Tumor size-based validation of contrast-enhanced ultrasound liver imaging reporting and data system (CEUS LI-RADS) 2017 for hepatocellular carcinoma characterizing

Camrelizumab combined with transcatheter arterial chemoembolization and sorafenib or lenvatinib for unresectable hepatocellular carcinoma: A multicenter, retrospective study

INTRODUCTION AND OBJECTIVES

We initiated this study to explore the efficacy of camrelizumab combined with transcatheter arterial chemoembolization (TACE) plus sorafenib or lenvatinib versus TACE plus sorafenib or Lenvatinib for unresectable hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From June 2019 to November 2022, 127 advanced HCC patients were retrospectively analyzed in this study. This consisted of 44 patients that received camrelizumab plus TACE plus sorafenib or lenvatinib (triple therapy group) and 83 patients that received TACE plus sorafenib or lenvatinib (double treatment group). The overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) were compared between the two patient groups.

RESULTS

Our findings demonstrated that patients received the triple therapy exhibited superior median OS (15.8 vs. 10.3 months, P=0.0011) and median PFS (7.2 vs. 5.2 months, P=0.019) compared to the double treatment group. In addition, the triple therapy group exhibited better 6-month (93.5% vs. 66.3%), 12-month (67.2% vs. 36.3%), and 24-month (17.2% vs. 7.6%) survival rates than the double treatment group. However, the ORR (43.2% vs. 28.9%, P = 0.106) and DCR (93.2% vs. 81.9%, P = 0.084) of the two groups were similar. Subgroup analysis showed that compared with the double treatment group, the triple therapy group had a better mOS for HCC with HBV (15.8 vs. 9.6 months, P = 0.0015) and tumor diameter ≥ 5cm (15.3 vs. 9.6 months, P = 0.00055).

CONCLUSIONS

Camrelizumab plus TACE and sorafenib or lenvatinib may be a promising treatment approach for the clinical management of unresectable HCC patients.

Compared with SonoVue® LR-5, Sonazoid® modified LR-5 has better diagnostic sensitivity for hepatocellular carcinoma: a systematic review and meta-analysis

Background

The contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) is a standardized system for reporting liver nodules in patients at risk of developing hepatocellular carcinoma (HCC) and is only recommended for pure blood pool agents such as SonoVue®. A modified LI-RADS was proposed for Sonazoid®, a Kupffer cell-specific contrast agent. This meta-analysis was conducted to compare the diagnostic efficiency of the CEUS LI-RADS for SonoVue® and the modified LI-RADS for Sonazoid®.

Methods

The PubMed, Medline, Web of Science, Embase, and Cochrane Library databases were systematically searched to retrieve studies on the diagnostic efficiency of the CEUS LI-RADS algorithms in diagnosing HCC using SonoVue® and/or Sonazoid® from January 2016 to June 2023. Histopathology or imaging follow-up served as the reference standards. Only articles published in English on retrospective or prospective studies with full reports were included in the meta-analysis. A bivariate random-effects model was used. Data pooling, meta-regression, and sensitivity analysis were performed for the meta-analysis. Deeks' funnel plot asymmetry test was used to evaluate publication bias, and the QUADAS-2 tool was used to assess the methodological quality of eligible studies.

Results

In total, 26 studies comprising 8,495 patients with 9,244 lesions were included in the meta-analysis. The pooled data results for SonoVue® LI-RADS category 5 (LR-5) and Sonazoid® modified LR-5 were as follows: pooled sensitivity: 0.68 [95% confidence interval (CI): 0.64-0.73, I2=89.20%; P<0.01] and 0.82 (95% CI: 0.74-0.87, I2=85.39%; P<0.01) (P<0.05); pooled specificity: 0.93 (95% CI: 0.90-0.96, I2=86.52%; P<0.01) and 0.86 (95% CI: 0.79-0.91, I2=59.91%; P=0.01) (P<0.05); pooled area under the curve (AUC): 0.86 (95% CI: 0.82-0.89) and 0.91 (95% CI: 0.88-0.93) (P<0.05), respectively. The meta-regression analysis revealed that the study design, subject enrollment method, and reference standard contributed to the heterogeneity of SonoVue® LR-5, and the number of lesions was a source of heterogeneity for Sonazoid® modified LR-5. The diagnostic performance of the LI-RADS category M (LR-M) algorithms of SonoVue® and Sonazoid® was comparable.

Conclusions

The Sonazoid® modified LR-5 algorithm had a higher diagnostic sensitivity, lower specificity, and higher AUC than SonoVue® LR-5.

LI-RADS LR-5 on contrast-enhanced ultrasonography has satisfactory diagnostic specificity for hepatocellular carcinoma: a systematic review and meta-analysis

Background

The Liver Imaging Reporting and Data System (LI-RADS) for contrast-enhanced ultrasonography (CEUS) was invented to define suspected liver nodules based on their imaging characteristics. Among the categories of nodules of LI-RADS for CEUS, LR-5 is generally considered to be definitely malignant; however, the exact diagnostic performance of this liver nodule category has varied between different studies. Therefore, we performed this systematic review and meta-analysis to calculate the pooled diagnostic sensitivity, specificity based on important data extracted from some influential clinical studies.

Methods

A preliminary search of national and international databases, including PubMed/Ovid Medline, Embase, Cochrane Library, Web of Science, and Wan Fang Data, for relevant studies on CEUS LI-RADS LR-5 published between January 2017 and June 2021 was conducted. A literature screening and selection process was undertaken to evaluate the relevance of the articles, and studies deemed eligible for inclusion in the review were subsequently identified. The updated Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was applied as the main method to assess the risk of bias and applicability of the studies. A meta-analysis of the diagnostic sensitivity and specificity of CEUS LI-RADS LR-5 was performed using the free software, Meta-DiSc 1.4 (Ramóny Cajal Hospital, Madrid, Spain). The area under curve (AUC) was calculated to help determine the diagnostic efficiency. A meta-regression analysis was also performed to identify factors that could have contributed to heterogeneity between the studies.

Results

Twelve studies with 20 observations focused on investigating the relative diagnostic performance of the CEUS LI-RADS LR-5 category for hepatocellular carcinoma (HCC) detection were finally recruited into the systematic review and meta-analysis. The pooled diagnostic sensitivity was 0.71 [95% confidence interval (CI): 0.69-0.72], with heterogeneity (I²) of 88.4%, and the pooled specificity was 0.93 (95% CI: 0.92-0.95), with an I² of 71.2%. Study heterogeneity was observed and statistically correlated with the number of centers and the reference standard.

Conclusions

The CEUS LI-RADS LR-5 category has satisfactory diagnostic efficacy for HCC, as evidenced by an acceptable diagnostic sensitivity of 0.71 and a good diagnostic specificity of 0.93.

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.

Clinical value of contrast-enhanced ultrasound in early diagnosis of small hepatocellular carcinoma (≤ 2 cm)

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common type of primary liver malignancy. Contrast-enhanced ultrasound (CEUS) uses contrast microbubbles during ultrasound, allowing the detection and characterization of malignant focal liver lesions with much higher diagnostic accuracy than conventional ultrasound; however, there are few reports focusing on the pattern of enhancement of CEUS for the diagnosis of HCC smaller than 2 cm.

AIM

To investigate the clinical value of CEUS in the early detection of small HCC with high risk factors.

METHODS

A total of 395 patients with 632 nodules at high risk of HCC, who underwent regular follow-up at Xuhui Dahua Hospital from January 2007 to December 2021, were retrospectively examined. Conventional ultrasonography combined with CEUS was adopted to analyze the echo, size, location, and enhancement characteristics of benign and malignant nodules, as well as the enhancement methods for HCC with different diameters.

RESULTS

The follow-up rate and duration were 92.15% (364/395) and 51.28 ± 45.09 mo, respectively. Conventional ultrasonography combined with CEUS revealed 65 (11.80%) nodules with a follow-up diagnosis of HCC, 19 (3.45%) dysplastic nodules, and 467 (84.75%) benign cirrhotic hyperplastic nodules. Among 65 cases of confirmed HCC, 40 (61.54%) were transformed from hypoechoic nodules, 9 (13.85%) from hyperechoic nodules, and the remaining 16 (24.62%) from isoechoic nodules. Significant differences in CEUS characteristics were found among cirrhotic nodules, dysplastic nodules, and HCC nodules at each phase. Significant differences in the enhancement mode were observed between nodules ≤ 1 cm and those 1–2 cm. The smaller the HCC nodule, the later the contrast agent began to flush and the longer the duration of contrast enhancement.

CONCLUSION

Conventional ultrasonography combined with CEUS could identify small HCC and help monitor patients with an early diagnosis of HCC. Significant differences in the enhancement mode are noted between nodules ≤ 1 cm and those 1–2 cm.

Contrast-enhanced ultrasound Liver Imaging Reporting and Data System: Lights and shadows in hepatocellular carcinoma and cholangiocellular carcinoma diagnosis

BACKGROUND

Contrast-enhanced ultrasound (CEUS) is considered a secondary examination compared to computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of hepatocellular carcinoma (HCC), due to the risk of misdiagnosing intrahepatic cholangiocarcinoma (ICC). The introduction of CEUS Liver Imaging Reporting and Data System (CEUS LI-RADS) might overcome this limitation. Even though data from the literature seems promising, its reliability in real-life context has not been well-established yet.

AIM

To test the accuracy of CEUS LI-RADS for correctly diagnosing HCC and ICC in cirrhosis.

METHODS

CEUS LI-RADS class was retrospectively assigned to 511 nodules identified in 269 patients suffering from liver cirrhosis. The diagnostic standard for all nodules was either biopsy (102 nodules) or CT/MRI (409 nodules). Common diagnostic accuracy indexes such as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed for the following associations: CEUS LR-5 and HCC; CEUS LR-4 and 5 merged class and HCC; CEUS LR-M and ICC; and CEUS LR-3 and malignancy. The frequency of malignant lesions in CEUS LR-3 subgroups with different CEUS patterns was also determined. Inter-rater agreement for CEUS LI-RADS class assignment and for major CEUS pattern identification was evaluated.

RESULTS

CEUS LR-5 predicted HCC with a 67.6% sensitivity, 97.7% specificity, and 99.3% PPV (P < 0.001). The merging of LR-4 and 5 offered an improved 93.9% sensitivity in HCC diagnosis with a 94.3% specificity and 98.8% PPV (P < 0.001). CEUS LR-M predicted ICC with a 91.3% sensitivity, 96.7% specificity, and 99.6% NPV (P < 0.001). CEUS LR-3 predominantly included benign lesions (only 28.8% of malignancies). In this class, the hypo-hypo pattern showed a much higher rate of malignant lesions (73.3%) than the iso-iso pattern (2.6%). Inter-rater agreement between internal raters for CEUS-LR class assignment was almost perfect (n = 511, k = 0.94, P < 0.001), while the agreement among raters from separate centres was substantial (n = 50, k = 0.67, P < 0.001). Agreement was stronger for arterial phase hyperenhancement (internal k = 0.86, P < 2.7 × 10^-214; external k = 0.8, P < 0.001) than washout (internal k = 0.79, P < 1.6 × 10^-202; external k = 0.71, P < 0.001).

CONCLUSION

CEUS LI-RADS is effective but can be improved by merging LR-4 and 5 to diagnose HCC and by splitting LR-3 into two subgroups to differentiate iso-iso nodules from other patterns.