Comparison of Contrast-Enhanced Ultrasound and Gadolinium-Ethoxybenzyl-Diethylenetriamine Pentaacetic Acid-Enhanced MRI for the Diagnosis of Macroscopic Type of Hepatocellular Carcinoma

The Clinical Utility of Liver-Specific Ultrasound Contrast Agents During Hepatocellular Carcinoma Imaging

Hepatocellular carcinoma (HCC) is the most common form of hepatic malignancy, with high mortality rates recorded globally. Early detection through clinical biomarkers, medical imaging and histological assessment followed by rapid intervention are integral for positive patient outcomes. Although contrast-enhanced computed tomography scans and magnetic resonance imaging are recognised as the reference standard for the diagnosis and staging of HCC in international guidelines, ultrasound (US) examination is recommended as a screening tool for patients at risk. Contrast-enhanced US (CEUS) elevates the standard of an US examination using US contrast agents (UCAs), capable of diagnosing focal liver lesions with high efficacy. Most UCAs are purely intravascular, offering clinicians a dynamic representation of a lesions' arterial phase vascular kinetics, which is seldom seen in such detail during computed tomography or magnetic resonance imaging assessments. Despite its benefits, there is incongruity between international societies on the role of CEUS in the HCC clinical pathway. The transient nature of pure blood-pool agents is suggested to be insufficient to justify CEUS as a primary modality due to the inability to consistently perform whole liver imaging, alongside disputes regarding its capabilities to differentiate HCC from intrahepatic cholangiocarcinoma. A sinusoidal phase UCA affords clinicians the opportunity to perform whole liver imaging through Kupffer cell uptake in addition to visualising lesion vascular kinetics in the arterial and portal venous phases. Therefore, the purpose of this review was to examine the role of CEUS in the HCC clinical pathway in its current practice and observe how a Kupffer cell sinusoidal phase UCA may supplement contemporary diagnostic techniques through a multi-modality, multi-agent approach.

LI-RADS Morphological Type Predicts Prognosis of Patients with Hepatocellular Carcinoma After Radical Resection

PURPOSE

This study aimed to explore the association of preoperative magnetic resonance imaging (MRI) tumor morphological classification with early recurrence (ER) and overall survival (OS) after radical surgery of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

A retrospective analysis of 296 patients with HCC who underwent radical resection was performed. On the basis of LI-RADS, tumor imaging morphology was classified into three types. The clinical imaging features, ER, and survival rates of three types were compared. Univariate and multivariate Cox regression analyses were conducted to identify prognostic factors associated with OS and ER after hepatectomy for HCC.

RESULTS

There were 167 tumors of type 1, 95 of type 2, and 34 of type 3. In patients with type 3 HCC, postoperative mortality and ER were significantly higher than in patients with type 1 and type 2 (55.9% versus 32.6% versus 27.5% and 52.9% versus 33.7% versus 28.7%). In multivariate analysis, the LI-RADS morphological type was a stronger risk factor for predicting poor OS [hazard ratio (HR) 2.77, 95% confidence interval (CI) 1.59-4.85, P < 0.001] and ER (HR 2.14, 95% CI 1.24-3.70, P = 0.007). A subgroup analysis revealed that type 3 was associated with poor OS and ER in > 5 cm cases but not in < 5 cm cases.

CONCLUSIONS

ER and OS of patients with HCC undergoing radical surgery can be predicted using the preoperative tumor LI-RADS morphological type, which could help to select personalized treatment plans for patients with HCC in the future.

Utility of Sonazoid-Enhanced Ultrasound for the Macroscopic Classification of Hepatocellular Carcinoma: A Meta-analysis

We assessed the diagnostic value of Sonazoid-enhanced ultrasound (SEUS) in determining the macroscopic classification of hepatocellular carcinoma (HCC) because of its strong relevance to the poor prognosis of the non-simple nodular (non-SN) type. The PubMed, EMBASE, Web of Science and Cochrane Library databases were searched for studies investigating patients who underwent surgery for HCC after undergoing SEUS pre-operatively. Five studies involving a total of 334 patients met the inclusion criteria. The summary sensitivity and specificity were 0.74 (95% confidence interval [CI]: 0.63-0.83) and 0.92 (95% CI: 0.82-0.97), respectively. The positive and negative likelihood ratios of SEUS for determining the macroscopic classification of HCC in Kupffer phase were 9.21 (95% CI: 4.02-21.13) and 0.28 (95% CI: 0.19-0.41), respectively. The diagnostic odds ratio of SEUS for determining the macroscopic classification of HCC was 34.2 (95% CI: 11.64-100.51), and the area under the summary receiver operating characteristic curve was 0.87 (95% CI: 0.84-0.90). Subgroup analysis suggested that small HCCs (≤30 mm) and studies including fewer than 70 patients may be associated with a higher diagnostic odds ratio than the corresponding subsets. SEUS had moderate diagnostic value for determining the macroscopic classification of HCC in the Kupffer phase.

Contrast-Enhanced Intraoperative Ultrasound of the Liver

Contrast-enhanced intraoperative ultrasound (CE-IOUS) is a relatively new but valuable tool that is increasingly used as an adjunct to computed tomography, MRI, and IOUS for patients undergoing liver surgery. CE-IOUS has an important role in 2 main settings: the discrimination of indeterminate lesions detected in cirrhotic livers by conventional IOUS and in the detection of colorectal liver metastasis that may be overlooked by other imaging modalities. The intraoperative nature of the imaging and interpretation allows for CE-IOUS to directly affect surgical decision-making that may importantly affect patient outcomes.

A comparative study of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging and contrast-enhanced ultrasound in the detection of intrahepatic lesion

We evaluated the diagnostic performance of both gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-MRI) and contrast-enhanced ultrasound (CEUS) for focal liver lesions, especially for the detection of small (<2 cm) intrahepatic lesions. We retrospectively reviewed patients who underwent Gd-EOB-DTPA-MRI and CEUS before liver resection and compared Gd-EOB-DTPA-MRI and CEUS in the detection of focal liver lesions. A total of 216 patients were included, and 309 lesions were found. The sensitivity values of MRI and CEUS for the main lesion were both more than 95%, and the coincidence rates were both more than 80%. Regarding lesions <2 cm, 135 such lesions were detected by MRI, whereas only 85 were detected by CEUS. For lesions <2 cm, the sensitivity, specificity, and coincidence rates of MRI were significantly better than those of CEUS. Among 27 patients, 50 more lesions were detected by MRI than CEUS, 56% (28/50) of which were malignant. For the large lesion, the diagnostic performance is similar between Gd-EOB-DTPA-MRI and CEUS, and the sensitivity and coincidence rates of both methods are high. Gd-EOB-DTPA-MRI is likely to detect small (<2 cm) focal intrahepatic lesions.

Discrepancy of contrast-enhanced ultrasonographic pattern with two contrast agents in steatohepatitic subtype hepatocellular carcinoma: A case report

Contrast-enhanced ultrasound (CEUS) is one of the important imaging modalities for diagnosis of hepatocellular carcinoma (HCC). Sonovue and Sonazoid are the third-generation of ultrasound contrast agents that have been commercialized and widely used in clinical applications. This study introduces the imaging differences between these two agents in vascular phases for the first time. A 54-year-old man clinical suspected liver cancer. He had chronic hepatitis B for more than 20 years. The result of alpha-fetoprotein was 36.45μg/L (normal< 20μg/L). The imaging pattern of CEUS with Sonovue was “fast-in and fast-out” performance, while the pattern of “fast-out” was absent after portal phase with Sonazoid, even in Kupffer phase. The lesion was diagnosed as lipid-rich HCC by contrast-enhanced MRI. After liver resection, pathology revealed that it was hepatocellular carcinoma contained poor-differentiated steatohepatitis subtype and moderate-differentiated microtrabecular subtype. The imaging difference mainly existed in the part of steatohepatitis subtype. Steatohepatitis subtype HCC can be showed as “fast-in and no wash-out” characteristic in Sonazoid CEUS. Though the mechanism remains not fully clarified, this different enhancing pattern may provide a potential for the supplement of the guidelines and differential of steatohepatitis subtype HCC.

Perfluorobutane contrast-enhanced ultrasonography for the diagnosis of HCC: a systematic review and meta-analysis

OBJECTIVES

Perfluorobutane ultrasound contrast agent as a new type of contrast agent has a good performance in the diagnosis of hepatocellular carcinoma (HCC). This study aim to evaluate the accuracy and reliability of Perfluorobutane contrast-enhanced ultrasonography (P-CEUS) in the diagnosis of HCC with a systematic review and meta-analysis.

METHODS

Web of Science, EMBASE, Cochrane, Clinical Key, Wan Fang, CBM and CNKI databases were systematically searched and checked for studies using P-CEUS in HCC, from 2007 to 2020. Data necessary to construct 2 × 2 contingency tables were extracted from included studies. The QUADAS tool was utilized to assess the methodologic quality of the studies. Meta-analysis included data pooling, subgroup analyses, meta-regression and investigation of publication bias was comprehensively performed.

RESULTS

Nine studies were included in this meta-analysis and the overall diagnostic accuracy in characterization of HCC was as follows: pooled sensitivity, 0.90 (95% confidence interval: 0.82-0.95); pooled specificity, 0.97 (0.93-0.98); pooled positive likelihood ratio, 27.2 (14.1 to - 52.3); and pooled negative likelihood ratio, 0.10 (0.06-0.18). The area under the comprehensive receiving operation characteristic curve was 0.98 (0.97-0.99).

CONCLUSION

The sensitivity and specificity of P-CEUS are more valuable than other imaging techniques (such as computer tomography or magnetic resonance imaging). However, due to the large differences in the data samples collected in this study, statistical heterogeneity results. P-CEUS can significantly improve the diagnostic efficiency of previous contrast-enhanced ultrasound for HCC. PROSPERO registration number: PROSPERO (CRD42020200040).

Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other's work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

The diagnostic performance of gadoxetic acid disodium-enhanced magnetic resonance imaging and contrast-enhanced ultrasound in detecting hepatocellular carcinoma: A meta-analysis

The purpose of this study was to identify and compare the diagnostic performance of gadolinium-ethoxybenzyl-diethyltriethylenetriacetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) in hepatocellular carcinoma (HCC).Two researchers searched PubMed, EMBASE, and Cochrane Library databases from the inception of each database to 10 February 2020, to find comparative studies of Gd-EOB-DTPA-MRI and CEUS in detection of HCC.The study included eight studies (374 patients). MRI is superior to CEUS in diagnostic sensitivity of HCC, P = .03. The diagnostic sensitivity of MRI in lesions with a diameter of less than 30 mm was significantly higher than that of CEUS, P = .04. MRI and CEUS had no significant difference in diagnostic specificity of HCC, P = .95. Summary Receiver Operating Characteristics (SROC) of MRI showed a larger than that of CEUS, but with P > .05.Gd-EOB-DTPA-MRI showed higher sensitivity than CEUS for hepatocellular carcinoma lesions, especially for lesions of less than 30 mm across.

Comparative Diagnostic Accuracy of Contrast-Enhanced Ultrasound and Shear Wave Elastography in Differentiating Benign and Malignant Lesions: A Network Meta-Analysis

Background: We performed a network meta-analysis to compare the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) and shear wave elastography (SWE) in differentiating benign and malignant lesions in different body sites.

Methods: A computerized literature search of Medline, Embase, SCOPUS, and Web of Science was performed using relevant keywords. Following data extraction, we calculated sensitivity, specificity, positive likelihood ratio (LR), negative LR, and diagnostic odds ratio (DOR) for CEUS, and SWE compared to histopathology as a reference standard. Statistical analyses were conducted by MetaDiSc (version 1.4) and R software (version 3.4.3).

Results: One hundred and fourteen studies (15,926 patients) were pooled in the final analyses. Network meta-analysis showed that CEUS had significantly higher DOR than SWE (DOR = 27.14, 95%CI [2.30, 51.97]) in breast cancer detection. However, there were no significant differences between CEUS and SWE in hepatic (DOR = −6.67, 95%CI [−15.08, 1.74]) and thyroid cancer detection (DOR = 3.79, 95%CI [−3.10, 10.68]). Interestingly, ranking analysis showed that CEUS achieved higher DOR in detecting breast and thyroid cancer, while SWE achieved higher DOR in detecting hepatic cancer. The overall DOR for CEUS in detecting renal cancer was 53.44, 95%CI [29.89, 95.56] with an AUROC of 0.95, while the overall DOR for SWE in detecting prostate cancer was 25.35, 95%CI [7.15, 89.89] with an AUROC of 0.89.

Conclusion: Both diagnostic tests showed relatively high sensitivity and specificity in detecting malignant tumors in different organs. Network meta-analysis showed that CEUS had higher diagnostic accuracy than SWE in detecting breast and thyroid cancer, while SWE had higher accuracy in detecting hepatic cancer. However, the results were not statistically significant in hepatic and thyroid malignancies. Further head-to-head comparisons are needed to confirm the optimal imaging technique to differentiate each cancer type.

Combining the Arterial Phase of Contrast-Enhanced Ultrasonography, Gadoxetic Acid-Enhanced Magnetic Resonance Imaging and Diffusion-Weighted Imaging in the Diagnosis of Hepatic Nodules ≤20 mm in Patients with Cirrhosis

Contrast-enhanced ultrasonography (CEUS) and gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) were compared with respect to diagnostic efficacy in the detection of small hepatocellular carcinoma. A new diagnostic strategy that combines the arterial phase of CEUS, the hepatobiliary phase of EOB-MRI and diffusion-weighted MR imaging (DWI) is described. One hundred sixteen nodules were enrolled to validate the performance of the strategy. For lesions ≤20 mm in size, the areas under the receiver operating characteristic curves (Az) of CEUS and EOB-MRI were 0.930 (95% confidence interval [CI]: 0.867-0.969) and 0.920 (95% CI: 0.855-0.962) (p = 0.796), respectively. The Az value of the new diagnostic strategy was 0.985 (95% CI: 0.942-0.999) (vs. CEUS, p = 0.026; vs. EOB-MRI, p = 0.014). The sensitivity, specificity and diagnostic accuracy of the new strategy were 95.5% (95% CI: 88.9%-98.8%), 96.3% (95% CI: 81.0%-99.9%) and 95.7% (95% CI: 91.9%-99.4%), respectively. The new diagnostic strategy based on the arterial phase of CEUS, hepatobiliary phase of EOB-MRI and DWI represents an appealing solution for distinguishing small hepatocellular carcinomas from benign lesions, especially when the nodules present atypical enhancement patterns.

Significance of contrast-enhanced ultrasonography in differential diagnosis of thyroid nodules

The present study was aimed to compare the application values between 2-dimensional color Doppler ultrasonography (2DUS) and contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of thyroid malignant nodules.A total of 124 patients suspectedly diagnosed with malignant thyroid nodules under conventional gray-scale ultrasonography were recruited in this study. All enrolled patients were examined by both 2DUS and CEUS.A total of 153 nodules (94.44%) and 45 cases (90.00%) with malignant nodules were detected by the CEUS. No significant differences were noted in nodule detection rates between 2DUS and CEUS (χ = 1.170, P = .279; χ = 0.796, P = .372). The aspect ratio, microcalcification, internal echo, borderline, Vmax, resistance index, and total scores of malignant nodules were higher than those of benign nodules (all P < .05) when diagnosed by 2DUS. The peripheral/internal enhancement time, peak intensity, local enhancement, ring enhancement, and total scores of malignant nodules were significantly higher compared with those of benign nodules (all P < .05) by CEUS. Total score of malignant nodules diagnosed by 2DUS was approximately 3.5 and 2.3 points for CEUS. The diagnostic accuracy of 2DUS as observed by area under the curve was 0.821 with the cut-off value of 3.9, the sensitivity was 82.5%, and the specificity was 85.6%. The diagnostic accuracy of CEUS was 0.862 with the cut-off value of 2.8, the sensitivity was 86.7%, and the specificity was 91.3%.Both 2DUS and CEUS are worthy of application values in the differential diagnosis from benign to malignant thyroid nodules.

Combination of acoustic radiation force impulse imaging, serological indexes and contrast-enhanced ultrasound for diagnosis of liver lesions

AIM

To assess the value of combined acoustic radiation force impulse (ARFI) imaging, serological indexes and contrast-enhanced ultrasound (CEUS) in distinguishing between benign and malignant liver lesions.

METHODS

Patients with liver lesions treated at our hospital were included in this study. The lesions were divided into either a malignant tumor group or a benign tumor group according to pathological or radiological findings. ARFI quantitative detection, serological testing and CEUS quantitative detection were performed and compared. A comparative analysis of the measured indexes was performed between these groups. Receiver operating characteristic (ROC) curves were constructed to compare the diagnostic accuracy of ARFI imaging, serological indexes and CEUS, alone or in different combinations, in identifying benign and malignant liver lesions.

RESULTS

A total of 112 liver lesions in 43 patients were included, of which 78 were malignant and 34 were benign. Shear wave velocity (SWV) value, serum alpha-fetoprotein (AFP) content and enhancement rate were significantly higher in the malignant tumor group than in the benign tumor group (2.39 ± 1.20 m/s vs 1.50 ± 0.49 m/s, 18.02 ± 5.01 ng/mL vs 15.96 ± 4.33 ng/mL, 2.14 ± 0.21 dB/s vs 2.01 ± 0.31 dB/s; P < 0.05). The ROC curve analysis revealed that the areas under the curves (AUCs) of SWV value alone, AFP content alone, enhancement rate alone, SWV value + AFP content, SWV value + enhancement rate, AFP content + enhancement rate and SWV value + AFP content + enhancement rate were 85.1%, 72.1%, 74.5%, 88.3%, 90.4%, 82.0% and 92.3%, respectively. The AUC of SWV value + AFP content + enhancement rate was higher than those of SWV value + AFP content and SWV value + enhancement rate, and significantly higher than those of any single parameter or the combination of any two of parameters.

CONCLUSION

The combination of SWV, AFP and enhancement rate had better diagnostic performance in distinguishing between benign and malignant liver lesions than the use of any single parameter or the combination of any two of parameters. It is expected that this would provide a tool for the differential diagnosis of benign and malignant liver lesions.

Diagnostic value of contrast-enhanced ultrasound in hepatocellular carcinoma: a meta-analysis with evidence from 1998 to 2016

Background

This meta-analysis is aimed at determining the diagnostic value of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS).

Materials and Methods

A comprehensive literature search of Pubmed, Web of Science, and the Cochrane Library was performed to identify published studies. The methodological quality of the included studies was evaluated. Data from eligible studies were used to estimate the pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratio (LR) and summary receiver operating characteristic (SROC) curve. Meta-Disc and STATA softwares were utilized for all statistical analyses.

Results

Fifty-three eligible studies (publication years ranged from 1998 to 2016) were selected according to inclusion criteria. The meta-analysis showed that the pooled sensitivity and specificity of CEUS to detect HCC were 0.85 (95% CI: 0.84–0.86) and 0.91 (95% CI: 0.90–0.92), respectively. The pooled positive and negative LRs were 6.28 (95% CI: 4.49–8.77) and 0.16 (95% CI: 0.12–0.22), respectively. The pooled DOR was 55.01 (95% CI: 35.25–83.47). The area under the SCOR curve was 0.9432. Meta-regression and funnel plot indicated that sample size, type of contrast agents and publication bias might be the major sources of heterogeneity.

Conclusions

CEUS is a valuable diagnostic tool for identifying HCC in clinic with highly sensitive and specific.

Study on the value of serum miR-106b for the early diagnosis of hepatocellular carcinoma

AIM

To analyze the incidence of hepatocellular carcinoma (HCC) in a population that underwent health checkups and had high serum miR-106b levels.

METHODS

A total of 335 subjects who underwent checkups in the Digestive and Liver Disease Department of our hospital were randomly selected. RT-PCR was used to detect the level of miR-106b in serum samples. Laboratory and imaging examinations were carried out to confirm the HCC diagnosis in patients who had a > 2-fold change in miR-106b levels. Ultrasound-guided biopsy was also used for HCC diagnosis when necessary. On this basis, the clinical data of these subjects, including history of hepatitis virus infection, obesity, long-term history of alcohol use and stage of HCC, were collected. Then, the impact of these factors on the level of miR-106b in serum was analyzed. Furthermore, receiver operating characteristic (ROC) curve was drawn to evaluate the diagnostic efficacy of miR-106b for HCC.

RESULTS

A total of 35 subjects had abnormal serum miR-106b levels, of which 20 subjects were diagnosed with HCC. t-test revealed that the difference in serum miR-106b level in terms of sex, age, history of hepatitis virus infection, obesity and long-term history of alcohol use was not statistically significant. However, serum miR-106b levels in patients with advanced HCC (stage III/IV) was higher than in patients with early HCC (stage I/II), and the difference was statistically significant (P = 0.000). Moreover, the ROC curve revealed that the area under the curve value for miR-106b was 0.885, which shows that serum miR-106b level has a certain clinical value for HCC diagnosis.

CONCLUSION

The random sampling survey shows that serum miR-106b level is a valuable diagnostic marker for HCC. However, the diagnostic threshold value needs to be further researched.