CT and MRI of hepatocellular carcinoma: an update

Pilot study of humanized glypican-3-targeted zirconium-89 immuno-positron emission tomography for hepatocellular carcinoma

Purpose

Glypican-3 (GPC3)-targeted radioisotope immuno-positron emission tomography (immunoPET) may lead to earlier and more accurate diagnosis of hepatocellular carcinoma (HCC), thus facilitating curative treatment, decreasing early recurrence, and enhancing patient survival. We previously demonstrated reliable HCC detection using a zirconium-89-labeled murine anti-GPC3 antibody (89Zr-αGPC3M) for immunoPET. This study evaluated the efficacy of the humanized antibody successor (αGPC3H) to further clinical translation of a GPC3-based theranostic for HCC.

Methods

In vitro αGPC3 binding to HepG2 cells was assessed by flow cytometry. In vivo 89Zr-αGPC3H and 89Zr-αGPC3M tumor uptake was evaluated by PET/CT and biodistribution studies in an orthotopic xenograft mouse model of HCC.

Results

αGPC3H maintained binding to GPC3 in vitro and 89Zr-αGPC3H immunoPET identified liver tumors in vivo. PET/CT and biodistribution analyses demonstrated high 89Zr-αGPC3H tumor uptake and tumor-to-liver ratios, with no difference between groups.

Conclusion

Humanized αGPC3 successfully targeted GPC3 in vitro and in vivo. 89Zr-αGPC3H immunoPET had comparable tumor detection to 89Zr-αGPC3M, with highly specific tumor uptake, making it a promising strategy to improve HCC detection.

Preoperative prediction of pathologic grade of HCC on gadobenate dimeglumine-enhanced dynamic MRI

PURPOSE

To evaluate the value of gadobenate dimeglumine-enhanced MRI in predicting the pathologic grade of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Patients with pathologically proven HCC who underwent preoperative gadobenate dimeglumine-enhanced dynamic MRI were included. Two radiologists blinded to pathology results evaluated images in consensus. Lesions were evaluated quantitatively in terms of ratio of enhancement (RE), and qualitatively based on image features related to tumor aggressiveness. Logistic regression and ROC analyses were used to determine the value of these parameters to predict pathologic grade.

RESULTS

In total, 221 patients (194 males, 27 females, aged 52.9 ± 11.7 years) with 49 poorly differentiated HCCs and 172 well/moderately differentiated HCCs were evaluated. Features significantly related to poorer pathologic grade at univariate analysis included lower RE in the early arterial phase (EAP) (p = 0.001), nonsmooth margins (p = 0.001), absence of capsule (p < 0.001), arterial peritumoral hyperenhancement (p < 0.001), higher AFP (p = 0.004), multiple tumors (p = 0.026), and larger tumor size (p = 0.028). At multivariate analysis, lower RE (EAP) (OR = 0.144, p = 0.002), absence of capsule (OR = 0.281, p = 0.004), and arterial peritumoral hyperenhancement (OR = 4.117, p < 0.001) were independent predictive factors for poorer pathologic grade. ROC analysis showed lower RE (EAP) was predictive of poorer pathologic grade (AUC = 0.667). AUC increased to 0.797 when combined with absence of capsule and presence of peritumoral hyperenhancement.

CONCLUSIONS

Lower RE (EAP), absence of capsule, and arterial peritumoral hyperenhancement were predictive biomarkers for poorer pathologic grade of HCC on gadobenate dimeglumine-enhanced dynamic MRI.

KEY POINTS

• Gadobenate dimeglumine-enhanced dynamic MRI was a useful quantitative biomarker for preoperative prediction of pathologic grade in patients with HCC. • Lower RE in the early arterial phase, absence of capsule, and arterial peritumoral hyperenhancement were potential imaging indicators for preoperative prediction of poorer pathologic grade of HCC on gadobenate dimeglumine-enhanced MRI. • A lower RE in the early arterial phase was effective at predicting poorer pathologic grade of HCCs but prediction is improved when combined with absence of capsule and presence of peritumoral hyperenhancement.

Fluid shear stress induces cell migration and invasion via activating autophagy in HepG2 cells

Fluid shear stress (FSS) regulates the metastasis of hepatocellular carcinoma (HCC). In the present study, we aimed to study the role of autophagy in HCC cells under FSS. The results showed that FSS upregulated the protein markers of autophagy, induced LC3B aggregation and formation of autophagosomes. Inhibition of integrin by Cliengitide (Cli) or inhibition of the microfilaments formation both inhibited the activation of autophagy in HepG2 under FSS. In addition, Cli inhibited the microfilaments formation and expressions of Rac1 and RhoA in HepG2 cells under FSS. Finally, inhibition of autophagy suppressed the cell migration and invasion in HepG2 under FSS. In conclusion, FSS induced autophagy to promote migration and invasion of HepG2 cells via integrin/cytoskeleton pathways.

Novel GPC3-binding WS2-Ga3+-PEG-peptide nanosheets for in vivo bimodal imaging-guided photothermal therapy

Aim: The diagnosis and treatment of hepatocarcinoma (HCC) is believed to be improved due to the development of specific targeting probes by molecular imaging methods. GPC3, which is a hepatocellular carcinoma (HCC)-specific tumor marker, anchors at most HCC cells. To target this cell membrane protein, we developed a novel nanoparticle by conjugating WS₂-Ga³⁺-PEG and a short peptide with favorable specificity and affinity to the GPC3 protein. Materials & methods: In in vitro assay, several physical properties of the novel probe were evaluated. In in vivo assay, MRI, photoacoustic imaging and photothermal therapy were performed in the subcutaneous HepG2-bearing mice with the novel probe. Results & conclusion: The effect of imaging and photothermal therapy was significant. We revealed that the novel nanosheet WS₂-Ga³⁺-PEG-peptide is promising to detect and treat HCC-expressing GPC3.

Association of genetic variants in the interleukin-18 gene promoter with risk of hepatocellular carcinoma and metastasis in patients with hepatitis C virus infection

Hepatocellular carcinoma (HCC) is a primary malignancy of the liver, characterized by high vascularization and rapid tumor progression. The current case-control study aimed to analyze the influence of -607C/A and -137G/C polymorphisms in the interleukin-18 (IL-18) promoter on the risk of HCC occurrence and metastasis in Egyptian patients infected with hepatitis C virus (HCV). Both genetic variations were genotyped in 279 subjects including HCV patients with and without HCC and unrelated healthy subjects, using the allele-specific polymerase chain reaction (AS-PCR) method. The relationship between clinico-laboratory parameters including serum level of alpha-fetoprotein (AFP) and these polymorphisms was evaluated in HCC patients. The IL-18-607A allele and AA genotype were significantly related to a higher risk of developing HCC when comparing patients with HCC and controls, and were significantly related to a higher risk of metastasis when comparing metastatic and nonmetastatic groups in the Egyptian patients. In contrast, the IL18-137C allele and GC genotype were significantly related to a lower risk of developing HCC when comparing patients with HCC and controls, and HCV patients with and without HCC. A significant association was found between multinodular HCC and IL-18-607AA genotype, while, uninodular HCC was significantly associated with IL-18-137GG genotype. In addition, IL18-607AA and -137GG genotypes showed significant association with higher level of serum AFP. The detection of polymorphisms in the IL-18 promoter, in a combination with an evaluation of level of serum AFP, could be used as a molecular biomarker in the early diagnosis of HCC, which would aid the early management of the disease, thus decreasing the rate of mortality of this disease. © 2018 IUBMB Life, 70(2):165-174, 2018.

The association between aquaporin-1 expression, microvessel density and the clinicopathological features of hepatocellular carcinoma

The present study aimed to evaluate the effects of aquaporin-1 (AQP1) level and intratumoral microvessel density (IMD) on the clinicopathological features of patients with hepatocellular carcinoma (HCC). The AQP1 expression levels, IMD and AQP1/IMD ratios in patients with HCC were measured using a semi-quantitative immunohistochemical technique. The association between these features and clinicopathological variables were evaluated. The prognostic impact of AQP1 and IMD on overall survival (OS), and 5-year disease-free survival (DFS) of HCC patients was investigated retrospectively. P<0.05 was considered to indicate a statistically significant difference. A total of 90 cases of HCC were included in the present study. AQP1 was markedly expressed in the membranes of microvessels and small vessels, but seldom in hepatocellular carcinoma cells. Blood vessels in the tumors were markedly stained by anti-cluster of differentiation 34 antibody. AQP1 expression and IMD was significantly correlated with tumor size, histologic grade, Child-Pugh classification, microvascular invasion and tumor-node-metastasis (TNM) stage (P<0.05). Concurrently, for the 5-year DFS and OS, a larger tumor size, poorly differentiated histological grade, B and C Child-Pugh classification, presence of microvascular invasion, high TNM stage, a high AQP1 expression and a high IMD were significant risk factors for mortality. Multivariate analysis revealed that TNM stage and IMD were independent unfavorable prognostic markers for 5-year DFS (P=0.049 and P=0.025, respectively) and OS (P=0.043 and P=0.042, respectively). These data suggest that high AQP1 expression and IMD are associated with tumor progression and prognosis in HCC. The IMD level may serve as an independent indicator for the 5-year DFS and OS.

MRI of hepatocellular carcinoma: an update of current practices

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and liver transplantation is the optimal treatment for selected patients with HCC and chronic liver disease (CLD). Accurate selection of patients for transplantation is essential to maximize patient outcomes and ensure optimized allocation of donor organs. Magnetic resonance imaging (MRI) is a powerful tool for the detection, characterization, and staging of HCC. In patients with CLD, the MRI findings of an arterial-enhancing mass with subsequent washout and enhancing capsule on delayed interstitial phase images are diagnostic for HCC. Major organizations with oversight for organ donor distribution, such as The Organ Procurement and Transplantation Network (OPTN), accept an imaging diagnosis of HCC, no longer requiring tissue biopsy. In patients that are awaiting transplantation, or are not candidates for liver transplantation, localized therapies such as transarterial chemoembolization and radiofrequency ablation may be offered. MRI can be used to monitor treatment response. The purpose of this review article is to describe the role of imaging methods in the diagnosis, staging, and follow-up of HCC, with particular emphasis on established and evolving MRI techniques employing nonspecific gadolinium chelates, hepatobiliary contrast agents, and diffusion weighted imaging. We also briefly review the recently developed Liver Imaging Reporting and Data System (LI-RADS) formulating a standardized terminology and reporting structure for evaluation of lesions detected in patients with CLD.

The Presence of Portal Vein Thrombosis Alters the Classic Enhancement Associated with Diagnosis of Hepatocellular Carcinoma

AIMS

To determine whether the presence of portal vein thrombosis (PVT) where venous flow within the liver may be altered may delay the diagnosis of HCC and be associated with more advanced disease. We characterized the incidence and imaging characteristics of patients diagnosed with hepatocellular carcinoma in a cohort of patients with PVT compared with those without PVT.

METHODS

This is a single-center retrospective study of a subset of HCC patients who underwent dynamic imaging for HCC screening and were found to have PVT. Data abstracted included demographic data, TNM stage, number/type of scans, AFP level, MELD score, and time to diagnosis.

RESULTS

Eighty-two patients newly diagnosed with HCC on screening were reviewed, of which 37 % (30/82) were found to have portal vein thrombosis. Patients with PVT had higher rates of atypical imaging associated with HCC compared with those without PVT (83 vs 56 %, p = 0.01) and had lower rates of portal venous washout (23 % vs 50 %, p = 0.018). Patients with PVT and HCC were also diagnosed at later TNM stage than those without PVT (70 vs 23 %, p < 0.001) and were significantly less likely to receive orthotopic liver transplant (3.6 vs 42 %, p < 0.001). Fourteen patients had preexisting PV clot without HCC; 16 developed PVT during screening or at diagnosis. Those with preexisting PVT were older (63. vs 55 years) and had higher rates of diagnosis of HCC using MRI (79 vs 21 % with CT, p = 0.01), compared with those without preexisting PVT.

CONCLUSION

The presence of PVT found on dynamic imaging was associated with advanced stage of HCC at the time of diagnosis. Clinicians should have a high suspicion for HCC diagnosis in new liver lesions with atypical enhancement in the setting of PVT. In this setting, MRI was more frequently associated with HCC diagnosis.

Pathology-MRI Correlation of Hepatocarcinogenesis: Recent Update

Understanding the important alterations during hepatocarcinogenesis as well as the characteristic magnetic resonance imaging (MRI) and histopathological features will be helpful for managing patients with chronic liver disease and hepatocellular carcinoma. Recent advances in MRI techniques, such as fat/iron quantification, diffusion-weighted images, and gadoxetic acid-enhanced MRI, have greatly enhanced our understanding of hepatocarcinogenesis.

The eEF1A Proteins: At the Crossroads of Oncogenesis, Apoptosis, and Viral Infections

Eukaryotic translation elongation factors 1 alpha, eEF1A1 and eEF1A2, are not only translation factors but also pleiotropic proteins that are highly expressed in human tumors, including breast cancer, ovarian cancer, and lung cancer. eEF1A1 modulates cytoskeleton, exhibits chaperone-like activity and also controls cell proliferation and cell death. In contrast, eEF1A2 protein favors oncogenesis as shown by the fact that overexpression of eEF1A2 leads to cellular transformation and gives rise to tumors in nude mice. The eEF1A2 protein stimulates the phospholipid signaling and activates the Akt-dependent cell migration and actin remodeling that ultimately favors tumorigenesis. In contrast, inactivation of eEF1A proteins leads to immunodeficiency, neural and muscular defects, and favors apoptosis. Finally, eEF1A proteins interact with several viral proteins resulting in enhanced viral replication, decreased apoptosis, and increased cellular transformation. This review summarizes the recent findings on eEF1A proteins indicating that eEF1A proteins play a critical role in numerous human diseases through enhancement of oncogenesis, blockade of apoptosis, and increased viral pathogenesis.

Glypican-3-targeting F(ab')2 for 89Zr PET of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasingly lethal malignancy for which management is critically dependent on accurate imaging. Glypican-3 (GPC3) is a cell surface receptor overexpressed in most HCCs and provides a unique target for molecular diagnostics. The use of monoclonal antibodies (mAbs) that target GPC3 (αGPC3) in PET imaging has shown promise but comes with inherent limitations associated with mAbs such as long circulation times. This study used (89)Zr-conjugated F(ab')2 fragments directed against GPC3 ((89)Zr-αGPC3-F(ab')2) to evaluate the feasibility of the fragments as a diagnostic immuno-PET imaging probe.

METHODS

Immobilized ficin was used to digest αGPC3, creating αGPC3-F(ab')2 fragments subsequently conjugated to (89)Zr. In vivo biodistribution and PET studies were performed on GPC3-expressing HepG2 and GPC3-nonexpressing RH7777 orthotopic xenografts.

RESULTS

Reliable αGPC3-F(ab')2 production via immobilized ficin digestion was verified by high-performance liquid chromatography and sodium dodecyl sulfate polyacrylamide gel electrophoresis. (89)Zr-αGPC3-F(ab')2 demonstrated F(ab')2-dependent, antigen-specific cell binding. HepG2 tumor uptake was higher than any other tissue, peaking at 100 ± 21 percentage injected dose per gram (%ID/g) 24 h after injection, a value 33- to 38-fold higher than GPC3-nonexpressing RH7777 tumors. The blood half-life of the (89)Zr-αGPC3-F(ab')2 conjugate was approximately 11 h, compared with approximately 115 h for historic mAb controls. This shorter half-life enabled clear tumor visualization on PET 4 h after administration, with a resultant peak tumor-to-liver contrast ratio of 23.3. Blocking antigen-expressing tumors with an excess of nonradiolabeled αGPC3 resulted in decreased tumor uptake similar to native liver. The kidneys exhibited high tissue uptake, peaking at 24 h with 83 ± 12 %ID/g. HepG2 tumors ranging from 1.5 to 7 mm were clearly visible on PET, whereas larger RH7777 tumors displayed signal lower than background liver tissue.

CONCLUSION

This study demonstrates the feasibility of using (89)Zr-αGPC3-F(ab')2 for intrahepatic tumor localization with small-animal PET. Faster blood clearance and lower background liver uptake enable excellent signal-to-noise ratios at early time points. Increased renal uptake is similar to that as has been seen with clinical radioactive peptide imaging. (89)Zr-αGPC3-F(ab')2 addresses some of the shortcomings of whole-antibody immuno-PET probes. Further optimization is warranted to maximize probe sensitivity and specificity in the process of clinical translation.

Resection of hepatitis B virus-related hepatocellular carcinoma: Evolving strategies and emerging therapies to improve outcome

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide, largely due to hepatitis B virus (HBV), hepatitis C virus and liver cirrhosis. Chronic HBV infection is estimated to cause 55%-60% of the cases of HCC worldwide and over 70% in Asian countries. Liver resection is currently the mainstay of treatment due to the low surgical mortality, a wider treatment indication, and simplicity of post-treatment follow-up. There is an ever-increasing demand on surgeons to perform curative liver resection in HCC, with the hope of avoiding tumor recurrences. Hepatitis B-related-HCC has distinct clinicopathological features, which should be considered when treating the disease. The author presents a review of the recently evolving strategies and emerging therapies to improve HCC postresectional outcomes and focus on perioperative measures to improve patient outcome, with particular reference to the current status of adjuvant therapies in HCC patients after liver resection.

Comparison of MRI features for the differentiation of hepatic angiomyolipoma from fat-containing hepatocellular carcinoma

OBJECTIVE

The purpose of this study was to evaluate MRI features for the differentiation of hepatic angiomyolipoma (HAML) from fat-containing hepatocellular carcinoma.

METHODS

We retrospectively reviewed the MRI findings of 20 patients with 22 hepatic angiomyolipomas and 25 patients with fat-containing hepatocellular carcinomas before surgery. The MRI features and apparent diffusion coefficient (ADC) for the two types of tumors were compared and analyzed.

RESULTS

Fat was not detected in nine (40.9%) of the angiomyolipomas. An enhancement pattern of the washout area was seen in eight (36.4%) of the angiomyolipomas and 21 of the hepatocellular carcinomas (84%) (p = 0.001). The sensitivity, specificity, and accuracy of the enhancement pattern for HAML were 63.6% (14/22), 84% (21/25), and 74.5% (35/47), respectively. An early draining vein was seen in 16 (72.7%) angiomyolipomas and two hepatocellular carcinomas (8%) (p < 0.001). The sensitivity, specificity, and accuracy of an early draining vein for detecting HAML was 72.7% (16/22), 92% (23/25), and 83.0% (39/47), respectively. Tumor vessels were noted in 18 (81.8%) angiomyolipomas and six hepatocellular carcinomas (24%) (p < 0.001). The sensitivity, specificity, and accuracy of tumor vessels for HAML were 81.8% (18/22), 76% (19/25), and 78.7% (37/47), respectively. Pseudocapsules were absent in 21 (95.5%) angiomyolipomas as compared with 3 (12%) hepatocellular carcinomas (p < 0.001). The sensitivity, specificity, and accuracy of pseudocapsules for HAML were 95.5% (21/22), 88% (22/25), and 91.5% (43/47), respectively. The ADC of the angiomyolipomas (1.92 ± 0.29 × 10(-3 )mm(2)/s) was significantly higher than that for hepatocellular carcinomas (1.33 ± 0.25 × 10(-3 )mm(2)/s) (p < 0.001).

CONCLUSION

The presence of an early draining vein and tumor vessels, the absence of pseudocapsules and a higher ADC in the hypervascular hepatic tumor on the MRI were helpful for the differentiation of hepatic angiomyolipoma from fat-containing hepatocellular carcinoma.

Glypican-3-targeted 89Zr PET imaging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a devastating malignancy in which imperfect imaging plays a primary role in diagnosis. Glypican-3 (GPC3) is an HCC-specific cell surface proteoglycan overexpressed in most HCCs. This paper presents the use of (89)Zr-conjugated monoclonal antibody against GPC3 ((89)Zr-αGPC3) for intrahepatic tumor localization using PET.

METHODS

Polymerase chain reaction confirmed relative GPC3 expression in cell lines. In vitro binding, in vivo biodistribution, and small-animal PET studies were performed on GPC3-expressing HepG2 and non-GPC3-expressing HLF and RH7777 cells and orthotopic xenografts.

RESULTS

(89)Zr-αGPC3 demonstrated antibody-dependent, antigen-specific tumor binding. HepG2 liver tumors exhibited high peak uptake (836.6 ± 86.6 percentage injected dose [%ID]/g) compared with background liver (27.5 ± 1.6 %ID/g). Tumor-to-liver contrast ratio was high and peaked at 32.5. The smallest HepG2 tumor (<1 mm) showed lower peak uptake (42.5 ± 6.4 %ID/g) and tumor-to-liver contrast (1.57) but was still clearly visible on PET. Day 7 tissue activity was still substantial in HepG2 tumors (466.4 ± 87.6 %ID/g) compared with control RH7777 tumors (3.9 ± 1.3 %ID/g, P < 0.01), indicating antigen specificity by (89)Zr-αGPC3. HepG2 tumor treated with unlabeled αGPC3 or heat-denatured (89)Zr-αGPC3 demonstrated tumor activity (2.1 %ID/g) comparable to that of control xenografts, confirming antibody dependency.

CONCLUSION

This study demonstrated the feasibility of using (89)Zr-αGPC3 to image HCC in the liver, as well as the qualitative determination of GPC3 expression via small-animal PET. The ability to clarify the identity of small liver lesions with an HCC-specific PET probe would provide clinicians with vital information that could significantly alter patient management, warranting further investigation for clinical translation.

Using multiple cytokines to predict hepatocellular carcinoma recurrence in two patient cohorts

BACKGROUND

Cytokines are tightly linked to the carcinogenesis, development and prognosis of hepatocellular carcinoma (HCC). We determined the prognostic value of 39 circulating cytokines in HCC patients after radical resection and then developed a novel cytokine-based prognostic classifier (CBPC) for the prediction of patient prognosis.

METHODS

A total of 179 patients were divided into two cohorts based on the date of radical resection. Thirty-nine cytokines were simultaneously analysed in patient serum samples using multiplex bead-based Luminex technology. Support vector machine-based methods and Cox proportional hazard models were used to develop a CBPC from the training cohort, which was then validated in the validation cohort.

RESULTS

Among seven cytokines significantly correlating with the disease-free survival (DFS) in the training cohort, six of them were validated to be significant prognostic factors to predict DFS and overall survival (OS) in the validation cohort, namely fibroblast growth factor 2 (FGF-2), growth-regulated oncogene (GRO), interleukin 8 (IL-8), interferon gamma-induced protein 10 (IP-10), vascular endothelial growth factor (VEGF), and interferon alpha-2 (IFN-α2). By integrating six cytokines and three clinical characteristics, we developed a CBPC to predict the recurrence and 3-year OS of HCC patients (sensitivity, 0.648; specificity, 0.918). In the validation cohort, the CBPC were confirmed to have significant predictive power for predicting tumour recurrence and OS (sensitivity, 0.585; specificity, 0.857). Interestingly, IFN-α2 was the only cytokine being independent prognostic factor in both patient cohorts.

CONCLUSION

Our study verifies the presence of specific cytokine-phenotype associations with patient prognosis in HCC. The CBPC developed include multiple circulating cytokines and may serve as a novel screening approach for identifying HCC patients with a high risk of post-resection recurrence and shorter OS. These individuals may also be suitable for cytokine-targeted therapies.

Targeted agents and systemic therapy in hepatocellular carcinoma

Cytotoxic chemotherapy, hormonal agents, and immunotherapy have been tested in hepatocellular cancer (HCC) with marginal efficacy to date. Recent insights into the molecular pathogenesis of HCC have identified several aberrant signaling pathways that have served as targets for novel therapeutic agents. These discoveries have been translated into the clinical realm with the use of the antiangiogenic and the Raf kinase inhibitor, sorafenib, and have revealed the potential of targeted agents to produce clinically meaningful survival benefits in patients with advanced HCC. Efforts continue in the quest to improve the outcome of HCC patients through the development and evaluation of other targeted agents, and to better understand the interactions between the underlying disease biology and response to therapy. Several pathways are now implicated in hepatocarcinogenesis and agents that target these pathways continue to be developed.

Histological characteristics of small hepatocellular carcinomas showing atypical enhancement patterns on gadoxetic acid-enhanced MR imaging

PURPOSE

To define the histological characteristics of hepatocellular carcinomas (HCCs) showing atypical dynamic enhancement patterns on gadoxetic acid-enhanced dynamic magnetic resonance imaging (EOB-MRI).

MATERIALS AND METHODS

We evaluated a total of 130 small (≤ 3 cm) HCCs from 114 patients that were surgically removed after EOB-MRI. Two radiologists blinded to the histological findings retrospectively classified the HCCs into typical or atypical lesions. Gross morphology, nuclear histological grade, presence of vascular invasion, and capsule formation and infiltration were compared between the two groups using Chi-square or Fisher tests.

RESULTS

Atypical dynamic enhancement patterns were seen in 23 HCCs (17.7%). None of the atypical HCC showed vascular invasion (P < 0.001). Atypical HCCs also showed more frequently smaller size (1.6 ± 0.6 cm versus 2.1 ± 0.6 cm, P = 0.001) with 86.9% (n = 20) of which 2 cm or less in diameter (P = 0.001), vaguely nodular appearance (56.5% vs 3.7%, P < 0.001), and nuclear grade I (69.6% versus 6.5%, P < 0.001), while less frequently showed capsule formation (26.1% versus 77.6%, P < 0.001) or capsular infiltration (16.7% versus 77.1%, P = 0.005).

CONCLUSION

Atypical HCCs on EOB-MRI may be characterized by the absence of vascular invasion, smaller (< 2 cm or less) size, vaguely nodular appearance, and well differentiation, and infrequent capsule formation or capsular infiltration.

Diagnosis of hepatocellular carcinoma: newer radiological tools

With the recent dramatic advances in diagnostic modalities, the diagnosis of hepatocellular carcinoma (HCC) is primarily based on imaging. Ultrasound (US) plays a crucial role in HCC surveillance. Dynamic multiphasic multidetector-row CT (MDCT) and magnetic resonance imaging (MRI) are the standard diagnostic methods for the noninvasive diagnosis of HCC, which can be made based on hemodynamic features (arterial enhancement and delayed washout). The technical development of MDCT and MRI has made possible the fast scanning with better image quality and resolution, which enables an accurate CT hemodynamic evaluation of hepatocellular tumor, as well as the application of perfusion CT and MRI in clinical practice. Perfusion CT and MRI can measure perfusion parameters of tumor quantitatively and can be used for treatment response assessment to anti-vascular agents. Besides assessing the hemodynamic or perfusion features of HCC, new advances in MRI can provide a cellular information of HCC. Liver-specific hepatobiliary contrast agents, such as gadoxetic acid, give information regarding hepatocellular function or defect of the lesion, which improves lesion detection and characterization. Diffusion-weighted imaging (DWI) of the liver provides cellular information of HCC and also has broadened its role in lesion detection, lesion characterization, and treatment response assessment to chemotherapeutic agents. In this article, we provide an overview of the state-of-the art imaging techniques of the liver and their clinical role in management of HCC.

Diagnostic accuracy of MRI in differentiating hepatocellular adenoma from focal nodular hyperplasia: prospective study of the additional value of gadoxetate disodium

OBJECTIVE

The purpose of this article is to prospectively determine the sensitivity of hepatobiliary phase gadoxetate disodium-enhanced MRI combined with standard MRI in differentiating focal nodular hyperplasia (FNH) from hepatocellular adenoma (HCA).

SUBJECTS AND METHODS

Patients suspected of having FNH or HCA larger than 2 cm underwent gadoxetate disodium-enhanced MRI. Standard MRI was evaluated separately from the additional hepatobiliary phase by two blinded radiologists. For the largest lesion in each patient, findings were compared with histologic diagnosis. Sensitivity, positive predictive value (PPV), and distinctive features were analyzed using McNemar and analysis of variance tests.

RESULTS

Fifty-two patients completed the study. Histologic diagnosis revealed 24 HCAs and 28 FNHs. Characterization on standard MRI was inconclusive in 40% (21/52) and conclusive in 60% (31/52) of lesions. The sensitivity of standard MRI for HCA was 50% (12/24) with a PPV of 100% (12/12). The sensitivity for FNH was 68% (19/28) with a PPV of 95% (18/19). After review of hepatobiliary phase, the sensitivity for HCA improved to 96% (23/24) with a PPV of 96% (23/24). The sensitivity for FNH improved to 96% (27/28) with a PPV of 96% (27/28). Features with significant predictive value for diagnosis in HCA included bleeding (p < 0.001), fat (p = 0.010), and glycogen (p = 0.024). The presence of a central scar was predictive for FNH (p < 0.001).

CONCLUSION

This study shows high sensitivity of gadoxetate disodium-enhanced MRI when standard series are combined with the hepatobiliary phase for differentiation of FNH and HCA in lesions larger than 2 cm.

Comparison of usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B endemic area

Background/Aims

We compared the accuracy and usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B virus (HBV)-endemic area.

Methods

We reviewed the medical records of 355 patients who had undergone liver resection or biopsy at our institution between January 2008 and December 2009. These patients were reevaluated using four noninvasive diagnostic criteria for hepatocellular carcinoma proposed by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD), the Korean Liver Cancer Study Group and the National Cancer Center (KLCSG/NCC), and National Comprehensive Cancer Network (NCCN) guidelines.

Results

The overall sensitivity was highest using the KLCSG/NCC criteria (79.8%), followed by the AASLD (51.5%), EASL (38.4%), and NCCN (10.1%; P<0.001) criteria, whereas the specificity (84.5-98.3%) and positive predictive value (96.2-98.3%) were similar for all of the criteria. The KLCSG/NCC criteria had an acceptable false-positive rate and the highest sensitivity among all of the patients, including those positive for HBsAg, those without liver cancer, and those with a tumor of at least 2 cm.

Conclusions

The KLCSG/NCC and AASLD criteria exhibited the highest sensitivity, and all four guidelines had a high specificity among all of the patients. Based on the sensitivity and false-positive rate, the KLCSG/NCC criteria was the most useful in the majority of patients. Inclusion of HBV infection in the clinical diagnostic criteria for hepatocellular carcinoma would be reasonable and may lead to an improvement in the sensitivity, with acceptable false-positive rates, in HBV-endemic areas.

Role of the multidisciplinary team in the diagnosis and treatment of hepatocellular carcinoma

It has long been appreciated that hepatocellular carcinoma (HCC) is a complex disease. HCC is typically preceded by liver cirrhosis, which is itself caused by various types of hepatitis of both viral and nonviral etiologies. Thus, the treatment of patients with HCC requires multiple healthcare professionals, including hepatologists, medical oncologists, surgical oncologists, transplantation surgeons, diagnostic radiologists, pathologists, nurses, nurse practitioners and interventional radiologists. These specialists should meet regularly to review patients' progress, ensure that treatments are individualized for each patient and agree on next steps. We review case presentations provided by the authors to illustrate the benefits and advantages of the multidisciplinary team matrix in the management of patients with HCC, including the effects of this treatment technique on patient outcome, survival and quality of life.

Hepatocellular carcinoma lesion characterization: single-institution clinical performance review of multiphase gadolinium-enhanced MR imaging--comparison to prior same-center results after MR systems improvements

PURPOSE

To measure diagnostic performance in the detection of hepatocellular carcinoma (HCC) by using the most recent technology and multiphase gadolinium-enhanced magnetic resonance (MR) imaging and to compare with earlier results at the same institution.

MATERIALS AND METHODS

This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was obtained. Between January 2008 and April 2010, 101 patients underwent liver transplantation and pretransplantation abdominal MR imaging within 90 days. Prospective image interpretations from the clinical record were reviewed for documentation of HCC, including size, number, and location. Liver explant histologic examination provided the reference standard for lesion analysis and was performed in axial gross slices in conjunction with the MR imaging report for direct comparison. Tumors were categorized according to size (≥ 2 cm or <2 cm), and MR imaging detection sensitivity, specificity, predictive values, and accuracy were calculated according to category. The Fisher exact test was used to compare results from this study against prior reported results.

RESULTS

Thirty-five (34.7%) of 101 patients had HCC at explant analysis. Patient-based analysis of all lesions showed a sensitivity and specificity of 97.1% (34 of 35) and 100% (66 of 66), respectively. For lesions 2 cm or larger, MR imaging had a sensitivity and specificity of 100% (23 of 23) and 100% (78 of 78), respectively. For lesions smaller than 2 cm, MR imaging had a sensitivity and specificity of 82.6% (19 of 23) and 100% (78 of 78), respectively. Lesion-based sensitivity for all tumors was 91.4% (53 of 58) in the current study, compared with 77.8% in 2007 (P = .07). For lesions smaller than 2 cm, the sensitivity was 87.5% (28 of 32) in the current study, compared with 55.6% previously (P = .02).

CONCLUSION

MR imaging remains a highly accurate diagnostic method for the preoperative evaluation of HCC, and detection of small (<2 cm) tumors has been significantly improved compared with that of earlier studies.

Molecular classification and clonal differentiation of hepatocellular carcinoma: the step forward for patient selection for liver transplantation

Liver transplantation is a successful treatment for hepatocellular carcinoma (HCC). However, advanced stages are not selected for transplant, based on the United Network for Organ Sharing selection criteria's. Nowadays, molecular biology-based techniques constitute an excellent option to better understand HCC origin differentiation and biological behavior. Moreover, microarray technology is a powerful tool to address a variety of tumor tissues at molecular level and is actively used for the discovery of biomarkers in cancer research. This article will discuss published data in the field of HCC origin differentiation and its potential impact on outcomes following liver transplantation. Although preliminary results are presented, these findings encourage the use of gene-expression profiling microarrays for studying HCC biology and behavior and ultimately optimizing treatment success.

Morphologic classification of microvessels in hepatocellular carcinoma is associated with the prognosis after resection

BACKGROUND AND AIM

The relationship between neovasculature in hepatocellular carcinoma (HCC) and the prognosis of patients still remains controversial. The aim of the present study was to investigate the prognostic significance of morphologic features of the microvessels in patients with HCC after resection.

METHODS

The paraffin-embedding specimens of 98 consecutive HCC patients, who received primary resection between 2000 and 2002, were collected from our prospective established tumor bank. The intratumoral microvessels were evaluated by immunohistochemical staining for CD31 and CD34. The disease-free survival (DFS) and overall survival (OS) of patients were analyzed by Kaplan-Meier analysis and Cox proportional hazards regression model.

RESULTS

There are two distinct microvessel types: capillary-like and sinusoid-like were identified in tumor tissues. The patients could be divided into two groups according to their microvessel types. Both DFS and OS of capillary group patients (n = 65) were better than those of sinusoid group patients (n = 33). Multivariate analyses showed that the microvessel type was an independent risk factor for DFS (P = 0.016) and OS (P = 0.004) of this cohort. Capillary-like microvessels were more common in small HCC, and were significantly associated with higher microvessel density, while sinusoid-like microvessels were significantly correlated with lower microvessel density.

CONCLUSIONS

The results of our study suggested that the microvessel type is an effective predictor of survival in patients with HCC after resection, which might serve as potential novel therapeutic targets for prevention of the recurrence of HCC after resection.