement of liver fibrosis, but not steatosis, after HCV eradication as assessment by MR-based imaging: Role of metabolic derangement and host genetic variants

Significant liver fibrosis regression occurs after hepatitis C virus (HCV) therapy. However, the impact of direct-acting antivirals (DAAs) on steatosis is less clear. This study was aimed at evaluating serial fibrosis and steatosis alterations in patients with HCV genotype 1, who achieved sustained virological response (SVR). We enrolled 55 HCV mono-infected and 28 HCV/HIV co-infected patients receiving elbasvir/grazoprevir from a clinical trial. Fibrosis and steatosis were assessed at baseline, follow-up week-24 (FUw24) and week-72 (FUw72) by magnetic resonance elastography (MRE) and proton density fat fraction (PDFF), respectively. Patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs738409, transmembrane six superfamily member 2 (TM6SF2) rs58542926 and membrane bound O-acyltransferase domain-containing 7 (MBOAT7) rs641738 polymorphisms were determined by allelic discrimination. Overall, mean MRE decreased significantly from baseline to FUw24 and FUw72. At FUw72, patients with baseline F2-F4 had higher rate of ≥30% MRE decline compared with individuals with baseline F0-F1 (30.2%vs.3.3%, P = 0.004). In multivariate analysis, significant fibrosis was associated with MRE reduction. The prevalence of steatosis (PDFF≥5.2%) at baseline was 21.7%. Compared to baseline, there were 17 (20.5%) patients with decreased PDFF values at FUw72 (<30%), while 23 (27.7%) patients had increased PDFF values (≥30%). Regarding the overall cohort, mean PDFF significantly increased from baseline to FUw72, and displayed positive correlation with body mass index (BMI) alteration. In multivariate analysis, the presence of diabetes, PNPLA3 CG+GG genotypes and increased BMI at FUw72 were significantly associated with progressive steatosis after SVR. Other genetic variants were not related to fibrosis and steatosis alteration. This study concluded that HCV eradication was associated with fibrosis improvement. However, progressive steatosis was observed in a proportion of patients, particularly among individuals with metabolic derangement and PNPLA3 variants. The combined clinical parameters and host genetic factors might allow a better individualized strategy in this sub-group of patients to alleviate progressive steatosis after HCV cure.

Video-assisted liver ultrasound training for non-radiologists: protocol and preliminary results

BACKGROUND

Ultrasound (US) is increasingly used as a bedside diagnostic tool, with training courses for non-radiologists being developed. However, the training time constraint is an important barrier for non-radiologists. We therefore created a short self-learning course for liver-US for non-radiologists.

AIM

Assess the participants' ability in identifying the organ structures during a liver-US.

METHOD

A short video-lecture on liver-US training and a portable guidebook for image acquisition were developed. Eighteen non-radiologist physicians studied the course and attended hands-on liver-US examinations to capture the assigned images and label the acquired organ/structures, which were evaluated by an expert radiologist.

RESULT

130 liver-US examinations were performed, 44 (33.8%) was cirrhosis. The overall of mean image acquisition score was 84.5 ± 9.7%. The mean score of the 1st examination was 75.2 ± 16.4. The mean score was >80% since the 2nd examination. The score was significant lower in cirrhotic cases as compared to non-cirrhotic cases (78.8 ± 17.3 vs. 88.3 ± 14.4, p = 0.001). The participants' year of study and experience in previous US training did not affect the image acquisition score.

CONCLUSION

The liver-US training course in a short video format with a portable guidebook is effective and relatively low time-consuming for teaching non-radiologists to perform bedside liver-US.

Liver fibrosis improvement assessed by magnetic resonance elastography and Mac-2-binding protein glycosylation isomer in patients with hepatitis C virus infection receiving direct-acting antivirals

AIM

Fibrosis regression has been observed in patients with chronic hepatitis C virus (HCV) infection treated with direct-acting antivirals. This study was aimed at evaluating dynamic changes of serum Mac-2-binding protein glycosylation isomer (M2BPGi) in patients with HCV genotype 1 receiving elbasvir/grazoprevir.

METHODS

M2BPGi were serially measured at baseline, during and after therapy. Its diagnostic performance at baseline and sustained virological response at 24 weeks after treatment (SVR24) were compared with transient elastography (TE) and the aspartate aminotransferase/platelet ratio index (APRI) using magnetic resonance elastography (MRE) as a reference.

RESULTS

Overall, 60 HCV mono-infected and 36 HCV/HIV co-infected patients were included with SVR24 rates of 93.3% and 97.2%, respectively. At baseline, TE, M2BPGi and APRI were correlated with MRE (r = 0.788, r = 0.703 and r = 0.564, respectively, p < 0.001). The area under the receiver operator characteristics curves for TE, M2BPGi and APRI in differentiating significant fibrosis were 0.88 (95% confidence interval; 0.81-0.95, p < 0.001), 0.86 (0.79-0.94, p < 0.001) and 0.74 (0.64-0.83, p < 0.001), respectively. The corresponding figures for cirrhosis were 0.95 (0.90-1.00, p < 0.001), 0.96 (0.92-1.00, p < 0.001) and 0.88 (0.79-0.97, p < 0.001), respectively. Compared with baseline, all fibrosis markers significantly declined after achieving SVR24. The correlations of TE, M2BPGi and APRI with MRE at time of SVR24 were r = 0.587 (p < 0.001), r = 0.457 (p < 0.001) and r = 0.293 (p = 0.004), respectively. In multivariate analysis, high baseline alanine aminotransferase level, HCV mono-infection and advanced fibrosis were factors associated with M2BPGi reduction.

CONCLUSIONS

HCV eradication is associated with liver fibrosis improvement. M2BPGi has a better performance than APRI in monitoring liver fibrosis in patients treated with direct-acting antivirals. This marker is applicable in resource-limited settings where imaging-based modalities are not widely accessible.

Determination of radiation dose and low-dose protocol for digital chest tomosynthesis using radiophotoluminescent (RPL) glass dosimeters

PURPOSE

This study aimed to determine a low-dose protocol for digital chest tomosynthesis (DTS).

METHODS

Five simulated nodules with a CT number of approximately 100 HU with size diameter of 3, 5, 8, 10, and 12 mm were inserted into an anthropomorphic chest phantom (N1 Lungman model), and then scanned by DTS system (Definium 8000) with varying tube voltage, copper filter thickness, and dose ratio. Three radiophotoluminescent (RPL) glass dosimeters, type GD-352 M with a dimension of 1.5 × 12 mm, were used to measure the entrance surface air kerma (ESAK) in each protocol. The effective dose (ED) was calculated using the recorded total dose-area-product (DAP). The signal-to-noise ratio (SNR) was determined for qualitative image quality evaluation. The image criteria and nodule detection capability were scored by two experienced radiologists. The selected low-dose protocol was further applied in a clinical study with 30 pulmonary nodule follow-up patients.

RESULTS

The average ESAK obtained from the standard default protocol was 1.68 ± 0.15 mGy, while an ESAK of 0.47 ± 0.02 mGy was found for a low-dose protocol. The EDs for the default and low-dose protocols were 313.98 ± 0.72 µSv and 100.55 ± 0.28 µSv, respectively. There were small non-significant differences in the image criteria and nodule detection scoring between the low-dose and default protocols interpreted by two radiologists. The effective dose of 98.87 ± 0.08 µSv was obtained in clinical study after applying the low-dose protocol.

CONCLUSIONS

The low-dose protocol obtained in this study can substantially reduce radiation dose while preserving an acceptable image quality compared to the standard protocol.

Premalignant lesions of cholangiocarcinoma: characteristics on ultrasonography and MRI

BACKGROUND AND OBJECTIVE

Cholangiocarcinoma (CCA) is an aggressive malignancy with high prevalence rate in Asia. The CCA premalignant lesions, including Biliary intraepithelial neoplasia (Bil-IN) and Intraductal papillary neoplasm of biliary tract (IPNB), share a common carcinogenesis; however, on imaging, patterns of presentation are different. Patterns and imaging characteristics on ultrasonography (US) and Magnetic resonance imaging (MRI) of both Bil-IN and IPNB are reported herein.

METHODS

In this retrospective study of imaging findings in premalignant CCA, pathology-proven cases of Bil-IN and IPNB at Chulabhorn Hospital were analyzed. Demographics, locations of lesions, imaging characteristics of both Bil-IN and IPNB were assessed, compared, and described.

RESULTS

Twenty-one premalignant lesions, 13 Bil-INs and 8 IPNBs, from 18 patients were included. Both Bil-IN and IPNB lesions were found more commonly at the right than left intrahepatic ducts (66.7% vs. 33.3%), and had more peripheral than central locations (85.7% vs. 14.3%). On US, Bil-IN commonly presented as focal bile duct dilatation (76.9%), whereas IPNB was more variable with hyperechoic nodules (37.5%), focal bile duct dilatation (37.5%), and diffuse bile duct dilatation with intraductal nodules (25%). On MRI, focal bile duct dilatation and nonfunctioning bile excretion are the most sensitive findings with sensitivities in the range of 84.6% to 100%. The presence of intraductal nodules and connection to the biliary system are findings that were significantly different between IPNB and Bil-IN, 62.5% versus 7.7% (p = 0.014) and 75% versus 15.4% (p = 0.018), respectively.

CONCLUSIONS

Premalignant lesions of CCA, including Bil-IN and IPNB, have different imaging presentations. Knowledge of imaging presentations may improve early detection and increase confidence in diagnosis.

Ultrasound surveillance for cholangiocarcinoma in an endemic area: A prove of survival benefits

BACKGROUND AND AIM

Cholangiocarcinoma (CCA) is an aggressive malignancy with rapid progression and poor prognosis. Abdominal ultrasound surveillance may detect early-stage malignancy and improve surgical outcome. However, little data exist on the benefits of abdominal ultrasound surveillance in populations at high risk for CCA development in an endemic area. This study compared survival outcomes of CCA patients recruited through abdominal ultrasound surveillance program and those presented to the hospital independent of surveillance.

METHODS

The surveillance population-based cohort was 4225 villagers in Northern Thailand, aged 30-60 years, who consented to a 5-year abdominal ultrasound surveillance program, which included interval ultrasound examinations every 6 months. The non-surveillance cohort was hospital-based CCA patients diagnosed during April 2007 to November 2015. Numbers of operable tumors, percentages of R0 resection, and survival analyses were compared between the two cohorts.

RESULTS

There were 48 and 192 CCA patients in the surveillance and the non-surveillance cohorts, respectively. Of these, 37/48 (77.1%) and 22/192 (11.5%) were in an operable stage and R0 resections performed in 36/48 (97.3%) and 14/192 (63.6%), respectively. The median survival in each group was 31.8 and 6.7 months, respectively (with correction of lead time bias) (P < 0.0001). By multivariate analysis, abdominal ultrasound surveillance (hazard ratio [HR] = 0.41; P = 0.012), operable stage (HR = 0.11; P < 0.001), and serum albumin ≥ 3.5 g/dL (HR = 0.42; P < 0.001) were significantly associated with decreased mortality, whereas size of CCA (HR = 1.11; P < 0.001), serum alanine aminotransferase > 40 IU/L (HR = 1.71; P = 0.017), and tumor recurrence (HR = 4.86; P = 0.017) were associated with increased mortality.

CONCLUSION

Abdominal ultrasound surveillance provided survival benefits and should be considered in areas highly endemic for CCA to reduce mortality.

Radiofrequency ablation of hepatocellular carcinoma as bridge therapy to liver transplantation: A 10-year intention-to-treat analysis

In a long-term (10-year) study of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) as bridging therapy in patients listed for orthotopic liver transplantation (LT), we evaluated the impact of RFA on waiting list dropout rate, post-LT tumor recurrence, and long-term intention-to-treat, disease-specific survival (DSS). From March 2004 to October 2014, RFA was performed as the initial stand-alone bridge therapy to LT for 121 patients (men/women ratio, 83:38; mean age, 60.0 years) with 156 de novo HCCs (mean size, 2.4 cm). Follow-up period from initial RFA ranged from 1.3 to 128.0 months (median, 42.9 months). We assessed the overall and tumor-specific waiting list dropout rates, post-LT tumor recurrence, and 10-year post-LT and intention-to-treat survival rates. Dropout from the waiting list due to tumor progression occurred in 7.4% of patients. HCC recurrence after LT occurred in 5.6% of patients. The post-LT overall survival (OS) rate at 5 and 10 years was 75.8% and 42.2%, respectively, and the recurrence-free survival (RFS) rate was 71.1% and 39.6%, respectively. Intention-to-treat OS, RFS, and DSS rates for the entire study population at 5 and 10 years were 63.5% and 41.2%, 60.8% and 37.7%, and 89.5% and 89.5%, respectively.

CONCLUSION

RFA as a first-line stand-alone bridge therapy to LT achieves excellent long-term overall and tumor-specific survivals, with a low dropout rate from tumor progression despite long wait list times and a sustained low tumor recurrence rate upon post-LT follow-up of up to 10 years. (Hepatology 2017;65:1979-1990).

Longterm follow-up of small pancreatic cystic lesions in liver transplant recipients

Incidental small pancreatic cystic lesions (PCLs) are often found on preoperative imaging in patients undergoing orthotopic liver transplantation (OLT). Although these are considered benign or of low malignant potential, the influence of immunosuppression after OLT may be of concern. The aim of this study was to observe the longterm outcome of these small PCLs in post-OLT patients. An institutional OLT database of 1778 consecutive OLT patients from January 2000 to December 2010 was analyzed. Computed tomography, magnetic resonance imaging, or endoscopic ultrasound at the time of OLT and all subsequent imaging, cytology, fluid analysis of PCLs, and patient status were evaluated. A total of 70 patients with 182 PCLs, of benign or low malignant potential, were identified with a mean follow-up time of 64 months. At initial diagnosis of PCLs in 48 patients, 7 branch duct-type intraductal papillary mucinous neoplasms (B-IPMNs), 1 serous cystadenoma (SCA), and 40 nonspecific benign cysts were identified. Final diagnosis at the end of the follow-up revealed 16 B-IPMNs, 3 SCAs, and a mixed acinar-neuroendocrine carcinoma, in which the latter developed 9 years after initial diagnosis of B-IPMN. During the follow-up time, average increase in size and number of PCLs were 4.5 mm and 1.4, respectively (P < 0.001 for both). The majority of incidental PCLs in OLT patients showed an indolent behavior despite immunosuppression. Risk of malignancy development was very low and comparable with normal population. Liver Transplantation 23 324-329 2017 AASLD.

Does hepatobiliary phase sequence qualitatively outperform unenhanced T1-weighted imaging in assessment of the ablation margin 24 hours after thermal ablation of hepatocellular carcinomas?

PURPOSE

To retrospectively determine whether hepatobiliary phase (HBP) sequence outperforms unenhanced T1-weighted imaging (uT1wI) in distinguishing the ablation margin (AM) from hepatocellular carcinoma (HCC) 24 h after thermoablation.

MATERIAL AND METHODS

Ninety-one patients [mean age, 65.7 years; 68 M/23F] with 138 HCCs (>6 months follow-up) underwent pre- and postablation gadoxetate disodium-enhanced MRI. AM showed a hyperintense middle zone (MZ) surrounding central hypo- or hyperintense HCCs on uT1wI, and an intermediate-intense MZ encompassing central hypo- or hyperintense HCCs during HBP. The visible AM was defined as persistent MZ around HCCs, which were demarcated from MZ, or peripherally band encompassing MZ, which were not demarcated from HCC. The indefinite AM was defined as no demarcating HCCs from MZ. The ability to distinguish AM from HCC was classified as visible or indefinite on axial (ax)-uT1wI, ax-HBP, coronal (cor)-HBP, and combined all images. To investigate the AM visibility during HBP, significance of differences upon comparison of ax-uT1wI with combined images was analyzed. Preablation liver-tumor contrast ratio (LTCR) on ax-uT1wI and ax-HBP sequence is compared between the visible and indefinite AM.

RESULTS

The McNemar test demonstrated a significant increase (p < 0.05) in visible AM from ax-uT1wI (60), to ax-HBP (70), cor-HBP (79), and combined images (83). TLCR with visible AM was significantly higher than that with indefinite AM on ax-uT1wI (0.4 vs. 0.2, p = 0.001) and ax-HBP sequence (0.9 vs. 0.6, p = 0.004).

CONCLUSIONS

HBP sequence might have higher feasibility to distinguish AM from tumor than ax-uT1wI. The TLCR value in visible AM was higher than that in indefinite AM on both ax-uT1wI and ax-HBP sequences.

Hepatocellular carcinoma screening and surveillance in 2293 chronic hepatitis B patients in an endemic area

AIM

To determine the role of screening and surveillance of hepatocellular carcinoma (HCC) in treatment-naïve chronic hepatitis B (CHB) patients.

METHODS

We recruited 2293 CHB patients (both males and females; aged 20-65 years). All patients were screened and underwent surveillance using abdominal ultrasonography (AUS) and serum alpha-fetoprotein (AFP) assay every 6 mo. The diagnosis, staging and treatment of HCC followed the American Association for the Study of Liver Diseases practice guidelines and the Barcelona Clinic Liver Cancer guidelines. The exclusion criteria included: decompensated cirrhosis; a history of any cancer in the last 5 years; previous antiviral treatment for CHB; concurrent infection with hepatitis C virus or human immunodeficiency virus; a Karnofsky Performance Status score < 60%; or any medical condition preventing eligibility to complete the protocol. The prevalence and incidence rates of HCC were determined; survival rates were calculated at 3-year post HCC diagnosis. The sensitivity and specificity were calculated on a per-patient basis.

RESULTS

Among 2293 treatment-naïve CHB patients, seven cases had HCC at initial screening, giving a prevalence rate of 305 per 100000 persons; 3.3% were diagnosed with liver cirrhosis, all of which were Child-Pugh class A. With a median follow-up time of 42 (range, 3-48) mo, 10 additional cases were diagnosed with HCC, resulting in an incidence rate of 143 per 100000 persons per year. This burden was as high as that reported in other studies from East Asian countries. All HCC patients were aged ≥ 40 years. Most were at an early stage (Stage 0, A or B); 14/17 cases were successfully treated with surgical resection or radiofrequency ablation, with a high 3-year survival rate of 90%. Hemangioma was the most common focal liver lesion in CHB patients detected by AUS; the main causes of AFP elevation at the initial screening were cirrhosis, increased alanine aminotransferase level and HCC. AUS detected 16/17 HCC cases whereas AFP levels ≥ 20 μg/L at diagnosis were observed in only 7/17 patients, most with a tumor size > 5 cm. For HCC screening and surveillance, AUS had a sensitivity and specificity of 94% and 82%, respectively, whereas the sensitivity and specificity of AFP at a cut-off value of ≥ 20 μg/L were 41% and 98%, respectively. Combined use of AUS and AFP assay did not improve effectiveness.

CONCLUSION

Implementation of active screening and surveillance using AUS to detect early-stage HCC in naïve CHB patients aged ≥ 40 years in an endemic area is of benefit.

Ultrasound screening for cholangiocarcinoma could detect premalignant lesions and early-stage diseases with survival benefits: a population-based prospective study of 4,225 subjects in an endemic area

Background

Thailand has a high incidence of cholangiocarcinoma (CCA), particularly in the north and northeastern regions. Most CCA patients come at a late, unresectable stage and presently no optimal screening test for CCA has been established. We determined the prevalence of CCA in a remote northern village and explored if screening could lead to early detection and survival benefits.

Methods

A 5-year population-based study was started in October, 2011 for consented Thai individuals, aged 30–60 years. The screening program comprised blood testing, stool examination and serial ultrasonography every 6 months.

Results

During the first 3 years, 4,225 eligible individuals were enrolled. CCA was detected in 32 patients, with a mean age of 51.9 years (41–62 years), and 21/32 cases were at a curative resectable stage. The prevalence rate of CCA was 165.7 per 100,000 and one- and two-year incidence rate was 236.7/100,000 and 520.7/100,000, respectively. One- and 2-year overall survival rates of CCA patients were 90.9 and 61.5 %, respectively. Prognosis was better in resectable cases with 100 % 1-year and 77.8 % 2-year survival rates. Interestingly, premalignant pathological lesions (stage 0) were identified in 11 cases with 100 % 3-year survival rate. Serum biomarkers and alkaline phosphatase were not sufficient to detect early-stage disease. In 22 patients, stool samples were positive for Opistorchis viverrini, based on polymerase chain reaction.

Conclusion

Detection of premalignant lesions and early-stage resectable CCA by ultrasonography resulted in improved clinical outcome. Ultrasonography should be offered as a first screening tool for CCA in an endemic area until other useful biological markers become available.

Microwave ablation of liver tumors: degree of tissue contraction as compared to RF ablation

PURPOSE

To compare the amount of tissue contraction after microwave (MW) versus radiofrequency (RF) ablation of liver tumors.

MATERIALS AND METHODS

Seventy-five hepatic tumors in 65 patients who underwent percutaneous MW or RF ablations were included in this retrospective study. All patients underwent MRI within 6 months before the ablation and 24 h after the procedure. Two blinded radiologists, by consensus, performed measurements on the corresponding series of pre and post-ablation MRI. Absolute and relative contraction of liver, tumor, and control were calculated and compared.

RESULTS

Thirty-one patients underwent MW ablations, and 44 patients underwent RF ablations. The absolute and relative contraction of the ablation zone were significantly greater with MW than RF ablation (p = 0.003 to <0.001). Thirty-two lesions were visible on both pre- and post-ablation MRI. MW ablation had significantly more tumor contraction as compared to RF ablation (p = 0.003 to 0.009). The control measurements demonstrated no significant difference in normal tissue variation between MW and RF groups.

CONCLUSIONS

MW ablation of hepatic tumors produced significantly more contraction of tumor and ablated hepatic tissue compared to RF ablation. Tissue contraction should be taken into account during pre-procedural planning and assessing treatment response by comparing pre- and post-ablation images.

Preliminary Outcome of Microwave Ablation of Hepatocellular Carcinoma: Breaking the 3-cm Barrier?

PURPOSE

To evaluate preliminary outcomes after microwave ablation (MWA) of hepatocellular carcinoma (HCC) up to 5 cm and to determine the influence of tumor size.

MATERIALS AND METHODS

Electronic records were searched for HCC and MWA. Between January 2011 and September 2014, 173 HCCs up to 5 cm were treated by MWA in 129 consecutive patients (89 men, 40 women; mean age, 66.9 y ± 9.5). Tumor characteristics related to local tumor progression and primary and secondary treatment efficacy were evaluated by univariate analysis. Outcomes were compared between tumors ≤ 3 cm and tumors > 3 cm.

RESULTS

Technical success, primary efficacy, and secondary efficacy were 96.5%, 99.4%, and 94.2% at a mean follow-up period of 11.8 months ± 9.8 (range, 0.8-40.6 mo). Analysis of tumor characteristics showed no significant risk factor for local tumor progression, including subcapsular location (P = .176), tumor size (P = .402), and perivascular tumor location (P = .323). The 1-year and 2-year secondary or overall treatment efficacy rates for tumors measuring ≤ 3 cm were 91.2% and 82.1% and for tumors 3.1-5 cm were 92.3% and 83.9% (P = .773). The number of sessions to achieve secondary efficacy was higher in the larger tumor group (1.13 vs 1.06, P = .005). There were three major complications in 134 procedures (2.2%).

CONCLUSIONS

With use of current-generation MWA devices, percutaneous ablation of HCCs up to 5 cm can be achieved with high efficacy.

A computed tomography radiogenomic biomarker predicts microvascular invasion and clinical outcomes in hepatocellular carcinoma

Microvascular invasion (MVI) in hepatocellular carcinoma (HCC) is an independent predictor of poor outcomes subsequent to surgical resection or liver transplantation (LT); however, MVI currently cannot be adequately determined preoperatively. Radiogenomic venous invasion (RVI) is a contrast-enhanced computed tomography (CECT) biomarker of MVI derived from a 91-gene HCC "venous invasion" gene expression signature. Preoperative CECTs of 157 HCC patients who underwent surgical resection (N = 72) or LT (N = 85) between 2000 and 2009 at three institutions were evaluated for the presence or absence of RVI. RVI was assessed for its ability to predict MVI and outcomes. Interobserver agreement for scoring RVI was substantial among five radiologists (κ = 0.705; P < 0.001). The diagnostic accuracy, sensitivity, and specificity of RVI in predicting MVI was 89%, 76%, and 94%, respectively. Positive RVI score was associated with lower overall survival (OS) than negative RVI score in the overall cohort (P < 0.001; 48 vs. >147 months), American Joint Committee on Cancer tumor-node-metastasis stage II (P < 0.001; 34 vs. >147 months), and in LT patients within Milan criteria (P < 0.001; 69 vs. >147 months). Positive RVI score also portended lower recurrence-free survival at 3 years versus negative RVI score (P = 0.001; 27% vs. 62%).

CONCLUSION

RVI is a noninvasive radiogenomic biomarker that accurately predicts histological MVI in HCC surgical candidates. Its presence on preoperative CECT is associated with early disease recurrence and poor OS and may be useful for identifying patients less likely to derive a durable benefit from surgical treatment.

Predicting clinical outcomes in patients with HBsAg-positive chronic hepatitis

BACKGROUND AND AIMS

The progression of HBsAg-positive chronic hepatitis is insidious and unpredictable. Identification of factors leading to either a benign or more serious clinical outcome may assist in decision making for antiviral therapy.

METHODS

From 1989 to 1998, 130 untreated patients with chronic hepatitis were enrolled in a prospective study and followed every 3-6 months with liver and virologic tests, platelet counts and alpha-fetoprotein (AFP) measurements.

RESULTS

During a mean follow-up of 107 ± 86 months, 16 (12.3 %) chronic hepatitis patients progressed to cirrhosis (annual rate 1.4 %), and 23 (17.7 %) reverted to being inactive carriers (annual rate 2.1 %). Compared to baseline values, chronic hepatitis patients who progressed to cirrhosis exhibited declines in mean platelet counts (225.7-195.2 mm(3), p = 0.008-0.04) during the first 4 years of follow-up, while those who reverted to being inactive carriers had substantial reductions in mean levels of AST (83.5-27.2 u/l, p < 0.001-0.002) and ALT (100.2-29.2 u/l, p < 0.001-0.007). In addition, during spontaneous alanine aminotransferase (ALT) flares, patients progressing to cirrhosis had concomitant elevations of AFP levels, while patients who became inactive carriers maintained normal AFP values during ALT flares (13.45 vs. 4.65 ng/ml, p = 0.001). These AFP differences during episodes of ALT flares were similarly observed when analyzed in two separate cohorts of cirrhosis and inactive carrier patients.

CONCLUSION

Patients with chronic hepatitis who progressed to cirrhosis exhibited declines in platelet counts and had AFP elevations during ALT flares. To prevent progression, serial measurements of these parameters during the chronic hepatitis stage will assist in identifying patients requiring antiviral therapy.

Evaluation of alpha-fetoprotein in detecting hepatocellular carcinoma recurrence after radiofrequency ablation

BACKGROUND AND AIM

The performance of alpha-fetoprotein (AFP) in the detection of hepatocellular carcinoma (HCC) recurrence after radiofrequency ablation was analyzed.

METHODS

One hundred and forty-six solitary HCC lesions treated by radiofrequency ablation were evaluated. Using the AFP cutoff level at ≥ 20 ng/mL, tumors were categorized into AFP or non-AFP-producing HCC. Factors associated with true and false interpretations for cancer recurrence including analysis of elevated alanine aminotransferase (ALT) were evaluated. The performance of AFP using different cutoff levels adjusted for abnormal ALT was compared.

RESULTS

Of 146 HCCs, 103 demonstrated no HCC recurrence while 43 had local recurrence. In non-recurrence HCC cases, increased AFP levels (false positive) were associated with concomitant ALT elevations, while those with normal AFP (true negative) had correspondingly normal ALT values (P < 0.001). The AFP false positive rate in cases of elevated ALT was significantly higher than those with normal ALT levels (31.9% vs 5.4%, P = 0.001). Among all positive AFP tests, those with false positive values (non-recurrence) had a significantly lower AFP level than the true positive (recurrence) HCC cases (39.8 ng/mL vs 372 ng/mL, P < 0.001). At the 20 ng/mL cutoff level, the sensitivities of AFP for detecting recurrence in non-AFP-producing HCC and AFP-producing HCC were 12.0%, and 72.2%, respectively. Using a modified AFP criteria of ≥ 100 ng/mL for cases where ALT ≥ 40 U/L, the sensitivity and specificity in AFP-producing tumors increased from 72.2% and 56% to 100% and 85%, respectively.

CONCLUSION

Serum AFP is a useful test in the detection of HCC recurrence in AFP-producing HCC. The performance in AFP-producing HCC was significantly improved after adjusting for elevation of serum ALT.

Hydrocolonic sonography: a complete colorectal evaluation technique with preliminary results

BACKGROUND

Hydrocolonic ultrasound (HUS) is a low-cost imaging modality as compared with standard colonoscopy. However, HUS is not popular in the clinical setting due to its somewhat complicated technique of examination and inability to visualize the rectum. We developed a technique to overcome these limitations.

METHODS

Ten patients with cancer-suggestive symptoms and 70 asymptomatic patients were included in this study. All patients underwent HUS, with the technique described herein, before colonoscopy on the same day. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

There were 30 men and 50 women with a mean age of 60.9 ± 7.3 (SD) years. Thirteen polyps with a size ≥0.6 cm (four lesions size 0.6 to 0.9 cm and nine lesions size ≥1 cm) were detected by colonoscopy. The detection rate of lesions by HUS was 25% for polyps size 0.6-0.9 cm and 89% for lesions size ≥1 cm in size. Three lesions were missed in the sigmoid colon, one in the transverse colon, and one in the rectum.

CONCLUSIONS

HUS is a low-cost and noninvasive procedure for colorectal study. This technique has the potential to be used for the detection of colorectal cancer and polyps.

Familial clustering of hepatocellular carcinoma in HBsAg-positive patients in the United States

PURPOSE

The impact of familial clustering of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV)-infected persons in a low HBV endemic area was investigated.

METHODS

Four hundred thirteen HBsAg-positive patients, 173 with HCC and 240 without HCC, were subgrouped into those with or without a family history of HCC and analyzed for risk factors associated with HCC development. In families with HCC clustering, the ages of HCC onset in parents and siblings were compared.

RESULTS

Forty-four of 173 (25.4 %) HCC patients, all of Asian descent, had 82 other blood relatives with HCC. Of these, 69 (84.1 %) were first-degree relatives. Compared to HCC patients without HCC family history, male HCC patients with family history developed HCC at a younger age than either their mothers or fathers with HCC (45.2 ± 10.3 years vs. 63.0 ± 6.8 years, p < 0.001 and 41.2 ± 14.8 years vs. 60.5 ± 5.5 years, p = 0.001, respectively); however, this was not observed in female HCC patients. In mothers of index HCC cases, 22/26 (84.6 %) tested were HBsAg positive and 14 (63.6 %) had HCC; in fathers, 11/21 (52.4 %) tested were HBsAg positive and 10 (90.9 %) had HCC. By multivariate analysis, independent risk factors for HCC development included family history (OR = 2.58, p = 0.05), male gender (OR = 3.23, p = 0.03), cirrhosis (OR = 2.4, p = 0.04), Child-Pugh classification (OR = 7.62, p = 0.004), AFP per log10 increase (OR = 1.68, p = 0.01), precore mutation (OR = 3.77, p = 0.003), and basal core promoter mutation (OR = 8.33, p < 0.001).

CONCLUSIONS

HBsAg-positive male HCC patients presented at a younger age than their parents with HCC. In adult patients with an HCC family history, HCC surveillance should begin at the time of the initial clinic encounter.

Complete tumor encapsulation on magnetic resonance imaging: a potentially useful imaging biomarker for better survival in solitary large hepatocellular carcinoma

The aim of this study was to determine the prognostic value of complete tumor encapsulation as visualized on magnetic resonance imaging (MRI) in patients with a solitary large hepatocellular carcinoma (HCC) beyond the Milan criteria for liver transplantation (LT). Between December 2000 and March 2011, 57 patients who had a solitary HCC exceeding 5 cm in diameter at the time of initial MRI before any treatment were identified. MRI images of the patients were independently reviewed by 2 experienced readers for the presence of complete tumoral encapsulation. The medical records of the patients were reviewed for an outcome analysis. Thirty of the 57 patients had completely encapsulated HCC according to MRI. There was excellent interobserver agreement between the 2 readers for the assessment of complete encapsulation (κ=0.86). Overall survival was significantly longer for patients with completely encapsulated HCC versus patients with incompletely or nonencapsulated tumors (P<0.001), and this included a subanalysis of 33 patients who received locoregional treatment (LRT; P=0.04). The presence of complete encapsulation was a strong predictor for survival in these patients according to both univariate [hazard ratio (HR)=0.24, 95% confidence interval (CI)=0.12-0.52, P<0.001] and multivariate analyses (HR=0.25, 95% CI=0.07-0.85, P=0.03). The rates of down-staging (P<0.001) and eventual LT (P=0.02) after LRT were also significantly higher in the patients with completely encapsulated tumors. In conclusion, complete tumor encapsulation on MRI is a potentially useful predictor for favorable biology in patients with a solitary large HCC. This new imaging biomarker may have a role in treatment selection for patients whose tumors exceed the Milan criteria size limits.

Tumor factors associated with clinical outcomes in patients with hepatitis B virus infection and hepatocellular carcinoma

BACKGROUND AND AIMS

Hepatitis B virus (HBV) infection is a common cause of hepatocellular carcinoma (HCC) in the United States. This study evaluated the impact of surveillance and treatment on HBV-infected HCC patients and identified factors associated with survival.

METHODS

From 1981 to 2010, 166 hepatitis B surface antigen (HBsAg)-positive HCC patients were evaluated. Fifty-eight patients had HCC detected by surveillance, while 108 patients presented with HCC.

RESULTS

Compared to patients detected by surveillance, those presenting with HCC had more symptoms (65.7% vs 41.4%; P=.002), were more frequently outside of Milan criteria (73.7% vs 29.6%; P<.001), more often presented with diffuse tumors (23.2% vs 1.9%; P<.001), and had a shortened median survival time (9.5 months vs 18.7 months; P=.003). Patients who presented with diffuse tumors were younger and more often male (P=.002-.007), had a higher alpha-fetoprotein (AFP) level (P=.023), and had a median survival time of only 1.68 months. By multivariate analysis, factors that were significantly associated with mortality included diffuse tumors (hazard ratio [HR], 6.30; 95% confidence interval [CI], 3.14-12.66; P<.001), being outside of Milan criteria (HR, 2.02; 95% CI, 1.26-3.23; P=.005), albumin level (HR per 1 standard deviation decrease, 1.4; 95% CI, 1.15-1.72; P=.001), AFP level (HR per 1 log standard deviation increase, 1.38; 95% CI, 1.13-1.67; P=.001), and receiving liver transplantation versus other treatments (HR, 0.08-0.38; 95% CI, 0.03-0.87; P<.001 to P=.022).

CONCLUSION

In the United States, HBV-related HCC is a common malignancy, especially among Asian immigrants. Identification of HBsAgpositive subjects and routine HCC surveillance are essential for improving survival in these patients.