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Huang H, Li CQ, He DN, Ruan SM, Li MD, Cheng MQ, Lu MD, Kuang M, Wang W, Wang Y, Chen LD. Surveillance for malignant progression of LI-RADS version 2017 category 3/4 nodules using contrast-enhanced ultrasound. Eur Radiol 2023; 33:9336-9346. [PMID: 37405501 DOI: 10.1007/s00330-023-09811-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES To identify the risk factors for predicting the malignant progression of LR-3/4 observations on the baseline and contrast-enhanced ultrasound (CEUS). METHODS In total, 245 liver nodules assigned to LR-3/4 in 192 patients from January 2010 to December 2016 were followed up by baseline US and CEUS. The differences in the rate and time of progression to hepatocellular carcinoma (HCC) among subcategories (defined as P1-P7) of LR-3/4 in CEUS Liver Imaging Reporting and Data System (LI-RADS) were analyzed. The risk factors to predict progression to HCC were analyzed by univariate and multivariate Cox proportional hazard model analysis. RESULTS A total of 40.3% of LR-3 nodules and 78.9% of LR-4 nodules eventually progressed to HCC. The cumulative incidence of progression was significantly higher for LR-4 than LR-3 (p < 0.001). The rate of progression was 81.2% in nodules with arterial phase hyperenhancement (APHE), 64.7% in nodules with late and mild washout, and 100% in nodules with both characteristics. The overall progression rate and median progression time of subcategory P1 nodules (LR-3a) were lower (38.0% vs. 47.6-100.0%) and later (25.1 months vs. 2.0-16.3 months) than those of other subcategories. The cumulative incidence of progression of LR-3a (P1), LR-3b (P2/3/4), and LR-4 (P5/6/7) categories were 38.0%, 52.9%, and 78.9%. The risk factors of HCC progression were Visualization score B/C, CEUS characteristics (APHE, washout), LR-4 classification, echo changes, and definite growth. CONCLUSION CEUS is a useful surveillance tool for nodules at risk of HCC. CEUS characteristics, LI-RADS classification, and changes in nodules provide useful information for the progress of LR-3/4 nodules. CLINICAL RELEVANCE STATEMENT CEUS characteristics, LI-RADS classification, and nodule changes provide important predictions for LR-3/4 nodule progression to HCC, which may stratify the risk of malignant progression to provide a more optimized and refined, more cost-effective, and time-efficient management strategy for patients. KEY POINTS • CEUS is a useful surveillance tool for nodules at risk of HCC, CEUS LI-RADS successfully stratified the risks that progress to HCC. • CEUS characteristics, LI-RADS classification, and changes in nodules can provide important information on the progression of LR-3/4 nodules, which may be helpful for a more optimized and refined management strategy.
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Affiliation(s)
- Hui Huang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Chao-Qun Li
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
- Department of Ultrasound Medicine, West China Xiamen Hospital of Sichuan University, Xiamen, China
| | - Dan-Ni He
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
- Department of Medical Ultrasonics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, China
| | - Si-Min Ruan
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Ming-de Li
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Mei-Qing Cheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Ming-de Lu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming Kuang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China
| | - Ying Wang
- Department of Medical Ultrasound, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang West Road, Guangzhou, 510120, China.
| | - Li-da Chen
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2, Guangzhou, 510080, People's Republic of China.
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Hu J, Burrowes DP, Caine BA, Gibson N, Bhayana D, Medellin A, Burak KW, Wilson SR. Nodules Identified on Surveillance Ultrasound for HCC: CEUS or MRI as the Initial Test? J Ultrasound Med 2023; 42:1181-1190. [PMID: 36807925 DOI: 10.1002/jum.16183] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 05/18/2023]
Abstract
OBJECTIVES Following positive surveillance ultrasound (US), magnetic resonance imaging (MRI) is recommended for further characterization. We propose contrast-enhanced ultrasound (CEUS) shows equivalent efficacy. METHODS This prospective institutional review board approved study recruited 195 consecutive at-risk patients with a positive surveillance US. All had CEUS and MRI. Biopsy (n = 44) and follow-up are gold standard. MRI and CEUS results are classified according to liver imaging reporting and data system (LI-RADS) and patient outcome. RESULTS As an US-based modality, CEUS is superior in confirming findings from surveillance US, correlation in 189/195 (97%) on CEUS compared to 153/195 (79%) on MRI. Within these negative MRI examinations, there are 2 hepatocellular carcinoma (HCC) and 1 cholangiocarcinoma (iCCA) diagnosed on CEUS and proven by biopsy. From 195 patients, there are 71 malignant diagnoses from all sources, including 58 LR-5 (45 on MRI and 54 on CEUS) and 13 others, including HCC outside of LR-5 category, and LR-M with biopsy proven iCCA (3 on MRI and 6 on CEUS). CEUS and MRI show concordant results in the majority of patients (146/195, 75%), including 57/146 malignant and 89/146 benign diagnoses. There are 41/57 concordant LR-5 and 6/57 concordant LR-M. When CEUS and MRI are discordant, CEUS upgraded 20 (10 biopsy-proven) from MRI LR-3/4 to CEUS LR-5 or LR-M by showing washout (WO) that MRI failed to show. Additionally, CEUS characterized time and intensity of WO and diagnosed 13/20 LR-5 by showing late and weak WO and 7 LR-M by showing fast and marked WO. CEUS is 81% sensitive and 92% specific in diagnosing malignancy. MRI is 64% sensitive and 93% specific. CONCLUSIONS CEUS performance is at least equivalent if not superior to MRI for initial evaluation of lesions from surveillance US.
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Affiliation(s)
- Jinghui Hu
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - David P Burrowes
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Benjamin A Caine
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Gibson
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Deepak Bhayana
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Medellin
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Medicine and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie R Wilson
- Radiology and Medicine, Division of Gastroentrology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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3
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Cococcia S, Dutta P, Moghim M, Hogan B, Tanwar S, Marshall A, Macdonald D, Yu D, O'Beirne J, Rosenberg WM, Trembling PM. The fate of indeterminate liver lesions: What proportion are precursors of hepatocellular carcinoma? BMC Gastroenterol 2022; 22:118. [PMID: 35272611 PMCID: PMC8908619 DOI: 10.1186/s12876-022-02135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background The natural history and incidence of hepatocellular carcinoma (HCC) arising from indeterminate liver lesions are not well described. We aimed to define the incidence of HCC in a cohort of patients undergoing surveillance by magnetic resonance imaging (MRI) and estimate any associations with incident HCC. Methods We performed a retrospective follow-up study, identifying MRI scans in which indeterminate lesions had been reported between January 2006 and January 2017. Subsequent MRI scan reports were reviewed for incident HCC arising from indeterminate lesions, data were extracted from electronic patient records and survival analysis performed to estimate associations with baseline factors. Results One hundred and nine patients with indeterminate lesions on MRI were identified. HCC developed in 19 (17%) patients over mean follow up of 4.6 years. Univariate Cox proportional hazards analysis found incident HCC to be significantly associated with baseline low platelet count (hazard ratio (HR) = 7.3 (95% confidence intervals (CI) 2.1–24.9), high serum alpha-fetoprotein level (HR = 2.7 (95% CI 1.0–7.1)) and alcohol consumption above fourteen units weekly (HR = 3.1 (95% CI 1.1–8.7)). Multivariate analysis, however, found that only low platelet count was independently associated with HCC (HR = 5.5 (95% CI 0.6–5.1)). Conclusions HCC arises in approximately one fifth of indeterminate liver lesions over 4.6 years and is associated with a low platelet count at the time of first diagnosis of an indeterminate lesion. Incidence of HCC was more common in people with viral hepatitis and in those consuming > 14 units of alcohol per week. Our data may be used to support a strategy of enhanced surveillance in patients with indeterminate lesions. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02135-x.
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Affiliation(s)
- Sara Cococcia
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.,First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Priti Dutta
- Department of Radiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Melika Moghim
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Brian Hogan
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Sudeep Tanwar
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Douglas Macdonald
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - James O'Beirne
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.,Department of Hepatology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - William M Rosenberg
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Paul M Trembling
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK. .,Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.
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Nadarevic T, Giljaca V, Colli A, Fraquelli M, Casazza G, Miletic D, Štimac D. Computed tomography for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2021; 10:CD013362. [PMID: 34611889 PMCID: PMC8493329 DOI: 10.1002/14651858.cd013362.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and fourth in terms of cancer deaths. In clinical practice, computed tomography (CT) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-foetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study CT or magnetic resonance imaging (MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is valid to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma is, therefore, missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of CT may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CT in people with chronic liver disease, who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma. OBJECTIVES Primary: to assess the diagnostic accuracy of multidetector, multiphasic contrast-enhanced CT for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of CT for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease. SEARCH METHODS We searched the Cochrane Hepato-Biliary Trials Register, Cochrane Hepato-Biliary Diagnostic-Test-Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science until 4 May 2021. We applied no language or document-type restrictions. SELECTION CRITERIA Studies assessing the diagnostic accuracy of CT for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up. DATA COLLECTION AND ANALYSIS At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses. MAIN RESULTS We included 21 studies, with a total of 3101 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Regarding applicability in the patient selection domain, we judged 14% (3/21) of studies to be at low concern and 86% (18/21) of studies to be at high concern owing to characteristics of the participants who were on waiting lists for orthotopic liver transplantation. CT for hepatocellular carcinoma of any size and stage: sensitivity 77.5% (95% CI 70.9% to 82.9%) and specificity 91.3% (95% CI 86.5% to 94.5%) (21 studies, 3101 participants; low-certainty evidence). CT for resectable hepatocellular carcinoma: sensitivity 71.4% (95% CI 60.3% to 80.4%) and specificity 92.0% (95% CI 86.3% to 95.5%) (10 studies, 1854 participants; low-certainty evidence). In the three studies at low concern for applicability (861 participants), we found sensitivity 76.9% (95% CI 50.8% to 91.5%) and specificity 89.2% (95% CI 57.0% to 98.1%). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results. AUTHORS' CONCLUSIONS In the clinical pathway for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, CT has roles as a confirmatory test for hepatocellular carcinoma lesions, and for staging assessment. We found that using CT in detecting hepatocellular carcinoma of any size and stage, 22.5% of people with hepatocellular carcinoma would be missed, and 8.7% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 28.6% of people with resectable hepatocellular carcinoma would improperly not be resected, while 8% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.
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Affiliation(s)
- Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Damir Miletic
- Department of Radiology , Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
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Hu J, Bhayana D, Burak KW, Wilson SR. Resolution of indeterminate MRI with CEUS in patients at high risk for hepatocellular carcinoma. Abdom Radiol (NY) 2020; 45:123-133. [PMID: 31440801 DOI: 10.1007/s00261-019-02181-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To show the contribution of CEUS to characterization of indeterminate MRI observations in high-risk patients for hepatocellular carcinoma (HCC). METHODS From July to December 2015, 42 consecutive patients referred to CEUS with indeterminate MRI scans comprise our study cohort. There are 50 indeterminate nodule-like observations and 10 arterial phase hyperenhancing foci, suggesting pseudolesions/arterio-portal shunts. MRI and CEUS lesions are classified according to their enhancement features in all phases and Liver Imaging and Reporting Data System (LI-RADS) in a blind read format. Clinical pathologic correlation and 24 months follow-up are performed. RESULTS A majority, 37/50 (74%), of indeterminate nodule-like observations have arterial phase enhancement without washout on MRI. CEUS further characterizes enhancement and shows washout in 14/37 (38%). In total, CEUS diagnoses 16 malignant lesions in 14 patients including 14 HCC and 2 ICC. 12/16 (75%) malignant lesions are confirmed by biopsy or follow-up. Ultrasound identification of a nodule differentiates real nodules from pseudolesions. Of the ten suspected arterial-portal shunts on MRI, two show a real nodule on ultrasound, confirmed as an HCC and a regenerative nodule. 15/42 (36%) patients have LI-RADS escalated from LR-3 or 4 on MRI to LR-4 or 5 on CEUS. Overall, the sensitivity of CEUS is (13/16) 81.3% and specificity is (37/37) 100% for malignant diagnosis. CONCLUSION Grayscale ultrasound detects true nodules. Dynamic CEUS detects and characterizes washout, correctly predicting HCC. CEUS is complimentary to MRI and can serve as a problem-solving tool when MRI is indeterminate.
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Kang Z, Wang N, Xu A, Wang L. Digital subtract angiography and lipiodol deposits following embolization in cirrhotic nodules of LIRADS category ≥3. Eur J Radiol Open 2019; 6:106-112. [PMID: 30899770 PMCID: PMC6405901 DOI: 10.1016/j.ejro.2019.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/01/2019] [Accepted: 02/09/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To assess the correlation between Liver Imaging Reporting and Data System (LIRADS) and digital substract angiography (DSA) and lipiodol deposits in cirrhotic nodules of LIRADS category ≥3 receiving interventional treatment. METHODS From June 2014 to June 2016, patients with cirrhotic nodules were identified retrospectively and MR images were reviewed by sub-specialty radiologists according to modified LIRADS v2014. Correlation between nodules of LIRADS category ≥3 and DSA findings and lipiodol deposits were analyzed. RESULTS 71 cirrhotic nodules were evaluated in 33 patients. 39/71 nodules were classified as LR-3, 9/71 nodules were categorized as LR-4, 23/71 nodules were grouped into LR-5. 43 nodules presented positive DSA, 37 nodules showed presence of lipiodol deposits during follow up. With the upgrade of LIRADS category of cirrhotic nodules, DSA and lipiodol deposits became more conspicuous. Spearman analysis demonstrated positive correlations between LIRADS and DSA (r = 0.567, P = 0.000) as well as LIRADS and lipiodol deposits (r = 0.616, P = 0.000). ROC analysis revealed a cut-off value of LR ≥ 4 resulted in a sensitivity of 67.4% and specificity of 89.3% in predicting positive DSA (RUC = 0.799, P < 0.0001), and a sensitivity of 75.7% and specificity of 88.2% in predicting lipiodol deposits (RUC = 0.818, P < 0.0001). Of 39 lesions of LR-3, 64.1% (25/39) showed negative DSA, and 76.9% (30/39) showed absence of lipiodol deposits during follow up. Logistic regression analysis identified arterial enhancement (OR = 26.837, P = 0.002) and lesion size (OR = 1.325, P = 0.022) were independently associated with positive DSA in nodule of LIRADS category ≥3, while no factors were associated with lipiodol deposits. CONCLUSION The LIRADS can be used to predict DSA findings and lipiodol deposits in nodules with LIRADS score 3 and above. LIRADS 3 nodules tend to be DSA-negative and have less lipiodol deposits. DSA and lipiodol deposits become more conspicuous in nodules from LIRADS 3 to 5.
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Key Words
- BCLC, Barcelona Clinic Liver Cancer
- DN, dysplastic nodules
- DSA, digital subtract angiography
- DWI, diffusion weighted imaging
- Digital substract angiography
- HCC, hepatocellular carcinoma
- LIRADS, Liver Imaging Reporting and Data System
- LR-M, probably or definitely malignant but not specific for HCC
- Lipiodol deposits
- Liver imaging reporting and data system
- PACS, picture archiving and communication system
- PWI, perfusion weighted imaging
- RIS, radiology information system
- RN, regenerative nodules
- T1WI, T1 weighted imaging
- T2WI, T2 weighted imaging
- TACE, transcatheter arterial chemoembolization
- TAE, transcatheter arterial embolization
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7
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Krishan S, Dhiman RK, Kalra N, Sharma R, Baijal SS, Arora A, Gulati A, Eapan A, Verma A, Keshava S, Mukund A, Deva S, Chaudhary R, Ganesan K, Taneja S, Gorsi U, Gamanagatti S, Madhusudan KS, Puri P, Shalimar, Govil S, Wadhavan M, Saigal S, Kumar A, Thapar S, Duseja A, Saraf N, Khandelwal A, Mukhopadyay S, Gulati A, Shetty N, Verma N. Joint Consensus Statement of the Indian National Association for Study of the Liver and Indian Radiological and Imaging Association for the Diagnosis and Imaging of Hepatocellular Carcinoma Incorporating Liver Imaging Reporting and Data System. J Clin Exp Hepatol 2019; 9:625-651. [PMID: 31695253 PMCID: PMC6823668 DOI: 10.1016/j.jceh.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind.
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Affiliation(s)
- Sonal Krishan
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Radha Krishan Dhiman, MD, DM, FACG, FRCP, FAASLD, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Navin Kalra
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay S. Baijal
- Department of Diagnostic and Intervention Radiology, Medanta Hospital, Gurgaon, India
| | - Anil Arora
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Ajay Gulati
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anu Eapan
- Department of Radiology, Christian Medical College, Vellore, India
| | - Ashish Verma
- Department of Radiology, Banaras Hindu University, Varanasi, India
| | - Shyam Keshava
- Department of Radiology, Christian Medical College, Vellore, India
| | - Amar Mukund
- Department of Intervention Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - S. Deva
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Chaudhary
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | | | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | | | - Kumble S. Madhusudan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Puri
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shalimar
- Department of GastroEnterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manav Wadhavan
- Institute of Digestive and Liver Diseases, BLK Hospital, Delhi, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | - Ashish Kumar
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shallini Thapar
- Department of Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | | | | | - Ajay Gulati
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Nitin Shetty
- Department of Radiology, Tata Memorial Hospital, Kolkata, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wnorowski AM, Cook TS, Lalevic D, Langer JE, Zafar HM. Outcome of liver lesions indeterminate for malignancy on ultrasound: the role of patient age, risk status, and lesion echogenicity. Abdom Radiol (NY) 2018; 43:2970-9. [PMID: 29594466 DOI: 10.1007/s00261-018-1571-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the relationship between final outcome of lesions indeterminate for malignancy on ultrasound (US) and patient and imaging characteristics. METHODS We identified all patients with indeterminate liver lesions on US between 9/1/2013 and 12/31/2014 using institutional codes based on radiologist opinion. Miscoded lesions (n = 30) and patients with no imaging, pathology, or clinical follow-up at our health system (n = 6) were excluded. Final diagnostic category of malignant, benign, pseudolesion, or indeterminate was assigned using imaging, pathology, and clinical follow-up. Differences in diagnostic categories were compared by patient (age, gender, race, known malignancy. or liver disease) and imaging characteristics (lesion size, echogenicity. and number). Independent likelihood of a benign final diagnostic category was adjusted for significant variables on univariate analysis. RESULTS Indeterminate liver lesions on US were found in 153/6813 patients (2%). Final diagnostic categories were malignant (11/153, 7%), benign (94/153, 61%), pseudolesion (42/153, 27%). and indeterminate (6/153, 4%). Nearly one-third of hypoechoic masses in patients with known malignancy or liver disease (i.e., high-risk status) ≥ 46 years of age were malignant (9/28, 32%). On multivariate analysis, patients of age ≥ 61 years and high-risk status were associated with decreased likelihood of benign diagnostic category (OR .19 (95% CI .07-.51) and OR .40 (95% CI .18-.88), p values .001 and .022, respectively). CONCLUSIONS 2% of patients undergoing abdominal US have sonographically indeterminate liver lesions, of which 7% are malignant. Older, high-risk patients with hypoechoic lesions should receive short-term follow-up as one-third will have malignant lesions. Younger, low-risk patients should receive conservative follow-up, regardless of US imaging features.
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Beal EW, Kearney JF, Chakedis JM, James Hanje A, Conteh LF, Black SM, Washburn K, Dittmar KM, Pawlik TM, Dillhoff MR, Schmidt CR. Interval Magnetic Resonance Imaging: an Alternative to Guidelines for Indeterminate Nodules Discovered in the Cirrhotic Liver. J Gastrointest Surg 2017; 21:1463-70. [PMID: 28550393 DOI: 10.1007/s11605-017-3454-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/11/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current guidelines for the management of indeterminate nodules discovered on surveillance imaging recommend alternate imaging modality or biopsy. This study evaluates the use of short interval MRI rather than immediate CT or biopsy. METHOD This retrospective cohort study examines outcomes of 111 patients with indeterminate nodules reviewed by a single institution's Liver Tumor Board 2011-2016. Analysis was focused on outcomes stratified by management decision. RESULTS The tumor board recommended biopsy or immediate repeat CT imaging in 13 (12%), 3-month interval MRI in 64 (58%) and 6-month interval MRI for 34 (30%) patients. Twenty-eight (29%) patients in the interval MRI subgroups were diagnosed with hepatocellular carcinoma (HCC) during the period of follow-up, and 21 (75%) of these were located within the original indeterminate nodule. The median time to diagnosis was 6.5 months. Twenty-three (82%) were eligible for potentially curative therapy at the time of HCC diagnosis. Delay in HCC diagnosis was not the reason for inability to provide potentially curative therapy in any patient. CONCLUSION This study supports the judicious use of interval MRI at 3 or 6 months in patients with liver cirrhosis and an indeterminate liver nodule rather than immediate CT scan or biopsy.
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Bird TG, Dimitropoulou P, Turner RM, Jenks SJ, Cusack P, Hey S, Blunsum A, Kelly S, Sturgeon C, Hayes PC, Bird SM. Alpha-Fetoprotein Detection of Hepatocellular Carcinoma Leads to a Standardized Analysis of Dynamic AFP to Improve Screening Based Detection. PLoS One 2016; 11:e0156801. [PMID: 27308823 PMCID: PMC4911090 DOI: 10.1371/journal.pone.0156801] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023] Open
Abstract
Detection of hepatocellular carcinoma (HCC) through screening can improve outcomes. However, HCC surveillance remains costly, cumbersome and suboptimal. We tested whether and how serum Alpha-Fetoprotein (AFP) should be used in HCC surveillance. Record linkage, dedicated pathways for management and AFP data-storage identified i) consecutive highly characterised cases of HCC diagnosed in 2009–14 and ii) a cohort of ongoing HCC-free patients undergoing regular HCC surveillance from 2009. These two well-defined Scottish patient cohorts enabled us to test the utility of AFP surveillance. Of 304 cases of HCC diagnosed over 6 years, 42% (129) were identified by a dedicated HCC surveillance programme. Of these 129, 47% (61) had a detectable lesion first identified by screening ultrasound (US) but 38% (49) were prompted by elevated AFP. Despite pre-HCC diagnosis AFP >20kU/L being associated with poor outcome, ‘AFP-detected’ tumours were offered potentially curative management as frequently as ‘US-detected’ HCCs; and had comparable survival. Linearity of serial log10-transformed AFPs in HCC cases and in the screening ‘HCC-free’ cohort (n = 1509) provided indicators of high-risk AFP behaviour in HCC cases. An algorithm was devised in static mode, then tested dynamically. A case/control series in hepatitis C related disease demonstrated highly significant detection (p<1.72*10−5) of patients at high risk of developing HCC. These data support the use of AFP in HCC surveillance. We show proof-of-principle that an automated and further refine-able algorithmic interpretation of AFP can identify patients at higher risk of HCC. This approach could provide a cost-effective, user-friendly and much needed addition to US surveillance.
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Affiliation(s)
- Thomas G Bird
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom.,Cancer Research UK Beatson Institute, Glasgow, G61 1BD, United Kingdom
| | | | | | - Sara J Jenks
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Pearce Cusack
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Shiying Hey
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Andrew Blunsum
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Sarah Kelly
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Catharine Sturgeon
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Peter C Hayes
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Sheila M Bird
- MRC Biostatistics Unit, Cambridge, CB2 0SR, United Kingdom.,Department of Mathematics and Statistics, Strathclyde University, Glasgow, G1 1XH, United Kingdom
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Li RK, Palmer SL, Zeng MS, Qiang JW, Chen F, Rao SX, Chen LL, Dai YM. Detection of Endogenous Iron Reduction during Hepatocarcinogenesis at Susceptibility-Weighted MR Imaging: Value for Characterization of Hepatocellular Carcinoma and Dysplastic Nodule in Cirrhotic Liver. PLoS One 2015; 10:e0142882. [PMID: 26605946 PMCID: PMC4659660 DOI: 10.1371/journal.pone.0142882] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/28/2015] [Indexed: 01/02/2023] Open
Abstract
Objective To investigate the value of susceptibility-weighted imaging (SWI) for characterization of hepatocellular carcinoma (HCC) and dysplastic nodule (DN). Materials and Methods Sixty-eight cirrhotic patients with 89 hepatocellular nodules underwent SWI. The radiological features of hepatocellular nodules on SWI were classified into three types: type A (iso- or hypointensity, and background liver siderosis), type B (hyperintensity, and background liver siderosis), or type C (hyperintensity, and no background liver siderosis). Intranodular and background liver iron content was quantified and correlated with SWI pattern. Prussian blue staining was performed to quantify intranodular and background liver iron content. Results Type A pattern (n = 12) contained 11 (91.7%) DNs and 1 (8.3%) HCC, Type B pattern (n = 66) comprised 1 (1.5%) DN and 65 (98.5%) HCCs (including 12 DN-HCCs and 53 overt HCCs), and type C pattern (n = 11) was exclusively seen in HCCs. The iron scores of DN-HCCs and overt HCCs were significantly lower than those of background livers [(0.091±0.30) VS (2.18±0.87), P = 0.000; (0.11±0.41) VS (2.16±0.97), P = 0.000; respectively]. There was no significant difference between iron scores of DNs and those of background livers [(1.92±0.29) VS (2.17±039), P = 0.191]. For lesion-based and patient-based analysis of HCCs (DN-HCCs and overt HCCs), type B pattern showed a sensitivity, specificity, accuracy, positive predicative value (PPV), and negative predicative value (NPV) of 84.4% and 84.4%, 91.7% and 75%, 85.4% and 83.8%, 98.5% and 98.2%, 47.8% and 23.1%, respectively. Conclusion SWI can provide valuable information for characterization of HCC and DN based on endogenous iron reduction during hepatocarcinogenesis.
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Affiliation(s)
- Ruo-kun Li
- Department of Diagnostic Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Suzanne L. Palmer
- Department of Radiology, Keck Medical Center, University of Southern California, Los Angeles, California, United States of America
| | - Meng-su Zeng
- Department of Diagnostic Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- * E-mail: (MSZ); (JWQ)
| | - Jin-wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
- * E-mail: (MSZ); (JWQ)
| | - Frank Chen
- Department of Radiology, Keck Medical Center, University of Southern California, Los Angeles, California, United States of America
| | - Sheng-xiang Rao
- Department of Diagnostic Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ling-li Chen
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong-ming Dai
- Siemens Ltd, China Healthcare Sector MR Business, Shanghai, China
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