Diagnostic performance of ultrasonography-guided core-needle biopsy according to MRI LI-RADS diagnostic categories

Performance of LI-RADS category 5 vs combined categories 4 and 5: a systemic review and meta-analysis

OBJECTIVE

Computed tomography (CT)/magnetic resonance imaging (MRI) Liver Imaging Reporting and Data System (LI-RADS, LR) category 5 has high specificity and modest sensitivity for diagnosis of hepatocellular carcinoma (HCC). The purpose of this study was to compare the diagnostic performance of LR-5 vs combined LR-4 and LR-5 (LR-4/5) for HCC diagnosis.

METHODS

MEDLINE and EMBASE databases through January 03, 2023 were searched for studies reporting the performance of LR-5 and combined LR-4/5 for HCC diagnosis, using CT/MRI LI-RADS version 2014, 2017, or 2018. A bivariate random-effects model was used to calculate the pooled per-observation diagnostic performance. Subgroup analysis was performed based on imaging modalities and type of MRI contrast material.

RESULTS

Sixty-nine studies (15,108 observations, 9928 (65.7%) HCCs) were included. Compared to LR-5, combined LR-4/5 showed significantly higher pooled sensitivity (83.0% (95% CI [80.3-85.8%]) vs 65.7% (95% CI [62.4-69.1%]); p < 0.001), lower pooled specificity (75.0% (95% CI [70.5-79.6%]) vs 91.7% (95% CI [90.2-93.1%]); p < 0.001), lower pooled positive likelihood ratio (3.60 (95% CI [3.06-4.23]) vs 6.18 (95% CI [5.35-7.14]); p < 0.001), and lower pooled negative likelihood ratio (0.22 (95% CI [0.19-0.25]) vs 0.38 (95% CI [0.35-0.41]) vs; p < 0.001). Similar results were seen in all subgroups.

CONCLUSIONS

Our meta-analysis showed that combining LR-4 and LR-5 would increase sensitivity but decrease specificity, positive likelihood ratio, and negative likelihood ratio. These findings may inform management guidelines and individualized management.

CLINICAL RELEVANCE STATEMENT

This meta-analysis estimated the magnitude of changes in the sensitivity and specificity of imaging criteria when LI-RADS categories 4 and 5 were combined; these findings can inform management guidelines and individualized management.

KEY POINTS

There is no single worldwide reporting system for liver imaging, partly due to regional needs. Combining LI-RADS categories 4 and 5 increased sensitivity and decreased specificity and positive and negative likelihood ratios. Changes in the sensitivity and specificity of imaging criteria can inform management guidelines and individualized management.

Usefulness of contrast-enhanced ultrasound-guided biopsy for suspected viable hepatocellular carcinoma after treatment: a single-arm prospective study

PURPOSE

The utility of contrast-enhanced ultrasound (CEUS)-guided liver biopsy in patients with treated hepatocellular carcinoma (HCC) was evaluated.

METHODS

This study prospectively enrolled 36 patients (mean age±standard deviation [SD], 65.3±9.2 years; 31 men) who underwent CEUS-guided biopsy for treated HCC between September 2020 and April 2022, constituting the CEUS group. An additional 60 patients (mean age±SD, 60.7±12.3 years; 50 men) who underwent B-mode image-guided biopsy for treated HCC between January 2017 and December 2018 were retrospectively enrolled in the B-mode, or control, group. Biopsy success rates were compared between CEUS and B-mode groups using the chi-square test.

RESULTS

The biopsy success rate in the CEUS group was 88.9% (32 of 36 patients), which was significantly higher than the 70.0% (42 of 60 patients) observed in the B-mode group (P=0.044). No significant difference was found between CEUS and B-mode groups in the size of the lesions targeted for biopsy (mean±SD, 3.8±2.3 cm vs. 3.7±3.3 cm, respectively; P=0.332). For both the whole tumor and the viable tumor, conspicuity scores were significantly higher on CEUS than on grayscale ultrasound in the CEUS group (whole tumor: 2.7±0.5 vs. 1.8±0.9, P<0.001; viable tumor: 2.6±0.7 vs. 1.4±0.8, P<0.001). Relative to non-diagnostic results, diagnostic results more frequently exhibited a late mild washout pattern (87.5% [28 of 32] vs. 25.0% [1 of 4], P=0.004). No significant difference in the arterial enhancement pattern was noted between these subgroups (P=0.415).

CONCLUSION

By increasing the viable-tumor conspicuity, CEUS-guided biopsy is useful for confirmative histopathologic diagnosis in patients with treated HCC.

Liver Imaging Reporting and Data System version 2018 category 5 for diagnosing hepatocellular carcinoma: an updated meta-analysis

OBJECTIVE

We performed an updated meta-analysis to determine the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS, LR) 5 category for hepatocellular carcinoma (HCC) using LI-RADS version 2018 (v2018), and to evaluate differences by imaging modalities and type of MRI contrast material.

METHODS

The MEDLINE and Embase databases were searched for studies reporting the performance of LR-5 using v2018 for diagnosing HCC. A bivariate random-effects model was used to calculate the pooled per-observation sensitivity and specificity. Subgroup analysis was performed based on imaging modalities and type of MRI contrast material.

RESULTS

Forty-eight studies qualified for the meta-analysis, comprising 9031 patients, 10,547 observations, and 7216 HCCs. The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC were 66% (95% CI, 61-70%) and 91% (95% CI, 89-93%), respectively. In the subgroup analysis, MRI with extracellular agent (ECA-MRI) showed significantly higher pooled sensitivity (77% [95% CI, 70-82%]) than CT (66% [95% CI, 58-73%]; p = 0.023) or MRI with gadoxetate (Gx-MRI) (65% [95% CI, 60-70%]; p = 0.001), but there was no significant difference between ECA-MRI and MRI with gadobenate (gadobenate-MRI) (73% [95% CI, 61-82%]; p = 0.495). Pooled specificities were 88% (95% CI, 80-93%) for CT, 92% (95% CI, 86-95%) for ECA-MRI, 93% (95% CI, 91-95%) for Gx-MRI, and 91% (95% CI, 84-95%) for gadobenate-MRI without significant differences (p = 0.084-0.803).

CONCLUSIONS

LI-RADS v2018 LR-5 provides high specificity for HCC diagnosis regardless of modality or contrast material, while ECA-MRI showed higher sensitivity than CT or Gx-MRI.

CLINICAL RELEVANCE STATEMENT

Refinement of the criteria for improving sensitivity while maintaining high specificity of LR-5 for HCC diagnosis may be an essential future direction.

KEY POINTS

• The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC using LI-RADSv2018 were 66% and 91%, respectively. • ECA-MRI showed higher sensitivity than CT (77% vs 66%, p = 0.023) or Gx-MRI (77% vs 65%, p = 0.001). • LI-RADS v2018 LR-5 provides high specificity (88-93%) for HCC diagnosis regardless of modality or contrast material type.

Intrahepatic cholangiocarcinoma: Evolving strategies in management and treatment

Intrahepatic cholangiocarcinoma is the second most frequent primary liver cancer after hepatocellular carcinoma. According to International Classification of Diseases-11 (ICD-11), intrahepatic cholangiocarcinoma is identified by a specific diagnostic code, different with respect to perihilar-CCA or distal-CCA. Intrahepatic cholangiocarcinoma originates from intrahepatic small or large bile ducts including the second-order bile ducts and has a silent presentation that combined with the highly aggressive nature and refractoriness to chemotherapy contributes to the alarming increasing incidence and mortality. Indeed, at the moment of the diagnosis, less than 40% of intrahepatic cholangiocarcinoma are suitable of curative surgical therapy, that is so far the only effective treatment. The main goals of clinicians and researchers are to make an early diagnosis, and to carry out molecular characterization to provide the patient with personalized treatment. Unfortunately, these goals are not easily achievable because of the heterogeneity of this tumor from anatomical, molecular, biological, and clinical perspectives. However, recent progress has been made in molecular characterization, surgical treatment, and management of intrahepatic cholangiocarcinoma and, this article deals with these advances.

Refining Liver Biopsy in Hepatocellular Carcinoma: An In-Depth Exploration of Shifting Diagnostic and Therapeutic Applications

The field of hepatocellular carcinoma (HCC) has faced significant change on multiple levels in the past few years. The increasing emphasis on the various HCC phenotypes and the emergence of novel, specific therapies have slowly paved the way for a personalized approach to primary liver cancer. In this light, the role of percutaneous liver biopsy of focal lesions has shifted from a purely confirmatory method to a technique capable of providing an in-depth characterization of any nodule. Cancer subtype, gene expression, the mutational profile, and tissue biomarkers might soon become widely available through biopsy. However, indications, expectations, and techniques might suffer changes as the aim of the biopsy evolves from providing minimal proof of the disease to high-quality specimens for extensive analysis. Consequently, a revamped position of tissue biopsy is expected in HCC, following the reign of non-invasive imaging-only diagnosis. Moreover, given the advances in techniques that have recently reached the spotlight, such as liquid biopsy, concomitant use of all the available methods might gather just enough data to improve therapy selection and, ultimately, outcomes. The current review aims to discuss the changing role of liver biopsy and provide an evidence-based rationale for its use in the era of precision medicine in HCC.

EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) develops inside the liver, between bile ductules and the second-order bile ducts. It is the second most frequent primary liver cancer after hepatocellular carcinoma, and its global incidence is increasing. It is associated with an alarming mortality rate owing to its silent presentation (often leading to late diagnosis), highly aggressive nature and resistance to treatment. Early diagnosis, molecular characterisation, accurate staging and personalised multidisciplinary treatments represent current challenges for researchers and physicians. Unfortunately, these challenges are beset by the high heterogeneity of iCCA at the clinical, genomic, epigenetic and molecular levels, very often precluding successful management. Nonetheless, in the last few years, progress has been made in molecular characterisation, surgical management, and targeted therapy. Recent advances together with the awareness that iCCA represents a distinct entity amongst the CCA family, led the ILCA and EASL governing boards to commission international experts to draft dedicated evidence-based guidelines for physicians involved in the diagnostic, prognostic, and therapeutic management of iCCA.

MRI-diagnosis of category LR-M observations in the Liver Imaging Reporting and Data System v2018: a systematic review and meta-analysis

OBJECTIVES

We performed a meta-analysis to determine the probability of hepatocellular carcinoma (HCC) and non-HCC malignancies in Liver Imaging Reporting and Data System (LI-RADS) category M (LR-M) observations and the frequency of defined LR-M imaging features on MRI using LI-RADS v2018.

METHODS

We searched the MEDLINE and EMBASE databases to identify studies published from 1 January 2018 to 16 March 2021 reporting the probability of category LR-M in HCC and non-HCC malignancies on MRI. The pooled percentages of HCC and non-HCC malignancies in the LR-M observations were evaluated. Meta-regression analysis was performed to identify factors for study heterogeneity. The frequencies of defined LR-M imaging features were also calculated. Risk of bias and concerns regarding applicability were evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

We identified 18 studies reporting the diagnostic performance of the LR-M category (3,812 observations in 3,615 patients), with nine studies reporting the frequencies of LR-M imaging features. The pooled percentages of HCC and non-HCC malignancies in the LR-M observations were 29% (95% confidence interval [CI], 21-38%) and 67% (95%CI, 57-77%), respectively. The study type and inclusion of benign lesions were significant factors for study heterogeneity. Of the 10 LR-M imaging features, rim arterial phase hyperenhancement (APHE) showed the highest frequency in non-HCC malignancies (68%; 95%CI, 61-75%).

CONCLUSIONS

The LR-M category was commonly used to characterize non-HCC malignancies, but also included 29% of HCC. The frequencies of the different LR-M imaging features were variable, with rim APHE showing the highest frequency in non-HCC malignancies.

KEY POINTS

• In the LR-M category using LI-RADS v2018 for MRI, the pooled percentage of malignancies in general was 96%, with 29% HCC and 67% non-HCC malignancies, while the remaining 4% was benign entity. • The study type and inclusion of benign lesions were significant factors contributing to substantial heterogeneity among included studies. • The frequencies of the different LR-M imaging features were variable, with rim APHE showing the highest frequency in non-HCC malignancies.