Hepatocellular carcinoma in advanced liver cirrhosis: CT detection in transplant patients

Cone Beam CT-Guided Chemoembolization of Probable Hepatocellular Carcinomas Smaller than 1 cm in Patients at High Risk of Hepatocellular Carcinoma

PURPOSE

To evaluate the effectiveness and safety of cone-beam computed tomography (CT)-guided chemoembolization for probable hepatocellular carcinomas (HCCs) smaller than 1 cm in patients at high risk for HCC.

MATERIALS AND METHODS

From December 2009 to May 2014, 57 patients (43 male and 14 female; mean age, 61.1 y) at high risk for HCC underwent cone-beam CT-guided conventional chemoembolization for 79 treatment-naive probable HCCs < 1 cm. Probable HCCs were diagnosed when hepatic nodules showed arterial enhancement and washout on dynamic CT or magnetic resonance images. The Kaplan-Meier method and Cox proportional-hazards regression were used to evaluate the time to local progression (TTLP), time to progression (TTP), and overall survival (OS).

RESULTS

Initial follow-up images obtained 2-3 months after chemoembolization showed complete response in all 79 tumors. The 1-, 2-, and 3-year local progression rates were 10.4%, 21.7%, and 35.7%, respectively. Subsegmental catheterization (P < .001; hazard ratio [HR] = .041) and segmental catheterization (P = .001; HR = .049) were significantly associated with longer TTLP. The 1-, 2-, and 3-year progression rates were 40.5%, 66.7%, and 78.6%, respectively. Tumor multiplicity (P = .004; HR = 2.612) was a significant risk factor for shorter TTP. The 1-, 2-, and 3-year OS rates were 100%, 98.2%, and 88.5%, respectively. Child-Turcotte-Pugh class B disease (P = .029; HR = 5.989) was significantly associated with shorter OS. No complications occurred after chemoembolization.

CONCLUSIONS

Cone-beam CT-guided chemoembolization can be a useful and safe option for probable HCCs < 1 cm in patients at high risk for HCC.

Diagnostic Accuracy of Preoperative Gadoxetic Acid-enhanced 3-T MR Imaging for Malignant Liver Lesions by Using Ex Vivo MR Imaging-matched Pathologic Findings as the Reference Standard

PURPOSE

To determine per-lesion sensitivity and positive predictive value (PPV) of gadoxetic acid-enhanced 3-T magnetic resonance (MR) imaging for the diagnosis of malignant lesions by using matched (spatially correlated) hepatectomy pathologic findings as the reference standard. Materials and

METHODS

In this prospective, institutional review board-approved, HIPAA-compliant study, 20 patients (nine men, 11 women; mean age, 59 years) with malignant liver lesions who gave written informed consent underwent preoperative gadoxetic acid-enhanced 3-T MR imaging for surgical planning. Two image sets were independently analyzed by three readers to detect liver lesions (set 1 without and set 2 with hepatobiliary phase [HBP] images). Hepatectomy specimen ex vivo MR imaging assisted in matching gadoxetic acid-enhanced 3-T MR imaging findings with pathologic findings. Interreader agreement was assessed by using the Cohen κ coefficient. Per-lesion sensitivity and PPV were calculated.

RESULTS

Cohen κ values were 0.64-0.76 and 0.57-0.84, and overall per-lesion sensitivity was 45% (42 of 94 lesions) to 56% (53 of 94 lesions) and 58% (55 of 94 lesions) to 64% (60 of 94 lesions) for sets 1 and 2, respectively. The addition of HBP imaging did not affect interreader agreement but significantly improved overall sensitivity for one reader (P < .05) and almost for another (P = .05). Sensitivity for 0.2-0.5-cm lesions was 0% (0 of 26 lesions) to 8% (two of 26 lesions) for set 1 and 4% (one of 26 lesions) to 12% (three of 26 lesions) for set 2. Sensitivity for 0.6-1.0-cm lesions was 28% (nine of 32 lesions) to 59% (19 of 32 lesions) for set 1 and 66% (21 of 32 lesions) to 69% (22 of 32 lesions) for set 2. Sensitivity for lesions at least 1.0 cm in diameter was at least 81% (13 of 16 lesions) for set 1 and was not improved for set 2. PPV was 98% (56 of 57 lesions) to 100% (60 of 60 lesions) for all readers without differences between image sets or lesion size.

CONCLUSION

Gadoxetic acid-enhanced 3-T MR imaging provides high per-lesion sensitivity and PPV for preoperative malignant liver lesion detection overall, although sensitivity for 0.2-0.5-cm malignant lesions is poor.

Total tumor volume predicts risk of recurrence following liver transplantation in patients with hepatocellular carcinoma

Criteria for the selection of candidates for liver transplantation in the presence of hepatocellular carcinoma (HCC) should accurately predict posttransplant recurrence while not excluding excessive numbers of patients from candidacy. Existing criteria are challenged by the limited accuracy of radiological assessment. The total tumor volume (TTV) was calculated by the addition of the volume of each individual tumor. A preliminary analysis was carried out on HCC patient data from the Alberta Liver Transplant Program (52 patients) and then validated on the populations of the Universities of Toronto and Colorado programs (154 and 82 patients). A TTV cutoff of 115 cm(3) was chosen on the basis of the risk of recurrence with use of a receiver operating characteristic curve. Radiology correlated more closely to pathology with TTV than with Milan and University of California at San Francisco (UCSF) criteria (91% versus 69% and 75% of patients, P < 0.0001). Although more patients met qualifying criteria for transplant with TTV (28%-53% more than Milan and 16%-26% more than UCSF), no deterioration of outcome was demonstrated in an analysis of patients within TTV < or = 115 cm(3) in comparison with those meeting Milan or UCSF classifications at all institutions. Patients with TTV > 115 cm(3) experienced more recurrences and lower patient survival in the Alberta and Colorado series (P < 0.05). When TTV with a cutoff of 115 cm(3) is used for candidate selection, the accuracy of pretransplant radiological assessment is enhanced, with posttransplant outcomes not different from those achieved with Milan and UCSF classifications despite a more inclusive patient population.

[Imaging nodules within cirrhotic liver: how do I do it?]

Cirrhosis is a chronic liver disease characterized by the presence of diffuse parenchymal necrosis, reactive fibrosis and nodular regeneration. These regenerative nodules may evolve into dysplastic nodules and finally nodules of hepatocellular carcinoma (HCC). Improved survival of cirrhotic patients with HCC depends on eligibility to liver transplantation. The purpose of this paper is to review the imaging features of liver nodules within cirrhotic liver and to propose the imaging strategies when considering the possibility of liver transplantation.

Value of the unenhanced phase for detection of hepatocellular carcinomas 3 cm or less when performing multiphase computed tomography in patients with cirrhosis

OBJECTIVE

To determine whether unenhanced images are of added benefit to dual-phase computed tomography (CT) for detection of hepatocellular carcinomas (HCCs) 3 cm or less.

METHODS

Thirty-six patients with cirrhosis underwent unenhanced, arterial and portal venous phase CT, 17 with pathologically proven HCCs 3 cm or less and 19 without HCC. Two radiologists reviewed dual-phase images with and without unenhanced images. Presence or absence of HCC in each segment (n = 324) and subjective added benefit of unenhanced images were recorded.

RESULTS

For readers 1 and 2, unenhanced CT was subjectively helpful in 16 (5%) of 324 and 23 (7%) of 324 segments. Sensitivity and area under the receiver operating characteristic curve were identical for dual-phase versus triple-phase images for reader 1 (82.4% and 0.882) and reader 2 (100% and 0.997).

CONCLUSIONS

Addition of unenhanced to dual-phase CT does not statistically significantly increase the diagnostic accuracy or sensitivity for HCCs 3 cm or less.

Multidetector Row CT of the Liver

CT has always played a major role in the imaging of the liver despite continuous challenge by ultrasound and MR imaging. Introduction of multidetector row CT technology has helped CT to excel in its already established indications and has expanded its capabilities by adding new clinical indications, such as CT angiography or liver perfusion. This article discusses the advantages of multidetector row CT scanners in liver imaging, examines the guidelines to improve image quality by optimizing scanning protocols and contrast administration strategies, and reviews the current and potential clinical applications.

Imaging diagnosis of hepatocellular carcinoma with differentiation from other pathology

Recent advances in liver imaging techniques and better understanding of imaging findings have facilitated the detection and characterization of hepatocellular nodules in a cirrhotic liver. It is important to recognize that various types of benign nodules and pseudolesions are identified on all imaging scans performed for the diagnosis of hepatocellular carcinoma. An accurate differentiation between them is critical for adequate management of cirrhotic patients. Unfortunately, any of the imaging tests and even percutaneous biopsy are not diagnostic for borderline lesions. Intimate collaboration of hepatologists, pathologists, surgeons, and radiologists with reasonable imaging and clinical criteria estimating the degree of malignancy is imperative.