Lack of arterial hypervascularity at contrast-enhanced ultrasound should not define the priority for diagnostic work-up of nodules <2 cm

MRI for hepatocellular carcinoma and the role of abbreviated MRI for surveillance of hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) constitutes the majority of liver cancers and significantly impacts global cancer mortality. While ultrasound (US) with or without alpha-fetoprotein is the mainstay for HCC surveillance, its limitations highlight the necessity for more effective surveillance tools. Therefore, this review explores evolving imaging modalities and abbreviated magnetic resonance imaging (MRI) (AMRI) protocols as promising alternatives, addressing challenges in HCC surveillance.

AREAS COVERED

This comprehensive review delves into the evaluation and challenges of HCC surveillance tools, focusing on non-contrast abbreviated MRI (NC-AMRI) and contrast-enhanced abbreviated MRI protocols. It covers the implementation of AMRI for HCC surveillance, patient preferences, adherence, and strategies for optimizing cost-effectiveness. Additionally, the article provides insights into prospects for HCC surveillance by summarizing meta-analyses, prospective studies, and ongoing clinical trials evaluating AMRI protocols.

EXPERT OPINION

The opinions underscore the transformative impact of AMRI on HCC surveillance, especially in overcoming US limitations. Promising results from NC-AMRI protocols indicate its potential for high-risk patient surveillance, though prospective studies in true surveillance settings are essential for validation. Future research should prioritize risk-stratified AMRI protocols and address cost-effectiveness for broader clinical implementation, alongside comparative analyses with US for optimal surveillance strategies.

Impact of Hepatocellular Carcinoma Tumor Size on Sonazoid Contrast-Enhanced Ultrasound Enhancement Features

OBJECTIVE

The aim of the work described here was to evaluate the impact of hepatocellular carcinoma (HCC) tumor size on Sonazoid contrast-enhanced ultrasound (CEUS) enhancement features, especially in tumors with diameters ≤30 mm and <10 mm.

METHODS

In this retrospective study, we included patients with histopathologically confirmed HCC lesions and divided them into three groups on the basis of tumor size. All patients underwent Sonazoid-enhanced CEUS examinations before surgery. B-mode ultrasound (BMUS) features and CEUS enhancement patterns were evaluated according to current World Federation for Ultrasound in Medicine and Biology Guidelines criteria. The χ2- and Student t-tests were used to compare differences between groups.

RESULTS

We included 132 patients with histopathologically confirmed HCC lesions from November 2020 to September 2022. On the basis of tumor size, patients were divided into group 1 (<10 mm, n = 5), group 2 (10-30 mm, n = 54) and group 3 (>30 mm, n = 73). On BMUS, most HCCs appeared heterogeneous but predominantly hypo-echoic (61.4%, 81/132) with ill-defined margins and irregular shapes. Meanwhile, iso-echoic features were more common in small HCCs ≤30 mm (15.3%, 9/59), but a mixed hyper- and hypo-echoic appearance was more common in HCCs >30 mm (17.8%, 13/73) (p = 0.003). On Sonazoid-enhanced CEUS, all HCCs presented arterial phase hyperenhancement (APHE) (100.0%, 132/132). Most HCCs >30 mm exhibited heterogeneous hyperenhancement (86.3%, 63/73), whereas nearly one-third of small HCCs ≤30 mm exhibited homogeneous hyperenhancement (35.6%, 21/59) (p = 0.003). In the portal venous phase, there was a significantly higher proportion of washout in HCCs >30 mm (84.9%, 62/73) than in small HCCs ≤30 mm (64.4%, 38/59) (p = 0.006). During the Kupffer phase, 11 additional hypo-enhanced lesions (mean size: 14.1 ± 4.1 mm, iso-echoic on BMUS), which were also suspected to be HCC lesions, were detected in 5 patients with small HCCs ≤30 mm and 4 patients with HCCs >30 mm. All 5 cases of HCCs <10 mm exhibited APHE and late washout (>60 s). The majority (3/5, 60%) exhibited washout in the portal venous phase (70, 74 and 75 s), one case did so in the late phase (125 s) and another in the Kupffer phase (420 s).

CONCLUSION

Tumor size had a significant impact on the washout features of HCC lesions on Sonazoid-enhanced CEUS. Small HCC lesions ≤30 mm had a higher proportion of relatively late washout in comparison to larger lesions. Sonazoid-enhanced CEUS might be helpful in the detection and characterization of HCC lesions <10 mm.

Atezolizumab and Bevacizumab Combination Therapy in the Treatment of Advanced Hepatocellular Cancer

Liver cancer, particularly hepatocellular carcinoma, is a global concern. This study focuses on the evaluation of Atezolizumab and Bevacizumab combination therapy as a promising alternative in the treatment of advanced hepatocellular carcinoma. The objectives of this systematic review include evaluating the efficacy of Atezolizumab and Bevacizumab combination therapy compared to conventional therapies with Sorafenib and other conventional therapies, analyzing the associated adverse effects, and exploring prognostic factors in the setting of advanced hepatocellular carcinoma. A systematic literature review was carried out using the PubMed and Web of Science databases. Fifteen related articles were included and evaluated according to their level of evidence and recommendation. Results: The combination therapy of Atezolizumab and Bevacizumab, along with Sorafenib, showed positive results in the treatment of patients with advanced hepatocellular carcinoma. Significant adverse effects were identified, such as gastrointestinal bleeding, arterial hypertension, and proteinuria, which require careful attention. In addition, prognostic factors, such as transforming growth factor beta (TGF-β), alpha-fetoprotein (AFP), and vascular invasion, were highlighted as key indicators of hepatocellular carcinoma progression. Conclusions: The combination of Atezolizumab and Bevacizumab is shown to be effective in the treatment of advanced hepatocellular carcinoma, although it is essential to take into consideration the associated adverse effects. The prognostic factors identified may provide valuable information for the clinical management of this disease. This study provides a comprehensive overview of a promising emerging therapy for liver cancer.

HCCs lacking arterial phase hyperenhancement (APHE) on contrast-enhanced ultrasound (CEUS) - a diagnostic challenge. Findings from the prospective multicenter DEGUM CEUS HCC trial

OBJECTIVES

Hepatocellular carcinoma (HCC) upon contrast-enhanced ultrasound (CEUS) typically shows arterial phase hyperenhancement (APHE), followed by late (> 60 seconds) and mild contrast washout (WO). Although APHE is considered as the hallmark of HCC, it can be absent in some HCCs. Thus, we explored which sonomorphological and histopathological features of HCC are associated with a lack of APHE upon CEUS.

METHODS

Focal liver lesions in high-risk patients for HCC were assessed with CEUS following a standardized protocol in a prospective multi-center real-life setting. CEUS patterns in HCC were assessed, and tumour and patient characteristics were compared for HCCs with and without APHE.

RESULTS

316 patients with HCC were recruited (cirrhosis, 76.9%). APHE occurred in 271/316 HCCs (85.8%). A lack of APHE was associated with portal vein thrombosis, tumour infiltration of the liver vessels (p<0.001), larger size, multilocularity, and higher depth location upon ultrasound (p<0.01). Histological grading did not differ between HCCs with and without APHE (p=0.39). Histopathological features of HCCs without APHE included cirrhotic stromal reaction, marked tumour cell steatosis and absence of the typical surrounding dilated sinusoidal vascular channels.

CONCLUSION

Correlation with histopathological findings support the fact that HCCs with a lack of APHE in CEUS are a heterogeneous group. The examiner has to be aware that particularly HCCs with portal vein thrombosis or macro-invasion of the liver vessels may lack APHE.

Value of Multimodal Data From Clinical and Sonographic Parameters in Predicting Recurrence of Hepatocellular Carcinoma After Curative Treatment

OBJECTIVE

The objective of the work described here was to assess the value of the combination of pre-operative multimodal data-including clinical data, contrast-enhanced ultrasound (CEUS) information and liver stiffness measurement (LSM) based on 2-D shear wave elastography (SWE)-in predicting early (within 1 y) and late (after 1 y) recurrence of hepatocellular carcinoma (HCC) after curative treatment.

METHODS

We retrospectively included 101 patients with HCC who met the Milan criteria and received curative treatment. The multimodel data from clinical parameters, LSM by 2-D SWE and CEUS enhancement patterns were collected. The association between different variables in HCC recurrence was accessed using a Cox proportional hazard model. On the basis of the independent factors of early recurrence, models with different source variables were established (Clinical Model, CEUS-Clinical Model, SWE-Clinical Model, CEUS-SWE-Clinical Model). The goodness-of-fit of models was evaluated and the performance trends of different models were calculated by time-dependent area under the curve (AUC).

RESULTS

Two-dimensional SWE, CEUS enhancement patterns and clinical parameters (spleen length, multiple tumors, α-fetoprotein, albumin and prothrombin time) were independently associated with early recurrence (all p values <0.05). Multiple tumors and a decrease in albumin independently contributed to the late recurrence. The model fit of CEUS-SWE-Clinical Model was superior to other models in predicting early recurrence (all p values <0.05). The AUCs of the CEUS-Clinical Model were higher from 2 mo to 7 mo, while the SWE-Clinical Model had higher AUCs from 9 mo to 12 mo.

CONCLUSION

CEUS enhancement patterns and 2-D SWE were independent predictors of HCC early recurrence as the two factors contributed to the predictive performance at different times. The multimodal model, which included diverse data in predicting early HCC recurrence, had the best goodness-of-fit.

High frame-rate contrast enhanced ultrasound (HIFR-CEUS) in the characterization of small hepatic lesions in cirrhotic patients

BACKGROUND

To show the effectiveness of plane wave HighFrame-Rate CEUS (HiFR-CEUS) compared with "conventional" (plane wave) CEUS (C-CEUS) in the characterization of small (< 2 cm) focal liver lesions (FLLs) not easily detected by CT in cirrhotic patients. HiFR-CEUS exploit an ultra-wideband nonlinear process to combine fundamental, second and higher-order harmonic signals generated by ultrasound contrast agents to increase the frame rate. C-CEUS is limited by the transmission principle, and its frame-rate is around 10 FPS. With HiFR-CEUS (Shenzhen Mindray Bio-Medical Electronics Co., China), the frame-rate reached 60 FPS.

MATERIAL AND METHODS

Ultrasound detected small FLLs (< 2 cm) in 63 cirrhotic patients during follow-up (June 2019-February 2020); (7 nodules < 1 cm and were not evaluable by spiral CT). Final diagnosis was obtained with MRI (47) or fine needle aspiration (16 cases) C-CEUS was performed and HiFR-CEUS was repeated after 5 min; 0.8-1.2 ml of contrast media (SonoVue, Bracco, Italy) was used. 57 nodules were better evaluable with HiFR-CEUS; 6 nodules were equally evaluable by both techniques; final diagnosis was: 44 benign lesions (29 hemangiomas, 1 amartoma, 2 hepatic cysts; 2 focal nodular hyperplasias, 3 regenerative macronodules, 3 AV-shunts, 3 hepatic sparing areas and 1 focal steatosis) and 19 malignant one (17 HCCs, 1 cholangioca, 1 metastasis); statistical evaluation for better diagnosis with X2 test (SPSS vers. 26); we used LI-RADS classification for evaluating sensitivity, specificity PPV, NPV and diagnostic accuracy of C- and HFR-CEUS. Corrispective AU-ROC were calculated.

RESULTS

C-CEUS and HiFR-CEUS reached the same diagnosis in 29 nodules (13 nodules > 1 < 1.5 cm; 16 nodules > 1.5 < 2 cm); HiFR-CEUS reached a correct diagnosis in 32 nodules where C-CEUS was not diagnostic (6 nodules < 1 cm; 17 nodules > 1 < 1.5 cm; 9 nodules > 1.5 < 2 cm); C-CEUS was better in 2 nodules (1 < 1 cm and 1 > 1 < 1.5 cm). Some patient's (sex, BMI, age) and nodule's characteristics (liver segment, type of diagnosis, nodule's dimensions (p = 0.65)) were not correlated with better diagnosis (p ns); only better visualization (p 0.004) was correlated; C-CEUS obtained the following LI-RADS: type-1: 18 Nodules, type-2: 21; type-3: 7, type-4: 7; type-5: 8; type-M: 2; HiFR-CEUS: type-1: 38 Nodules, type-2: 2; type-3:4, type-4: 2; type-5: 15; type-M: 2; In comparison with final diagnosis: C-CEUS: TP: 17; TN: 39; FP: 5; FN:2; HIFR-CEUS: TP: 18; TN: 41; FP: 3; FN:1; C-CEUS: sens: 89.5%; Spec: 88.6%, PPV: 77.3%; NPV: 95.1%; Diagn Acc: 88.6% (AU-ROC: 0.994 ± SEAUC: 0.127; CI: 0.969-1.019); HiHFR CEUS: sens: 94.7%; Spec: 93.2%, PPV: 85.7%; NPV: 97.6%; Diagn Acc: 93.2% (AU-ROC: 0.9958 ± SEAUC: 0.106; CI: 0.975-1.017) FLL vascularization in the arterial phase was more visible with HiFR-CEUS than with C-CEUS, capturing the perfusion details in the arterial phase due to a better temporal resolution. With a better temporal resolution, the late phase could be evaluated longer with HiFR-CEUS (4 min C-CEUS vs. 5 min HiFR-CEUS).

CONCLUSION

Both C-CEUS and HIFR-CEUS are good non invasive imaging system for the characterization of small lesions detected during follow up of cirrhotic patients. HiFR-CEUS allowed better FLL characterization in cirrhotic patients with better temporal and spatial resolution capturing the perfusion details that cannot be easily observed with C-CEUS.

Magnesium application improves the morphology, nutrients uptake, photosynthetic traits, and quality of tobacco (Nicotiana tabacum L.) under cold stress

Cold stress is one of the major constraints limiting the productivity of many important crops, including tobacco (Nicotiana tabacum L.) production and quality worldwide. However, the role of magnesium (Mg) nutrition in plants has been frequently overlooked, especially under cold stress, and Mg deficiency adversely affects plant growth and development. Here, we evaluated the influence of Mg under cold stress on tobacco morphology, nutrient uptake, photosynthetic and quality attributes. The tobacco plants were grown under different levels of cold stress, i.e., 8°C, 12°C, 16°C, including with a controlled temperature of 25°C, and evaluated their effects with Mg (+Mg) and without Mg (-Mg) application. Cold stress resulted in reduced plant growth. However, the +Mg alleviated the cold stress and significantly increased the plant biomass on an average of 17.8% for shoot fresh weight, 20.9% for root fresh weight, 15.7% for shoot dry weight, and 15.5% for root dry weight. Similarly, the nutrients uptake also increased on average for shoot-N (28.7%), root-N (22.4%), shoot-P (46.9%), root-P (7.2%), shoot-K (5.4%), root-K (28.9%), shoot-Mg (191.4%), root-Mg (187.2%) under cold stress with +Mg compared to -Mg. Mg application significantly boosted the photosynthetic activity (Pn 24.6%) and increased the chlorophyll contents (Chl-a (18.8%), Chl-b (25%), carotenoids (22.2%)) in the leaves under cold stress in comparison with -Mg treatment. Meanwhile, Mg application also improved the quality of tobacco, including starch and sucrose contents, on an average of 18.3% and 20.8%, respectively, compared to -Mg. The principal component analysis revealed that tobacco performance was optimum under +Mg treatment at 16°C. This study confirms that Mg application alleviates cold stress and substantially improves tobacco morphological indices, nutrient absorption, photosynthetic traits, and quality attributes. In short, the current findings suggest that Mg application may alleviate cold stress and improve tobacco growth and quality.

Contrast-enhanced ultrasound for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma occurs mostly in people with chronic liver disease. Worldwide, it ranks sixth in terms of incidence of cancer, and fourth in terms of cancer-related deaths. Contrast-enhanced ultrasound (CEUS) is used as an add-on test to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma after prior diagnostic tests such as abdominal ultrasound or measurement of alpha-foetoprotein, or both. According to guidelines, a single contrast-enhanced imaging investigation, with either computed tomography (CT) or magnetic resonance imaging (MRI), may show the typical hepatocellular carcinoma hallmarks in people with cirrhosis, which will be sufficient to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas show atypical imaging features, and therefore, are missed at imaging. Dynamic CEUS images are obtained similarly to CT and MRI images. CEUS differentiates between arterial and portal venous phases, in which sonographic hepatocellular carcinoma hallmarks, such as arterial hyperenhancement and subsequent washout appearance, are investigated. The advantages of CEUS over CT and MRI include real-time imaging, use of contrast agents that do not contain iodine and are not nephrotoxic, and quick image acquisition. Despite the advantages, the use of CEUS in the diagnostic algorithm for HCC remains controversial, with disagreement on relevant guidelines. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival as the conflicting results can be a consequence of an inaccurate detection, ineffective treatment, or both. Therefore, assessing the diagnostic accuracy of CEUS may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CEUS for the diagnosis of hepatocellular carcinoma is needed for either diagnosing hepatocellular carcinoma or ruling it out in people with chronic liver disease who are not included in surveillance programmes.

OBJECTIVES

1. To assess the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, in a surveillance programme or in a clinical setting. 2. To assess the diagnostic accuracy of CEUS for the diagnosis of resectable hepatocellular carcinoma in people with chronic liver disease and identify potential sources of heterogeneity in the results.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The last date of search was 5 November 2021.

SELECTION CRITERIA

We included studies assessing the diagnostic accuracy of CEUS 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

We used standard Cochrane methods to screen studies, extract data, and assess the risk of bias and applicability concerns, using the QUADAS-2 checklist. We used the bivariate model and provided estimates of summary sensitivity and specificity. We assessed the certainty of the evidence using GRADE. We presented uncertainty-of-the-accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 23 studies with 6546 participants. Studies were published between 2001 and 2021. We judged all 23 studies at high-risk of bias in at least one domain, and 13/23 studies at high concern for applicability. Most studies used different reference standards to exclude the presence of the target condition. The time interval between the index test and the reference standard was rarely defined. We also had major concerns on their applicability due to the characteristics of the participants. - CEUS for hepatocellular carcinoma of any size and stage: sensitivity 77.8% (95% CI 69.4% to 84.4%) and specificity 93.8% (95% CI 89.1% to 96.6%) (23 studies, 6546 participants; very low-certainty evidence). - CEUS for resectable hepatocellular carcinoma: sensitivity 77.5% (95% CI 62.9% to 87.6%) and specificity 92.7% (95% CI 86.8% to 96.1%) (13 studies, 1257 participants; low-certainty evidence). The observed heterogeneity in the results remains unexplained. The sensitivity analyses, including only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted with no knowledge of the results about the index test, showed no differences in the results.

AUTHORS' CONCLUSIONS

We found that by using CEUS, as an add-on test following abdominal ultrasound, to diagnose hepatocellular carcinoma of any size and stage, 22% of people with hepatocellular carcinoma would be missed, and 6% of people without hepatocellular carcinoma would unnecessarily undergo further testing or inappropriate treatment. As to resectable hepatocellular carcinoma, we found that 23% of people with resectable hepatocellular carcinoma would incorrectly be unresected, while 8% of people without hepatocellular carcinoma would undergo further inappropriate testing or treatment. The uncertainty resulting from the high risk of bias of the included studies, heterogeneity, and imprecision of the results and concerns on their applicability limit our ability to draw confident conclusions.

Metal-Organic Frameworks for Wastewater Decontamination: Discovering Intellectual Structure and Research Trends

Due to their simple synthesis method and excellent properties, such as superior adsorption and regeneration capabilities, with a large surface area and tunable pores, metal-organic frameworks (MOFs) have emerged as a suitable option for wastewater treatment. Although an exponential growth in MOF literature has been observed in recent years, conducting a quantitative literature analysis of MOF application in wastewater treatment is a novelty. To fill this gap, a total of 1187 relevant publications were extracted from the Web of Science, published during the last 50 years, and analyzed using bibliometric and content analysis techniques. A bibliometric analysis was conducted to reveal growing publication trends, leading journals, prolific countries, and organizations; whereas, a content analysis was used to highlight key research themes and hot topics in this field. The analyses revealed that there is a strong international collaboration among authors, countries, and organizations. Chemical Engineering Journal, Journal of Hazardous Materials, and Journal of Environmental Chemical Engineering are the most prolific journals in this field. Furthermore, the use of MOFs for removing antibiotics from wastewater was identified as a recent hot topic. In addition, performance enhancements of MOFs, in terms of a higher adsorption capacity and water stability, were identified as topics of great interest. To cater to these issues, the application of graphene, graphene oxides, nanoparticles, and quantum dots was also observed in the research fronts in this field.

The diagnostic value of contrast-enhanced ultrasound LI-RADS for hepatocellular carcinoma in patients with cirrhosis and chronic hepatitis B

PURPOSE

To explore the diagnostic value of American College of Radiology Contrast-Enhanced Ultrasound-Liver Imaging Reporting and Data System (ACR-CEUS-LI-RADS) for hepatocellular carcinoma (HCC) in patients with cirrhosis and chronic hepatitis B.

METHODS

A total of 205 patients at high risk of HCC with solitary hepatic nodule were enrolled and retrospectively analyzed. All patients were over 18 years old and had a single lesion with a diameter < 50 mm. Lesions were categorized according to size and contrast enhancement patterns in the arterial, portal venous and late phases. Diagnostic efficacy of CEUS LI-RADS for HCC, and the rate of non-HCC malignancies in the LR-M class were compared between patients with cirrhosis and chronic hepatitis B.

RESULTS

Of all 205 nodules (median nodule size was 34 mm), 142 (69.3%) were HCC. Of the 127 (61.9%) LR-5 category nodules, 95.8% (92/96) nodules were corresponded to HCC in cirrhosis, while 61.3% (19/31) nodules were corresponded to HCC in chronic hepatitis B (P = 0.000). Positive predictive value (PPV) of LR-5 category for HCC was 95.8% in cirrhosis and 61.3% in chronic hepatitis B (P = 0.000). More category of LR-4 nodules were proved to be HCC in patients with cirrhosis than chronic hepatitis B (80.0% vs 8.3%, P = 0.000). Of 41 LR-M category nodules, more non-HCC malignancies were found in chronic hepatitis B (76.0%) than that in cirrhosis (25.0%, P = 0.001).

CONCLUSIONS

The LR-5 category is highly specific for the diagnosis of HCC in patients with cirrhosis. However, LR-5 category nodules require further CT or MRI examination or histological confirmation in patients with chronic hepatitis B for its unsatisfactory PPV for HCC.

Liver Imaging Reporting and Data System: Review of Pros and Cons

The American College of Radiology has released the Liver Imaging Reporting and Data System (LI-RADS) scheme which categorizes focal liver lesions (FLLs) in patients at risk for hepatocellular carcinoma (HCC) according to the degree of risk of nodules to be HCC. It subgroups FLL in LR-1 (definitely benign), LR-2 (probably benign), LR-3 (intermediate probability of malignancy), LR-4 (probably HCC), LR-5 (definitely HCC), and LR-M (probable malignancy not specific for HCC). Computed tomography/magnetic resonance imaging (CT/MRI) and contrast enhanced ultrasound (CEUS) LI-RADS diagnostic algorithm have the goal to standardize the acquisition, interpretation, reporting, and data collection for imaging examinations in patients at risk for HCC. Nevertheless, there remain controversial issues that should be dealt with. The aim of this review is to discuss the pros and cons of the interpretation and reporting part of CT/MRI and CEUS LI-RADS diagnostic algorithm to permit future refinements of the scheme and optimize patient and nodule management.

Prognosis of Single Early-Stage Hepatocellular Carcinoma (HCC) with CEUS Inconclusive Imaging (LI-RADS LR-3 and LR-4) Is No Better than Typical HCC (LR-5)

The American College of Radiology (ACR) released the Liver Imaging Report and Data System (LI-RADS) scheme, which categorizes hepatic nodules in risk classes from LR-1 to LR-5 (according to the degree of risk to be HCC) and LR-M (probable malignancy not specific for HCC). The aim of this study was to test whether HCC with different LR patterns on CEUS have different overall survival (OS) and recurrence-free survival (RFS). We retrospectively enrolled 167 patients with the first definitive diagnosis of single HCC (by using CT/MRI or histological techniques if CT/MRI were inconclusive) for whom CEUS examination was available. The median size of HCC lesions was 2.2 cm (range 1.0-7.2 cm). According to CEUS LI-RADS classification, 28 patients were in LR-3, 48 in LR-4, 83 in LR-5, and 8 in LR-M. Patient liver function and nodule characteristics were not statistically different between CEUS LI-RADS classes. Using univariate analysis, CEUS LI-RADS class was not found to be a predictor of survival (p = 0.347). In conclusion, HCC showing the CEUS LI-RADS classes LR-3 and LR-4 have no better clinical outcome than typical HCC. Such data support the EASL policy, aimed at conclusive diagnostic investigations of indeterminate nodules up to obtaining histological proof to avoid leaving aggressive HCC not timely treated.

Contrast-Enhanced Ultrasound Patterns for the Non-invasive Diagnosis of Hepatocellular Carcinoma: A Prospective Multicenter Study in Histologically Proven Liver Lesions in a Real-Life Setting Demonstrating the Benefit of Extended Late Phase Observation

The hallmark for the non-invasive diagnosis of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS) in cirrhosis is arterial phase hyperenhancement (APHE), followed by late-onset (>60 s), mild washout. Large retrospective studies report this pattern of washout to occur in the vast majority of HCCs. However, a prospective multicenter validation of these findings is still missing. Thus, we initiated a prospective multicenter validation study assessing CEUS enhancement patterns in focal liver lesions of patients at risk for HCC. We analyzed lesions that were eventually histology proven in a real-life setting. CEUS patterns were assessed for subgroups of HCC, intrahepatic cholangiocellular carcinoma (iCCA) and non-HCC, non-iCCA lesions. The diagnosis was HCC in 316 lesions (median size: 40 mm), iCCA in 26 lesions (median size: 47.5 mm) and non-HCC, non-iCCA in 53 lesions (median size: 27 mm). Overall, 85.8% of HCCs exhibited APHE. APHE followed by washout occurred in 72.8% of HCCs and 50% of iCCAs and non-HCC, non-iCCA malignancies (p < 0.05). Early and marked washout was associated more commonly with iCCA; HCCs exhibited mostly late and mild washout (onset >4-6 min in 10% of cases). Our prospective data confirm that the typical pattern of APHE followed by late-onset, mild washout occurs in the majority of HCCs.

Diagnosis and treatment of hepatocellular carcinoma. Update of the consensus document of the AEEH, AEC, SEOM, SERAM, SERVEI, and SETH

Hepatocellular carcinoma (HCC) is the most common primary liver neoplasm and one of the most common causes of death in patients with cirrhosis of the liver. In parallel, with recognition of the clinical relevance of this cancer, major new developments have recently appeared in its diagnosis, prognostic assessment and in particular, in its treatment. Therefore, the Spanish Association for the Study of the Liver (AEEH) has driven the need to update the clinical practice guidelines, once again inviting all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document: Spanish Society for Liver Transplantation (SETH), Spanish Society of Diagnostic Radiology (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Association of Surgeons (AEC) and Spanish Society of Medical Oncology (SEOM). The clinical practice guidelines published in 2016 and accepted as National Health System Clinical Practice Guidelines were taken as the reference documents, incorporating the most important recent advances. The scientific evidence and the strength of the recommendation is based on the GRADE system.

Diagnostic Accuracy of Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) for Differentiating Between Hepatocellular Carcinoma and Other Hepatic Malignancies in High-Risk Patients: A Meta-Analysis

OBJECTIVES

 The American College of Radiology (ACR) contrast-enhanced ultrasound liver imaging reporting and data system (CEUS LI-RADS), which includes diagnostic criteria for hepatocellular carcinoma (HCC) and other hepatic malignancies (OM), is increasingly used in clinical practice. This study performed a meta-analysis to assess the diagnostic accuracy of CEUS LI-RADS for differentiating between HCC and OM in high-risk patients.

METHODS

 PubMed, Embase (Ovid), and Cochrane (CENTRAL) were searched for relevant studies. All studies that reported the percentage of HCC and OM in the LI-RADS categories were included. Random-effects models were used to calculate the pooled sensitivity and specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve.

RESULTS

 Eight studies involving 4215 focal liver lesions were included in the final analysis. The pooled sensitivity and specificity of the LR-5 criteria for HCC were 0.71 (95 % CI, 0.69-0.72) and 0.88 (0.85-0.91), respectively, the DOR was 18.36 (7.41-45.52), and the area under the SROC curve (AUC) was 0.8128. The pooled sensitivity and specificity of the LR-M criteria for OMs were 0.85 (0.81-0.88) and 0.86 (0.85-0.87), the DOR was 27.82 (11.83-65.40), respectively, and the SROC AUC was 0.9098.

CONCLUSION

 The CEUS LI-RADS can effectively distinguish HCC from other hepatic malignancy in high-risk patients based on LR-5 criteria and LR-M criteria. However, further studies are needed for validation due to the limited number of included studies and the potential heterogeneity among the included studies.

Pathological considerations of CEUS LI-RADS: correlation with fibrosis stage and tumour histological grade

OBJECTIVES

To evaluate the influence of pathological factors, such as fibrosis stage and histological grade, on the Liver Imaging Reporting and Data System (LI-RADS) v2017 category of contrast-enhanced ultrasonography (CEUS) in patients with high risk of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Between June 2015 and December 2016, 441 consecutive patients at high risk of HCC with 460 pathologically proven HCCs were enrolled in this retrospective study. All patients underwent a CEUS examination. The major features (arterial phase hyperenhancement, late and mild washout) were assessed, and LI-RADS categories were assigned according to CEUS LI-RADS v2017. CEUS LI-RADS categories and major features were compared in different histological grades and fibrosis stages.

RESULTS

The CEUS LR-5 category was more frequently assigned in the low-grade group (151/280) than in the high-grade group (66/159) (p = 0.013), whereas the LR-TIV category was more frequently assigned in the high-grade group (36/159) than in the low-grade group (40/280) (p = 0.035). CEUS LI-RADS category was not significantly different among different fibrosis stages (p ≥ 0.05). Arterial phase hyperenhancement (APHE) and the hepatic fibrosis stage showed a significant correlation in HCCs ≥ 2 cm and the low-grade group (p = 0.027 and p = 0.003, respectively). No major features of CEUS LI-RADS showed statistically significant differences between the low- and high-grade groups (p ≥ 0.05).

CONCLUSION

Hepatic fibrosis stage can influence APHE but showed no impact on the CEUS LI-RADS classification, whereas the histological grade of HCC influenced the LR-5 and LR-TIV categories.

KEY POINTS

• Histological grade influenced CEUS LR-5 and LR-TIV category (p = 0.013 and p = 0.035 respectively). Low-grade HCCs occurred more frequently in LR-5 category whereas high-grade HCCs occurred more frequently in LR-TIV category. • Fibrosis stage shows significant influence on APHE on HCCs of the size ≥ 2 cm and low-grade group (p = 0.027 and p = 0.003, respectively). • Hepatic fibrosis stage and HCC histological grade exhibited limited impact on CEUS LI-RADS. CEUS LI-RADS may be feasible for diagnosing HCC in patients regardless of histological grade and fibrosis stage.

Enhancement patterns of small hepatocellular carcinoma (≤ 30 mm) on contrast-enhanced ultrasound: Correlation with clinicopathologic characteristics

PURPOSE

To analyze the correlation between enhancement patterns of small hepatic carcinomas (HCCs; ≤ 30 mm) on contrast-enhanced ultrasound (CEUS) and the clinicopathologic characteristics.

METHODS

The retrospective study included 346 inpatients (288 males and 58 females) with 372 pathologically confirmed small HCCs between January 2017 and December 2018. All patients underwent CEUS examination before pathological examination. Statistical analysis was used to determine the correlation between enhancement patterns of small HCCs on CEUS and clinicopathologic characteristics including serum alpha-feto-protein level, protein induced by vitamin K absence or antagonist-II (PIVKA-II) level, primary or recurrent HCC condition, tumor number, tumor differentiation, tumor size, liver background and microvascular invasion (MVI).

RESULTS

Three hundred forty-seven out of 372 (93.3 %) HCCs manifested arterial phase hyper-enhancement (APHE). The arterial enhancement patterns were correlated with the tumor differentiation (odds ratio = 10.336, P = 0.000). Moderately- or poorly-differentiated HCCs were more likely to display APHE than well-differentiated HCCs (96.2 % vs 58.6 %, P < 0.001). Two hundred ninety-five of 372 (79.3 %) HCCs showed washout in the portal venous/late phase. Washout was correlated with serum PIVKA-II level, tumor size, tumor differentiation, and MVI on univariate analysis (P < 0.05). Logistic regression analysis revealed that only tumor size was significantly associated with washout of small HCCs (odds ratio = 2.335, P = 0.006). Large HCCs (20-30 mm) displayed a higher proportion of washout compared with that of HCCs ≤ 20 mm.

CONCLUSIONS

Enhancement patterns of small HCCs on CEUS were significantly correlated with tumor size and tumor differentiation among all clinicopathologic characteristics.

Current Opinion about Hepatocellular Carcinoma <10 mm

BACKGROUND

Early detection of hepatocellular carcinoma (HCC) is important. Advances in liver imaging techniques have facilitated the detection of HCC at an early stage. However, there is a controversial discussion on how to diagnose very small HCC by imaging. The aim of the current review is to present current published data on HCC ≤10 mm and discuss on how to best diagnose and treat such lesions.

SUMMARY

It is still challenging, however, to accurately characterize HCC <10 mm. The accuracy of contrast-enhanced ultrasound may be critical for early treatment decisions for cancer patients, particularly when CECT and/or CEMRI are inconclusive. Key Messages: The characterization of focal liver lesions <10 mm is frequently delayed until a follow-up imaging procedure demonstrates growth or stability. A repetition of ultrasound examination after 3 months for new nodules <1 cm should be recommended.

Role of Imaging in Surveillance and Diagnosis of Hepatocellular Carcinoma

The prognosis for hepatocellular carcinoma (HCC) is dependent on tumor stage at diagnosis, with curative treatment options more available to early-detected HCCs. Professional organizations have produced HCC screening guidelines in at-risk groups, with ultrasound the most commonly used screening tool and increased interest in MRI in specific populations. HCC may be diagnosed by imaging features alone and have been universally incorporated into management guidelines. The radiology community has standardized imaging criteria for HCC with the development of the Liver Imaging Reporting and Data System, which has expanded to incorporate computed tomography, MR, and contrast-enhanced ultrasound for diagnostic purposes.

Diagnosis and staging of hepatocellular carcinoma (HCC): current guidelines

One of the key strategies to improve the prognosis of HCC, beside prevention, is to diagnose the tumor in early stages, when the patient is asymptomatic and the liver function is preserved, because in this clinical situation effective therapies with survival benefit can be applied. Imaging techniques are a key tool in the surveillance and diagnosis of HCC. Screening should be based in US every 6 months and non-invasive diagnostic criteria of HCC based on imaging findings on dynamic-MR and/or dynamic-CT have been validated and thus, accepted in clinical guidelines. The typical vascular pattern depicted by HCC on CT and or MRI consists on arterial enhancement, stronger than the surrounding liver (wash-in), and hypodensity or hyposignal intensity compared to the surrounding liver (wash-out) in the venous phase. This has a sensitivity of around 60% with a 96-100% specificity. Major improvements on liver imaging have been introduced in the latest years, adding functional information that can be quantified: the use of hepatobiliary contrast media for liver MRI, the inclusion of diffusion-weighted sequences in the standard protocols for liver MRI studies and new radiotracers for positron-emission tomography (PET). However, all them are still a matter of research prior to be incorporated in evidence based clinical decision making. This review summarizes the current knowledge about imaging techniques for the early diagnosis and staging of HCC, and it discusses the most relevant open questions.

EASL and AASLD recommendations for the diagnosis of HCC to the test of daily practice

AIMS

To evaluate the diagnostic performance of CT, MRI and CEUS alone and in combination, for the diagnosis of HCC between 10 and 30 mm, in a large population of cirrhotic patients.

PATIENTS AND METHODS

In a multicentre prospective trial, 442 patients have been enrolled. Within a month, CEUS, CT and MRI were performed for all patients. A composite algorithm was defined to obtain the more accurate gold standard.

RESULTS

A total of 544 nodules in 381 patients have been retained for the performance analysis. Eighty-two percent of the patients were male, mean age was 62 years. For the 10-20 mm nodules (n=342), the sensitivity (Se) and specificity (Sp) for the diagnosis of HCC were, respectively, 70.6% and 83.2% for MRI, 67.9% and 76.8% for CT and 39.6% and 92.9% for CEUS. For the 20-30 mm nodules (n=202), the Se and Sp were, respectively, 72.3% and 89.4% for MRI, 71.6% and 93.6% for CT and 52.9% and 91.5% for CEUS. THE BEST COMBINATION FOR THE 10-20 MM NODULES WAS MRI + CT (SE: 55.1%, SP: 100.0%).: After a first inconclusive technique, CEUS as second image technique allowed the highest specificity with only a slight drop of sensitivity for 10-20 mm nodules and the highest sensitivity and specificity for 20-30 mm nodules.

CONCLUSION

This large multicentre study validates the EASL/AASLD recommendations in daily practice. Specificity using CT or MRI in 10-20 mm HCC was low, but we do not recommend combined imaging at first as sensitivity would be very low. The best sequential approach combined MRI and CEUS.

Diagnostic accuracy of contrast-enhanced ultrasound for the differential diagnosis of hepatocellular carcinoma: ESCULAP versus CEUS-LI-RADS

OBJECTIVE

A comparison is made of two contrast-enhanced ultrasound (CEUS) algorithms for the diagnosis of hepatocellular carcinoma (HCC) in high-risk patients: Erlanger Synopsis of Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at Risk (ESCULAP) and American College of Radiology Contrast-Enhanced Ultrasound-Liver Imaging Reporting and Data System (ACR-CEUS-LI-RADSv.2016).

PATIENTS AND METHODS

Focal liver lesions in 100 high-risk patients were assessed using both CEUS algorithms (ESCULAP and CEUS-LI-RADSv.2016) for a direct comparison. Lesions were categorized according to size and contrast enhancement in the arterial, portal venous and late phases.For the definite diagnosis of HCC, categories ESCULAP-4, ESCULAP-Tr and ESCULAP-V and CEUS-LI-RADS-LR-5, LR-Tr and LR-5-V were compared. In addition, CEUS-LI-RADS-category LR-M (definitely/probably malignant, but not specific for HCC) and ESCULAP-category C [intrahepatic cholangiocellular carcinoma (ICC)] were compared.Histology, CE-computed tomography and CE-MRI served as reference standards.

RESULTS

The reference standard among 100 lesions included 87 HCCs, six ICCs and seven non-HCC-non-ICC-lesions. For the diagnosis of HCC, the diagnostic accuracy of CEUS was significantly higher with ESCULAP versus CEUS-LI-RADS (94.3%/72.4%; p<0.01). Sensitivity, specificity and positive predictive value (PPV) and negative predictive value for ESCULAP/CEUS-LI-RADS were 94.3%/72.4%; 61.5%/69.2%; 94.3%/94%; and 61.5%/27.3%, respectively.The diagnostic accuracy for ICC (LR-M/ESCULAP-C) was identical with both algorithms (50%), with higher PPV for ESCULAP-C versus LR-M (75 vs. 50%).

CONCLUSION

CEUS-based algorithms contribute toward standardized assessment and reporting of HCC-suspect lesions in high-risk patients. ESCULAP shows significantly higher diagnostic accuracy, sensitivity and negative predictive value with no loss of specificity compared with CEUS-LI-RADS. Both algorithms have an excellent PPV. Arterial hyperenhancement is the key feature for the diagnosis of HCC with CEUS. Washout should not be a necessary prerequisite for the diagnosis of definite HCC. CEUS-LI-RADS in its current version is inferior to ESCULAP for the noninvasive diagnosis of HCC. There are two ways to improve CEUS-LI-RADS: firstly, combination of the categories LR-4 and LR-5 for the diagnosis of definite HCC, and secondly, use of subtotal infiltration of a liver lobe as an additional feature.

Natural history of liver imaging reporting and data system category 4 nodules in MRI

PURPOSE

The purpose of this study was to characterize the MR imaging features and outcomes of liver imaging reporting and data system (LI-RADS) category 4 (LR4) nodules, with an emphasis on upgrade to category 5 (LR5) and development of contraindications to curative therapy.

METHODS

Institutional review board approval was obtained for this retrospective, dual-institutional Health Insurance Portability and Accountability Act-compliant study. The requirement for informed consent was waived. Contrast-enhanced MRI studies performed on patients with cirrhosis were retrospectively assessed using LI-RADS 2014 by at least two readers. All nodules were individually evaluated to determine their major imaging features at diagnosis, and follow-up data were used to determine the associated imaging outcomes.

RESULTS

One hundred eighty-one untreated LR4 nodules in 139 patients had adequate imaging and follow-up for inclusion in the study. Most (61% [111/181]) of these demonstrated arterial phase hyperenhancement, washout, and diameter less than 20 mm. During the follow-up period (median 163 days), 31% (56/181) of the nodules upgraded to LR5, 40% (73/181) remained stable, and 29% (52/181) downgraded. Of the nodules that upgraded, 61% (34/56) increased their size category and 54% (30/56) developed newly visualized capsules. No LR4 nodules developed venous invasion, satellites nodules, or new intrahepatic or extrahepatic metastatic disease. 75% (42/56) of the nodules that upgraded to LR5 did so within 6 months.

CONCLUSIONS

Approximately one-third of LR4 nodules upgrade to LR5, and the short-term risk of developing venous invasion or metastasis is very low.

[Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH]

Hepatocellular carcinoma is the most common primary malignancy of the liver and one of the most frequent causes of death in patients with liver cirrhosis. Simultaneously with the recognition of the clinical relevance of this neoplasm, in recent years there have been important developments in the diagnosis, staging and treatment of HCC. Consequently, the Asociación Española para el Estudio del Hígado has driven the need to update clinical practice guidelines, continuing to invite all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document (Sociedad Española de Trasplante Hepático, Sociedad Española de Radiología Médica, Sociedad Española de Radiología Vascular e Intervencionista y Sociedad Española de Oncología Médica). The clinical practice guidelines published in 2009 accepted as Clinical Practice Guidelines of the National Health System has been taken as reference document, incorporating the most important advances that have been made in recent years. The scientific evidence for the treatment of HCC has been evaluated according to the recommendations of the National Cancer Institute (www.cancer.gov) and the strength of recommendation is based on the GRADE system.

Early diagnosis of liver cancer: an appraisal of international recommendations and future perspectives

All Societies, AASLD, EASL, APASL and JSH, identify patients with cirrhosis as a target population for surveillance, with minor differences for additional categories of patients, such as chronic hepatitis B and hepatitis C patients with advanced fibrosis. According to AASLD, liver disease related to metabolic diseases including diabetes and obesity is a recognized target of screening, since those conditions have been causally related to HCC. All societies endorse radiological non-invasive techniques as the mainstay for early diagnosis of HCC, but discrepancies exist between Societies on the utilization of contrast-enhanced ultrasound and utilization of serum markers for surveillance and diagnosis of HCC. The diagnostic algorithm of the international societies differ substantially in the anatomic paradigm of EASL and APASL which identify 1 cm size as the starting point for radiological diagnosis of HCC compared to APASL algorithm based on the dynamic pattern of contrast imaging, independently on tumour size. While strengthening prediction in individual patients is expected to improve cost-effectiveness ratios of screening, the benefits of pre-treatment patient stratification by clinical, histological and genetic scores remain uncertain and exclusion of patients with severe co-morbidities and advanced age is still debated.

Imaging Diagnosis of Hepatocellular Carcinoma: Recent Advances of Contrast-Enhanced Ultrasonography with SonoVue®

Due to the ability to detect the typical contrast-imaging pattern for hepatocellular carcinoma (HCC), that is hyperenhancement in the arterial phase and hypoenhancement in the late phase on a cirrhotic background, contrast-enhanced ultrasonography (CEUS) was included in the American diagnostic algorithm for HCC in 2005. However, its role has been questioned because of the possibility of misdiagnosis of cholangiocarcinoma. The present review aims to describe the advantages and disadvantages of CEUS applications using Sonovue® for HCC. In particular there is focus on the accuracy of CEUS in detecting the typical HCC pattern, the CEUS patterns of intrahepatic cholangiocarcinoma (ICC), the risk of misdiagnosis with HCC, the diagnostic use of CEUS in cases of locoregional and systemic treatments, and the evaluation of response to antiangiogenic treatment using dedicated software.