Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients

Detection of hepatocellular carcinoma during Fontan-associated liver disease follow-up: a report of three cases

We herein demonstrate three patients diagnosed with early hepatocellular carcinoma (HCC) during follow-up for Fontan-associated liver disease (FALD). Case 1: Twenty-one years after undergoing the Fontan procedure, a 26-year-old female was diagnosed with FALD. At the initial consultation, her serum alpha-fetoprotein (AFP) levels were markedly elevated, and dynamic enhanced computed tomography (CT) revealed HCC measuring 40 mm in diameter. She underwent partial hepatectomy. Ten months later, she underwent conventional transcatheter arterial chemoembolization (cTACE) for recurrent HCC near the resected hepatic stump as a curative treatment. Case 2: Twenty-one years after undergoing the Fontan procedure, a 25-year-old male was diagnosed with FALD and underwent HCC surveillance every 6 months. Thirteen months after the initial consultation, dynamic enhanced CT revealed HCC measuring 10 mm in diameter. He received cTACE as a curative treatment. Case 3. Twenty-eight years after undergoing the Fontan procedure, a 37-year-old male was diagnosed with FALD and underwent HCC surveillance every 3 months. Fourteen months later, abdominal ultrasonography (US) revealed HCC measuring 13 mm in diameter. He received radiofrequency ablation. These cases showed that HCC surveillance using abdominal US and AFP measurements in patients with FALD enables the detection of HCC and increases the chance of a cure.

Screening of liver cancer with abbreviated MRI

Current recommendations for the surveillance of HCC are based on the semiannual liver ultrasound (with or without serum alpha-fetoprotein) in patients with cirrhosis and in subgroups with chronic hepatitis B infection. However, the sensitivity of this strategy is suboptimal for the detection of early-stage tumors, especially in obese patients, due to interoperator variability and poor adherence. The detection rate of focal liver lesions is excellent with MRI, making it the best alternative candidate for surveillance. However, performing a full contrast-enhanced MRI is unrealistic because of limited availability and health economics. Abbreviated MRI (AMRI) corresponds to the acquisition of a limited number of sequences with a high detection rate. The theoretical benefits of AMRI are a reduced acquisition time (≤10 min) with improved time-effectiveness and cost-effectiveness compared with conventional MRI, and greater accuracy than ultrasound. Numerous protocols may be performed, including T1-weighted, T2-weighted, and DWI sequences, with or without contrast administration. Although published studies report promising per-patient results, they should be interpreted with caution. Indeed, most studies were simulated, retrospectively reviewing a subset of sequences in relatively small populations who underwent a full MRI. They also included groups that were not representative of screening populations. In addition, most were published by Asian groups, with at-risk populations that were different from Western populations. There are no existing longitudinal studies that directly compare the different AMRI approaches or AMRI to ultrasound. Finally, it is possible that 1 approach will not fit all patients and that strategies should be tailored to the risk of HCC, in particular in relation to the cost and availability of AMRI. Several trials are ongoing to evaluate these questions.

Association between the risk of hepatitis virus-related hepatocellular carcinoma and EGF polymorphism: A PRISMA-compliant updated meta-analysis

BACKGROUND

The study aims to provide a comprehensive account of the association between the epidermal growth factor (EGF) + 61A/G polymorphism (rs4444903) and susceptibility to virus-related hepatocellular carcinoma (HCC).

METHODS

Electronic searching of the Chinese National Knowledge Infrastructure, Wanfang, Chinese Scientific Journal Database (VIP), PubMed, Web of Science, and Embase was conducted to select eligible studies. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated to assess the strength of the association.

RESULTS

In this study, a total of 18 articles were included with 2692 cases and 5835 controls for assessing the association between rs4444903 and HCC risk. The pooled results showed that the EGF + 61A/G polymorphism was significantly associated with the risk of virus-related HCC in all genetic models. Stratified analyses were conducted based on ethnicity, study quality, source of controls, type of controls, number of cases and genotyping method. The results showed that EGF + 61A/G polymorphisms significantly affect HCC susceptibility in different stratified populations. High heterogeneity was observed across included studies, and meta-regression analysis demonstrated that race, type of controls, and study quality contribute to the observed heterogeneity.

CONCLUSION

This pooled analysis found that EGF + 61A/G polymorphism was significantly associated with the risk of HCC.

Comparison of unenhanced magnetic resonance imaging and ultrasound in detecting very small hepatocellular carcinoma

BACKGROUND

In hepatocellular carcinoma (HCC), detection and treatment prior to growth beyond 2 cm are important as a larger tumor size is more frequently associated with microvascular invasion and/or satellites. In the surveillance of very small HCC nodules (≤ 2 cm in maximum diameter, Barcelona clinical stage 0), we demonstrated that the tumor markers alpha-fetoprotein and PIVKA-Ⅱ are not so useful. Therefore, we must survey with imaging modalities. The superiority of magnetic resonance imaging (MRI) over ultrasound (US) to detect HCC was confirmed in many studies. Although enhanced MRI is now performed to accurately diagnose HCC, in conventional clinical practice for HCC surveillance in liver diseases, unenhanced MRI is widely performed throughout the world. While, MRI has made marked improvements in recent years.

AIM

To make a comparison of unenhanced MRI and US in detecting very small HCC that was examined in the last ten years in patients in whom MRI and US examinations were performed nearly simultaneously.

METHODS

In 394 patients with very small HCC nodules, those who underwent MRI and US at nearly the same time (on the same day whenever possible or at least within 14 days of one another) at the first diagnosis of HCC were selected. The detection rate of HCC with unenhanced MRI was investigated and compared with that of unenhanced US.

RESULTS

The sensitivity of unenhanced MRI for detecting very small HCC was 95.1% (97/102, 95% confidence interval: 90.9-99.3) and that of unenhanced US was 69.6% (71/102, 95% confidence interval: 60.7-78.5). The sensitivity of unenhanced MRI for detecting very small HCC was significantly higher than that of unenhanced US (P < 0.001). Regarding the location of HCC in the liver in patients in whom detection by US was unsuccessful, S_7-8 was identified in 51.7%.

CONCLUSION

Currently, unenhanced MRI is a very useful tool for the surveillance of very small HCC in conventional clinical follow-up practice.

Abdominal ultrasound and alpha-foetoprotein for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma (HCC) occurs mostly in people with chronic liver disease and ranks sixth in terms of global instances of cancer, and fourth in terms of cancer deaths for men. Despite that abdominal ultrasound (US) is used as an initial test to exclude the presence of focal liver lesions and serum alpha-foetoprotein (AFP) measurement may raise suspicion of HCC occurrence, further testing to confirm diagnosis as well as staging of HCC is required. Current guidelines recommend surveillance programme using US, with or without AFP, to detect HCC in high-risk populations despite the lack of clear benefits on overall survival. Assessing the diagnostic accuracy of US and AFP may clarify whether the absence of benefit in surveillance programmes could be related to under-diagnosis. Therefore, assessment of the accuracy of these two tests for diagnosing HCC in people with chronic liver disease, not included in surveillance programmes, is needed.

OBJECTIVES

Primary: the diagnostic accuracy of US and AFP, alone or in combination, for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of abdominal US and AFP, alone or in combination, for the diagnosis of resectable HCC; to compare the diagnostic accuracy of the individual tests versus the combination of both tests; to investigate sources of heterogeneity in the results.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic-Test-Accuracy Studies Register, Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, until 5 June 2020. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of US and AFP, independently or in combination, for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional and case-control designs, using one of the acceptable reference standards, such as pathology of the explanted liver, histology of resected or biopsied focal liver lesion, or typical characteristics on computed tomography, or magnetic resonance imaging, all with a six-months follow-up.

DATA COLLECTION AND ANALYSIS

We independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest-plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 373 studies. The index-test was AFP (326 studies, 144,570 participants); US (39 studies, 18,792 participants); and a combination of AFP and US (eight studies, 5454 participants). We judged at high-risk of bias all but one study. Most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Most studies with AFP had a case-control design. We also had major concerns for the applicability due to the characteristics of the participants. As the primary studies with AFP used different cut-offs, we performed a meta-analysis using the hierarchical-summary-receiver-operating-characteristic model, then we carried out two meta-analyses including only studies reporting the most used cut-offs: around 20 ng/mL or 200 ng/mL. AFP cut-off 20 ng/mL: for HCC (147 studies) sensitivity 60% (95% CI 58% to 62%), specificity 84% (95% CI 82% to 86%); for resectable HCC (six studies) sensitivity 65% (95% CI 62% to 68%), specificity 80% (95% CI 59% to 91%). AFP cut-off 200 ng/mL: for HCC (56 studies) sensitivity 36% (95% CI 31% to 41%), specificity 99% (95% CI 98% to 99%); for resectable HCC (two studies) one with sensitivity 4% (95% CI 0% to 19%), specificity 100% (95% CI 96% to 100%), and one with sensitivity 8% (95% CI 3% to 18%), specificity 100% (95% CI 97% to 100%). US: for HCC (39 studies) sensitivity 72% (95% CI 63% to 79%), specificity 94% (95% CI 91% to 96%); for resectable HCC (seven studies) sensitivity 53% (95% CI 38% to 67%), specificity 96% (95% CI 94% to 97%). Combination of AFP (cut-off of 20 ng/mL) and US: for HCC (six studies) sensitivity 96% (95% CI 88% to 98%), specificity 85% (95% CI 73% to 93%); for resectable HCC (two studies) one with sensitivity 89% (95% CI 73% to 97%), specificity of 83% (95% CI 76% to 88%), and one with sensitivity 79% (95% CI 54% to 94%), specificity 87% (95% CI 79% to 94%). The observed heterogeneity in the results remains mostly unexplained, and only in part referable to different cut-offs or settings (surveillance programme compared to clinical series). The sensitivity analyses, excluding studies published as abstracts, or with case-control design, showed no variation in the results. We compared the accuracy obtained from studies with AFP (cut-off around 20 ng/mL) and US: a direct comparison in 11 studies (6674 participants) showed a higher sensitivity of US (81%, 95% CI 66% to 90%) versus AFP (64%, 95% CI 56% to 71%) with similar specificity: US 92% (95% CI 83% to 97%) versus AFP 89% (95% CI 79% to 94%). A direct comparison of six studies (5044 participants) showed a higher sensitivity (96%, 95% CI 88% to 98%) of the combination of AFP and US versus US (76%, 95% CI 56% to 89%) with similar specificity: AFP and US 85% (95% CI 73% to 92%) versus US 93% (95% CI 80% to 98%).

AUTHORS' CONCLUSIONS

In the clinical pathway for the diagnosis of HCC in adults, AFP and US, singularly or in combination, have the role of triage-tests. We found that using AFP, with 20 ng/mL as a cut-off, about 40% of HCC occurrences would be missed, and with US alone, more than a quarter. The combination of the two tests showed the highest sensitivity and less than 5% of HCC occurrences would be missed with about 15% of false-positive results. The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

Ultrasound or Sectional Imaging Techniques as Screening Tools for Hepatocellular Carcinoma: Fall Forward or Move Forward?

Hepatocellular carcinoma (HCC) is probably the epitome of a screening target, with a well-defined high-risk population, accessible screening methods, and multiple curative-intent treatments available for early disease. Per major societies guideline consensus, biannual ultrasound (US) surveillance of the at-risk patients is the current standard of care worldwide. Yet, despite its documented success in the past decades, this standard is far from perfect. While the whole community is working to further tighten the knots, a worrying number of cases still slip through this safety net. Consequently, these patients lose their chance to a curative solution which leads to a high disease burden with disproportionate mortality. While US will probably remain the fundamental staple in the screening strategy, key questions are seeking better answers. How can its caveats be addressed, and the technique be improved? When are further steps needed? How to increase accuracy without giving up on accessibility? This narrative review discusses the place of US surveillance in the bigger HCC picture, trying to navigate through its strengths and limits based on the most recent available evidence.

Real impact of tumor marker AFP and PIVKA-II in detecting very small hepatocellular carcinoma (≤ 2 cm, Barcelona stage 0) - assessment with large number of cases

BACKGROUND

In hepatocellular carcinoma (HCC), detection and treatment prior to growth beyond 2 cm are relevant as a larger tumor size is more frequently associated with microvascular invasion and/or satellites.

AIM

To examine the impact of the tumor marker alpha-fetoprotein (AFP) or PIVKA-II in detecting very small HCC nodules (≤ 2 cm in maximum diameter, Barcelona stage 0) in the large number of very small HCC. The difference in the behavior of these tumor markers in HCC development was also examined.

METHODS

A total of 933 patients with single-nodule HCC were examined. They were subdivided into 394 patients with HCC nodules ≤ 2 cm in maximum diameter and 539 patients whose nodules were > 2 cm. The rates of patients whose AFP and PIVKA-II showed normal values were examined.

RESULTS

The positive ratio of the marker PIVKA-II was significantly different (P < 0.0001) between patients with nodules ≤ 2 cm in diameter and those with nodules > 2 cm, but there was no significant difference in AFP (P = 0.4254). In the patients whose tumor was ≤ 2 cm, 50.5% showed normal levels in AFP and 68.8% showed normal levels in PIVKA-II. In 36.4% of those patients, both AFP and PIVKA-II showed normal levels. The PIVKA-II-positive ratio was markedly increased with an increase in the tumor size. In contrast, the positivity in AFP was increased gradually and slowly.

CONCLUSION

In the surveillance of very small HCC nodules (≤ 2 cm in diameter, Barcelona clinical stage 0) the tumor markers AFP and PIVKA-II are not so useful.

A Bibliometric Analysis of Citation Classics in the Journal of Ultrasound in Medicine

OBJECTIVES

A bibliometric analysis of articles in the Journal of Ultrasound in Medicine (JUM) identified the journals' most impactful articles.

METHODS

A bibliometric analysis of citation classics that were published in the JUM from its inception in 1982 to 2019 was performed. All citation classics, defined as articles cited 100 or more times, were evaluated for the number of citations, citations per year, publication year, subspecialty, design, and country of origin. Characteristics were compared before and after 1998 by the Mann-Whitney test for unpaired data and 2-sample z tests of sample proportions. The Kruskal-Wallis test for nonparametric continuous data was used to compare the median number of citations per year by decade of publication.

RESULTS

A total of 7868 articles were published in the JUM between 1982 and 2019; 54 (0.7%) were citation classics. The median citation classics year of publication was 1998 (interquartile range [IQR], 1991-2003). Most citation classics originated from the United States (36 of 54 [66.7%]), were observational (47 of 54 [87%]), and were related to obstetric and gynecologic topics (16 of 54 [29.6%]). Citation classics after 1998 received significantly more citations per year (9.3 versus 4.7; P < .001), with no other differences noted. The median number of citations per year increased for each decade, with medians of 4 citations (IQR, 3.6-4.7) in 1982 to 1991 and 11.2 citations (IQR, 9-13.9) in 2002 to 2012 (P < .001).

CONCLUSIONS

This list provides insight into the most influential articles that were published in the JUM. Most citation classics were observational, were from the United States, and covered obstetric and gynecologic topics. Citation classics received more citations per year after 1998.

Hepatocellular Carcinoma Multidisciplinary Clinic-Cairo University (HMC-CU) score: A new simple score for diagnosis of HCC

BACKGROUND AND STUDY AIMS

The risk of hepatocarcinogenesis depends on background liver factors, of which fibrosis is a major determinant. Serum markers and scores are of increasing importance in non-invasive diagnosis of hepatic fibrosis. Our aim was to predict the occurrence of hepatocellular carcinoma (HCC) using a non-invasive fibrosis score calculated using routine patient data.

PATIENTS AND MTHODS

Our retrospective study included 1,291 hepatitis C related-HCC Egyptian patients (Group 1) recruited from the multidisciplinary HCC clinic, Faculty of Medicine, Cairo University in the period between February 2009 and June 2016 and 1072 chronic hepatitis C-naïve patients (Group 2) with advanced fibrosis (≥F3) and cirrhosis (F4). King score, Fibro Q score, Aspartate aminotransferase-to-platelet ratio index (APRI), AST to ALT ratio (AAR), LOK score, Göteborg University Cirrhosis Index (GUCI), Fibro-α and Biotechnology Research Center (BRC) scores were calculated for all patients. Regression analysis and receiver operating characteristics (ROC) were used to calculate the sensitivity, specificity and predictive values for significant scores with the best cut-off for predicting HCC. A regression equation was used to calculate predicted probabilities of HCC using the following variables; age, gender, haemoglobin, international normalised ratio (INR), albumin and alpha fetoprotein. The appropriate score cut-off points yielding optimal sensitivity and specificity were determined by ROC curve analysis.

RESULTS

There was a highly significant difference between the two groups for all calculated scores (P = 0.0001). Our new score, the Hepatocellular Carcinoma Multidisciplinary Clinic-Cairo University (HMC-CU) score (Logit probability of HCC =  - 2.524 + 0.152*age - 0.121*Hb - 0.696*INR - 1.059*Alb + 0.022*AFP + 0.976*Sex. Male = 1, Female = 0), with a cut-off of 0.559 was superior to other scores for predicting HCC, having a sensitivity of 90% and specificity of 80.6%.

CONCLUSION

The HMC-CU score is a promising, easily calculated, accurate, cost-effective score for HCC prediction in chronic HCV patients with advanced liver fibrosis.

The Evaluation of Angiogenesis Markers in Hepatocellular Carcinoma and Precursor Lesions in Liver Explants From a Single Institution

Hepatocellular carcinoma (HCC) is a global health problem associated with chronic liver disease. Precursor lesions are described, and the correct diagnosis of liver nodules is paramount when considering liver transplantation. We evaluated the immunohistochemical expression of vascular endothelial growth factor (VEGF) and angiopoietin-2 in HCC and precursors lesion in a single institution series of whole liver explants between 2013 and 2015, evaluating morphologic and clinical variables. The study comprised 67 patients (32.8% female) and 107 nodules. The mean age of the patients was 52.7 years (29 to 70 y). There were no significant epidemiologic differences among malignant lesions, dysplastic nodules, and regenerative nodules. Angiopoietin-2 expression was significantly more expressed in carcinoma when compared with regenerative lesions (P<0.0001). A statistically significant relationship was noted between the expression of VEGF in hepatocytes and Ang-2 expression in the small vasculature (P=0.006). VEGF expression also correlated significantly with the number of nonpaired arteries (P=0.03), although it was not useful in separating benign from malignant cases. We identified a sensitivity of 54% and a specificity of 96% using angiopoietin-2, and a sensitivity of 68.7% and a specificity of 31.2% when using VEGF for the diagnosis of HCC. There was no significant correlation between the immunohistochemical parameters and the clinical staging, the number of gross lesions, and the histologic grade in cases of HCC. Angiopoietin-2 may be a candidate biomarker in assessing liver nodules in transplant patients, and may assist in the diagnosis of difficult lesions and in small biopsies pretransplant.

Validation of US Liver Imaging Reporting and Data System Version 2017 in Patients at High Risk for Hepatocellular Carcinoma

Background The 2017 version of the Liver Imaging Reporting and Data System (LI-RADS) recently included standardized interpretation, reporting, and management guidelines for US (US LI-RADS); however, this system has not yet been validated. Purpose To evaluate the diagnostic performance of US LI-RADS version 2017 for detecting hepatocellular carcinoma (HCC) in participants at high risk and to determine the clinical factors associated with a poor visualization score. Materials and Methods This study included 407 prospectively recruited participants (mean age, 56 years; age range, 28-76 years) with cirrhosis at high risk for HCC who underwent US surveillance from November 2011 to August 2012. Two radiologists retrospectively analyzed US images, assigning a LI-RADS category (US-1 = negative, US-2 = subthreshold, US-3 = positive) and a visualization score (A = no or minimal limitations, B = moderate limitations, C = severe limitations). The sensitivity and specificity for diagnosing HCC were calculated on a per-patient and per-lesion basis, using pathologic results and typical CT or MRI as reference standards. The risk factors for a poor visualization score were determined by using univariable and multivariable analyses. Results Of 429 lesions in 407 participants, there were 32 HCCs in 28 participants. In the per-lesion analysis, the specificity for US-3 was 366 of 397 (92%; 95% confidence interval [CI]: 89%, 95%) and the sensitivity was 11 of 32 (34%; 95% CI: 20%, 52%). In the per-patient analysis, the specificity for US-3 was 352 of 379 (93%; 95% CI: 90%, 95%) and the sensitivity was 11 of 28 (39%; 95% CI: 24%, 58%). Visualization score C (114 of 407 [28%] participants) had the highest false-negative rate (six of seven [86%] participants). High body weight (adjusted odds ratio [OR], 2.1 [95% CI: 1.2, 3.6]; P = .01), Child-Pugh class B disease (OR, 2.9 [95% CI: 1.7, 4.9]; P < .001), and moderate to severe fatty liver (OR, 1.7 [95% CI: 1.0, 2.8]; P = .047) were associated with a poor visualization score of C. Conclusion The US-3 category demonstrated high specificity but low sensitivity for diagnosing hepatocellular carcinoma. The visualization score C had a higher false-negative rate than scores A or B, and patients with high body weight, Child-Pugh class B disease, and moderate to severe fatty liver may present limitations for US surveillance. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Milot in this issue.

Hepatocellular Carcinoma: State of the Art Imaging and Recent Advances

The incidence of hepatocellular carcinoma (HCC) is increasing, with this trend expected to continue to the year 2030. Hepatocarcinogenesis follows a predictable course, which makes adequate identification and surveillance of at-risk individuals central to a successful outcome. Moreover, imaging is central to this surveillance, and ultimately to diagnosis and management. Many liver study groups throughout Asia, North America and Europe advocate a surveillance program for at-risk individuals to allow early identification of HCC. Ultrasound is the most commonly utilized imaging modality. Many societies offer guidelines on how to diagnose HCC. The Liver Image Reporting and Data System (LIRADS) was introduced to standardize the acquisition, interpretation, reporting and data collection of HCC cases. The LIRADS advocates diagnosis using multiphase computed tomography or magnetic resonance imaging (MRI) imaging. The 2017 version also introduces contrast-enhanced ultrasound as a novel approach to diagnosis. Indeed, imaging techniques have evolved to improve diagnostic accuracy and characterization of HCC lesions. Newer techniques, such as T1 mapping, intravoxel incoherent motion analysis and textural analysis, assess specific characteristics that may help grade the tumor and guide management, allowing for a more personalized approach to patient care. This review aims to analyze the utility of imaging in the surveillance and diagnosis of HCC and to assess novel techniques which may increase the accuracy of imaging and determine optimal treatment strategies.

Hepatocellular carcinoma surveillance: Eastern and Western perspectives

Eastern and Western guidelines for the management of hepatocellular carcinoma (HCC) are known to significantly differ on many points, because they reflect different diagnostic and therapeutic approaches to this cancer. Importantly, these guidelines are primarily consensus-driven when it comes to surveillance, both in term of the tests used and surveillance program design. The main difference between East and West lies in clinical practice, as several Eastern countries implement coordinated and systematic surveillance programs, while most Western countries rely on individual adherence to surveillance recommendations. This review article presents an overview of the evidence supporting surveillance programs for HCC, with a particular focus on the efficacy, cost-effectiveness, and consequences of this approach for patient survival. Western and Eastern guideline recommendations are discussed.

Hepatocellular carcinoma surveillance with ultrasound-cost-effectiveness, high-risk populations, uptake

Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer and the second cause of cancer-related deaths worldwide. In most cases, it is diagnosed in patients with identified risk factors, mainly cirrhosis from all causes. These patients are candidates for a surveillance program that, depending on guidelines, involves regular liver ultrasound alone or combined with serum markers. These programs have been shown to improve the oncological outcome by detecting earlier stage tumors and providing patients with potentially curative treatment and improved survival. Yet, the level of evidence supporting these guidelines remains limited. This review article presents an overview of the evidence supporting surveillance programs for hepatocellular carcinoma, in particular the efficacy, cost-effectiveness, and consequences of this approach for patient survival. Western and Eastern guideline recommendations are described and discussed.

US LI-RADS: ultrasound liver imaging reporting and data system for screening and surveillance of hepatocellular carcinoma

Ultrasound is the most widely used imaging tool for hepatocellular carcinoma (HCC) screening and surveillance. Until now, this method has lacked standardized guidelines for interpretation, reporting, and management recommendations [1-5]. To address this need, the American College of Radiology (ACR) has developed the Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) algorithm. The proposed algorithm has two components: detection scores and visualization scores. The detection score guides management and has three categories: US-1 Negative, US-2 Subthreshold, and US-3 Positive. The visualization score informs the expected sensitivity of the ultrasound examination and also has three categories: Visualization A: No or minimal limitations; Visualization B: Moderate limitations; and Visualization C: Severe limitations. Standardization in ultrasound utilization, reporting, and management in high-risk individuals has the capacity to improve communication with patients and referring physicians, unify screening and surveillance algorithms, impact outcomes, and supply quantitative data for future research.

Screening and Surveillance of Hepatocellular Carcinoma: An Introduction to Ultrasound Liver Imaging Reporting and Data System

Given the high prevalence, increasing incidence, and significant morbidity and mortality related to hepatocellular carcinoma (HCC), a robust and cost-effective screening and surveillance program is needed. Most societies recommend ultrasound for HCC screening, despite lack of standardization in imaging acquisition, reporting content and language, and follow-up recommendations. The American College of Radiology Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) fills this unmet need by providing standardization in the use of US in at-risk patients. It is anticipated that US LI-RADS will improve the performance of ultrasound for HCC screening and surveillance and unify management recommendations.

Diagnosis of hepatocellular carcinoma: An update on international guidelines

Imaging is essential for the successful management of patients with or at risk of developing hepatocellular carcinoma (HCC). If ultrasound remains the key screening modality, computed tomography and magnetic resonance imaging (MRI) can play a major role in the characterization and noninvasive diagnosis of nodules in patients at risk of developing HCC. Each technique has succeeded in adapting to the wide histological spectrum of focal liver lesions. In this review, we discuss recent advancements in imaging techniques and evaluation - notably diffusion-weighted imaging, contrast-enhanced ultrasound, and liver-specific MRI contrast agents - as well as their addition to international guidelines and reporting systems such as the Liver imaging reporting and data system (LI-RADS).

Cone Beam CT-Guided Chemoembolization of Probable Hepatocellular Carcinomas Smaller than 1 cm in Patients at High Risk of Hepatocellular Carcinoma

PURPOSE

To evaluate the effectiveness and safety of cone-beam computed tomography (CT)-guided chemoembolization for probable hepatocellular carcinomas (HCCs) smaller than 1 cm in patients at high risk for HCC.

MATERIALS AND METHODS

From December 2009 to May 2014, 57 patients (43 male and 14 female; mean age, 61.1 y) at high risk for HCC underwent cone-beam CT-guided conventional chemoembolization for 79 treatment-naive probable HCCs < 1 cm. Probable HCCs were diagnosed when hepatic nodules showed arterial enhancement and washout on dynamic CT or magnetic resonance images. The Kaplan-Meier method and Cox proportional-hazards regression were used to evaluate the time to local progression (TTLP), time to progression (TTP), and overall survival (OS).

RESULTS

Initial follow-up images obtained 2-3 months after chemoembolization showed complete response in all 79 tumors. The 1-, 2-, and 3-year local progression rates were 10.4%, 21.7%, and 35.7%, respectively. Subsegmental catheterization (P < .001; hazard ratio [HR] = .041) and segmental catheterization (P = .001; HR = .049) were significantly associated with longer TTLP. The 1-, 2-, and 3-year progression rates were 40.5%, 66.7%, and 78.6%, respectively. Tumor multiplicity (P = .004; HR = 2.612) was a significant risk factor for shorter TTP. The 1-, 2-, and 3-year OS rates were 100%, 98.2%, and 88.5%, respectively. Child-Turcotte-Pugh class B disease (P = .029; HR = 5.989) was significantly associated with shorter OS. No complications occurred after chemoembolization.

CONCLUSIONS

Cone-beam CT-guided chemoembolization can be a useful and safe option for probable HCCs < 1 cm in patients at high risk for HCC.

Republished: Non-alcoholic fatty liver disease: a practical approach to treatment

Non-alcoholic fatty liver disease (NAFLD) affects up to a third of the population in many developed countries. Between 10% and 30% of patients with NAFLD have non-alcoholic steatohepatitis (NASH) that can progress to cirrhosis. There are metabolic risk factors common to both NAFLD and cardiovascular disease, so patients with NASH have an increased risk of liver-related and cardiovascular death. Management of patients with NAFLD depends largely on the stage of disease, emphasising the importance of careful risk stratification. There are four main areas to focus on when thinking about management strategies in NAFLD: lifestyle modification, targeting the components of the metabolic syndrome, liver-directed pharmacotherapy for high risk patients and managing the complications of cirrhosis.

The role of the diffusion sequence in magnetic resonance imaging for the differential diagnosis between hepatocellular carcinoma and benign liver lesions

Background and aim

To assess the role of diffusion weighted imaging sequence (DWI), routinely used in hepatic magnetic resonance imaging (MRI) for the differentiation of hepatocellular carcinoma (HCC) from benign liver lesions.

Methods

A number of 56 liver MRI examinations were retrospectively analyzed independently by two experienced radiologists, blinded to each other results. A total number of 70 Focal Liver Lesions (FLLs) assessed by liver MRI in 56 patients were included in the present study. All lesions were retrospectively analyzed by two experienced radiologists, independently from each other and who were not aware of the previous results given by using different imaging techniques. All included FLLs had a final histological diagnosis, or the final diagnosis was based on consensus reading by two experienced radiologists. The signal of the included FLLs was qualitatively appreciated on the b-800 sequences and on the apparent diffusion coefficient (ADC) map. The ADC value of each FLL was measured and the ADC ratio between the ADC value of the assessed FLL and that of the surrounding liver parenchyma was calculated.

Results

The mean ADC value for benign FLLs as assessed by the two independent readers was 1.75 × 10⁻³ and 1.72 × 10⁻³. The mean ADC value for HCC nodules was 0.92 × 10⁻³ for the first reader and 0.91 × 10⁻³ for the second reader respectively. The mean ADC ratio for benign FLLs was 1.81 and 1.84 for the two readers, respectively. The ADC ratio for HCC nodules was 0.91 and 0.91, respectively. The ADC value is an indicator which is less prone to interobserver variability (correlation of 0.919→1). The ADC ratio has, as the analysis of the ROC curve shows, the best predictive value for differentiation between benign FLLs and HCC nodules. Analysis of the signal intensity on the DWI b-800 image alone is of no significance in differentiating benign FLLs from HCC nodules (p>0.005).

Conclusions

The ADC value and the ADC ratio assessed on liver DWI are useful diagnostic tools in the differential diagnosis of benign FLLs vs HCC nodules. Quantitative methods such as calculating the ADC value or ADC ratio have better diagnostic value than qualitative techniques.

A concise review of updated guidelines regarding the management of hepatocellular carcinoma around the world: 2010-2016

Many guidelines for hepatocellular carcinoma (HCC) have been published and updated globally. In contrast to other cancers, there is a range of treatment options for HCC involving several multidisciplinary care of the patient. Consequently, enormous heterogeneity in management trends has been observed. To support standard care for HCC, we systematically appraised 8 current guidelines for HCC around the world, including 3 guidelines from Asia, 2 from Europe, and 3 from the United States according to the selection criteria of credibility influence and multi-faceted. After a systematic appraisal, we found that these guidelines have both similarities and dissimilarities in terms of surveillance and treatment allocation recommendations due to regional differences in disease and other variables (diagnosis, staging systems) secondary to the lack of a solid, high level of evidence. In contrast to other tumors, the geographic differences in tumor biology (i.e., areas of increased hepatitis B prevalence) and available resources (organ availability for transplantation, medical technology, accessibility to treatment, health systems, and health resources) make it impractical to have an internationally universal guideline for all patients with HCC. Although Barcelona-Clinic Liver Cancer (BCLC) has long been dominant system for treatment-guiding staging of HCC, many Asia-pacific experts do not fully agree with its principle. The concepts of BCLC, for surgical resection or other locoregional therapy, are considered too conservative. Asian guidelines represent consensus about surgical resection and TACE indication for more advanced tumor.

Highly sensitive alpha-fetoprotein, Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein and des-gamma-carboxyprothrombin for hepatocellular carcinoma detection

AIM

Hepatocellular carcinoma (HCC) develops with high incidence in patients with chronic liver disease (CLD), and particularly in those with cirrhosis. Currently, diagnosis and surveillance are mainly based on imaging methods. The aim of this study was to evaluate the diagnostic accuracy of highly sensitive measurement of α-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3) and des-γ-carboxyprothrombin (DCP) alone and in combination, for HCC detection. In addition, a recently proposed statistical model, including these three biomarkers plus sex and age, the GALAD model, was applied.

METHODS

In a total of 98 patients (44 CLD patients without HCC [23 men, 21 women; mean age, 53.2 ± 13.4 years] and 54 patients with HCC [45 men, nine women; 69.5 ± 9.8 years]), AFP, AFP-L3 and DCP levels were determined using a highly sensitive assay on an μTASWako i30 immuno-analyzer. Areas under the curve (AUC), sensitivity and specificity were calculated and compared to assess diagnostic performance of the HCC biomarkers and of the GALAD model.

RESULTS

AFP, AFP-L3 and DCP serum levels were significantly elevated in HCC compared with CLD patients (P < 0.0001). AUC values were 0.891, 0.867 and 0.870, respectively. The combination of the three biomarkers resulted in an AUC of 0.947, whereas the GALAD model showed an AUC of 0.976 with a difference between AUC values of 0.029 (P = 0.028).

CONCLUSION

The combination of AFP, AFP-L3 and DCP is superior to a single biomarker in HCC detection. Furthermore, GALAD model performance is significantly higher than simple combination of these three biomarkers.

Serum lipidomic profiling as a useful tool for screening potential biomarkers of hepatitis B-related hepatocellular carcinoma by ultraperformance liquid chromatography-mass spectrometry

Background

Chronic hepatitis B (CHB) virus infection is a major cause of hepatocellular carcinoma (HCC), as late diagnosis is the main factor for the poor survival of patients. There is an urgent need for accurate biomarkers for early diagnosis of HCC. The aim of the study was to explore the serum lipidome profiles of hepatitis B-related HCC to identify potential diagnostic biomarkers.

Methods

An ultraperformance liquid chromatography mass spectrometry (UPLC-MS) lipidomic method was used to characterize serum profiles from HCC (n = 32), liver cirrhosis (LC) (n = 30), CHB (n = 25), and healthy subjects (n = 34). Patients were diagnosed by clinical laboratory and imaging evidence and all presented with CHB while healthy controls had normal liver function and no infectious diseases.

Results

The UPLC-MS-based serum lipidomic profile provided more accurate diagnosis for LC patients than conventional alpha-fetoprotein (AFP) detection. HCC patients were discriminated from LC with 78 % sensitivity and 64 % specificity. In comparison, AFP showed sensitivity and specificity of 38 % and 93 %, respectively. HCC was differentiated from CHB with 100 % sensitivity and specificity using the UPLC-MS approach. Identified lipids comprised glycerophosphocolines, glycerophosphoserines and glycerophosphoinositols.

Conclusions

UPLC-MS lipid profiling proved to be an efficient and convenient tool for diagnosis and screening of HCC in a high-risk population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1995-1) contains supplementary material, which is available to authorized users.

Imaging of HCC-Current State of the Art

Early diagnosis of hepatocellular carcinoma (HCC) is crucial for optimizing treatment outcome. Ongoing advances are being made in imaging of HCC regarding detection, grading, staging, and also treatment monitoring. This review gives an overview of the current international guidelines for diagnosing HCC and their discrepancies as well as critically summarizes the role of magnetic resonance imaging (MRI) and computed tomography (CT) techniques for imaging in HCC. The diagnostic performance of MRI with nonspecific and hepatobililiary contrast agents and the role of functional imaging with diffusion-weighted imaging will be discussed. On the other hand, CT as a fast, cheap and easily accessible imaging modality plays a major role in the clinical routine work-up of HCC. Technical advances in CT, such as dual energy CT and volume perfusion CT, are currently being explored for improving detection, characterization and staging of HCC with promising results. Cone beam CT can provide a three-dimensional analysis of the liver with tumor and vessel characterization comparable to cross-sectional imaging so that this technique is gaining an increasing role in the peri-procedural imaging of HCC treated with interventional techniques.

Quantitative assessment of the effect of epidermal growth factor 61A/G polymorphism on the risk of hepatocellular carcinoma

The association between hepatocellular carcinoma (HCC) and the epidermal growth factor (EGF) 61A/G polymorphism has been analyzed in several studies, but results remain inconsistent. Therefore, the aim of the present study was to quantitatively summarize the association between the EGF 61A/G polymorphism and the risk of HCC. The PubMed and EMBASE databases were searched for studies published prior to May 1, 2014. The overall, subgroup and sensitivity analyses were conducted using Comprehensive Meta-Analysis software, version 2.2. In total, 12 published case-control studies, consisting of 2,095 patients with HCC and 3,766 control individuals, were included in the present study. Meta-analysis of the included studies revealed that EGF 61A/G polymorphism contributed to the risk of HCC under all four genetic models, consisting of the G vs. A (OR, 1.25; 95% CI, 1.11-1.40), GG vs. AA (OR, 1.53; 95% CI, 1.26-1.85), GG vs. AG + AA (OR, 1.34; 95% CI, 1.13-1.58) and GG + AG vs. AA (OR, 1.27; 95% CI, 1.08-1.49) comparisons. Subgroup analysis further suggested that EGF 61A/G polymorphism was associated with the risk of HCC in patients and control individuals with liver disease, based on ethnicity and source of control, respectively. No other significance in residual subgroup analysis was observed. The present meta-analysis suggests that the EGF 61A/G polymorphism is associated with an increased risk of HCC and may be a potential marker for liver disease, such as hepatitis B virus infection, hepatitis C virus infection and liver cirrhosis.

Clinical evaluation of synthetic aperture harmonic imaging for scanning focal malignant liver lesions

The purpose of the study was to perform a clinical comparison of synthetic aperture sequential beamforming tissue harmonic imaging (SASB-THI) sequences with a conventional imaging technique, dynamic receive focusing with THI (DRF-THI). Both techniques used pulse inversion and were recorded interleaved using a commercial ultrasound system (UltraView 800, BK Medical, Herlev, Denmark). Thirty-one patients with malignant focal liver lesions (confirmed by biopsy or computed tomography/magnetic resonance) were scanned. Detection of malignant focal liver lesions and preference of image quality were evaluated blinded off-line by eight radiologists. In total, 2,032 evaluations of 127 image sequences were completed. The sensitivity (77% SASB-THI, 76% DRF-THI, p = 0.54) and specificity (71% SASB-THI, 72% DRF-THI, p = 0.67) of detection of liver lesions and the evaluation of image quality (p = 0.63) did not differ between SASB-THI and DRF-THI. This study indicates the ability of SASB-THI in a true clinical setting.

Economic evaluation and budget impact analysis of the surveillance program for hepatocellular carcinoma in Thai chronic hepatitis B patients

BACKGROUND

The incidence rate and the treatment costs of hepatocellular carcinoma (HCC) are high, especially in Thailand. Previous studies indicated that early detection by a surveillance program could help by down-staging. This study aimed to compare the costs and health outcomes associated with the introduction of a HCC surveillance program with no program and to estimate the budget impact if the HCC surveillance program were implemented.

MATERIALS AND METHODS

A cost utility analysis using a decision tree and Markov models was used to compare costs and outcomes during the lifetime period based on a societal perspective between alternative HCC surveillance strategies with no program. Costs included direct medical, direct non-medical, and indirect costs. Health outcomes were measured as life years (LYs), and quality adjusted life years (QALYs). The results were presented in terms of the incremental cost-effectiveness ratio (ICER) in Thai THB per QALY gained. One- way and probabilistic sensitivity analyses were applied to investigate parameter uncertainties. Budget impact analysis (BIA) was performed based on the governmental perspective.

RESULTS

Semi-annual ultrasonography (US) and semi-annual ultrasonography plus alpha-fetoprotein (US plus AFP) as the first screening for HCC surveillance would be cost-effective options at the willingness to pay (WTP) threshold of 160,000 THB per QALY gained compared with no surveillance program (ICER=118,796 and ICER=123,451 THB/QALY), respectively. The semi-annual US plus AFP yielded more net monetary benefit, but caused a substantially higher budget (237 to 502 million THB) than semi-annual US (81 to 201 million THB) during the next ten fiscal years.

CONCLUSIONS

Our results suggested that a semi-annual US program should be used as the first screening for HCC surveillance and included in the benefit package of Thai health insurance schemes for both chronic hepatitis B males and females aged between 40-50 years. In addition, policy makers considered the program could be feasible, but additional evidence is needed to support the whole prevention system before the implementation of a strategic plan.

Plasma osteopontin is a biomarker for the severity of alcoholic liver cirrhosis, not for hepatocellular carcinoma screening

Background

Implementation of surveillance programs for at-risk populations and identification of biomarkers for early hepatocellular carcinoma (HCC) detection are a major public health goal. Recently, osteopontin (OPN) has attracted attention as a promising biomarker, with some potential advantages compared to alpha-fetoprotein (AFP), but its role in the context of alcoholic cirrhosis has never been assessed. The aims of this study are to assess the utility of plasma OPN in the diagnosis of HCC in alcoholic cirrhotic patients and to investigate whether increased values are due to the tumor or underlying liver disease severity.

Methods

A total of 90 consecutively alcoholic cirrhosis patients, observed between Jun 2013 and May 2014 at a Liver Disease Unit, were included and divided into two groups: 45 without (group I) and 45 with HCC (group II). Plasma levels of OPN (ELISA, Immuno-Biological Laboratories, Gunma, Japan) and AFP (IMMULITE® 2000 AFP, Siemens Healthcare Diagnostics, Tarrytown, New York) were assessed. The diagnostic accuracy of each marker was evaluated using Receiver-Operating Characteristic (ROC) curve analysis (AUC) and its 95 % Confidence Interval (CI).

Results

Plasma OPN levels in group I patients (1176.28 +/–744.59 ng/mL) weren’t significantly different from those of group II (1210.75 +/–800.60 ng/mL) (p = 0.826). OPN levels significantly increased with advancing BCLC tumor stage and with advancing Child-Pugh class, in both groups. Comparing the two groups, AUC for OPN and AFP were 0.51 (95 % CI: 0.39–0.63) and 0.79 (95 % CI: 0.70–0.89), respectively. Based on the ROC analysis, there were no satisfactory cut-off values for OPN that would distinguish patients with from those without tumour.

Conclusions

Despite having a correlation with BCLC stage, the same was observed with progressive deterioration of underlying liver function in terms of Child-Pugh class and MELD score, and isn’t a useful diagnostic biomarker for HCC in alcoholic cirrhotic patients, particularly in the early stages. AFP confirms the performance evidenced in other studies, being superior to OPN. Searching more specific biomarkers for early diagnosis of HCC in alcoholic cirrhosis is still warranted.

Non-hypervascular hepatobiliary phase hypointense nodules on gadoxetic acid-enhanced MRI: risk of HCC recurrence after radiofrequency ablation

BACKGROUND & AIMS

Hepatobiliary phase images (HBPI) of gadoxetic acid-enhanced MRI can depict borderline hepatocellular nodules that have the potential to progress into hypervascular hepatocellular carcinomas (HCCs), as non-hypervascular hypointense nodules. We retrospectively evaluated the impact of the presence of non-hypervascular hypointense nodules at HBPI of gadoxetic acid-enhanced MRI on the patient's prognosis after radiofrequency ablation (RFA) for early stage HCCs.

METHODS

A total of 139 patients who underwent pre-procedural gadoxetic acid-enhanced MRI followed by RFA were included. After a mean follow-up of 44.6±13.2 months, we compared the results of tumor recurrence as well as overall and recurrence-free survival (RFS) with the presence of non-hypervascular hypointense nodules on HBPI.

RESULTS

The presence of non-hypervascular hypointense nodules on HBPI did not affect overall survival (p=0.136). However, the estimated 5-year RFS rate was 71.3% in 29 patients without non-hypervascular hypointense nodules on HBPI compared to 27.9% in 110 patients with non-hypervascular hypointense nodules on HBPI, indicating a significant difference (hazard ratio=2.84 [1.39-5.98], p=0.006). When we classified recurrence into local tumor progression [LTP], intrahepatic distant recurrence [IDR], and extra-hepatic metastasis [EM], five-year cumulative incidences (CI) of IDR in patients with non-hypervascular hypointense nodules on HBPI were significantly higher than those in patients without non-hypervascular hypointense nodules on HBPI (17.9% vs. 67.5%, p<0.001). Five-year CIs of LTP and EM showed no significant difference (p>0.05).

CONCLUSIONS

The presence of non-hypervascular hypointense hepatocellular nodules on HBPI of gadoxetic acid-enhanced MRI taken prior to RFA is a significant predictive factor of recurrence after RFA of early stage HCCs, particularly IDR.

Hepatocellular carcinoma surveillance: a national survey of current practices in the USA

BACKGROUND

The incidence rate of hepatocellular carcinoma (HCC) in the USA is rapidly rising. Surveillance using biannual ultrasound (US) is recommended, but actual practices are unknown.

AIM

To determine current HCC surveillance practices among gastroenterology and hepatology providers in the USA.

METHODS

A 21-question electronic survey was emailed to 12,485 gastroenterology and hepatology providers in the USA. The survey contained questions concerning provider background, surveillance practices, and opinions. Pearson chi-square and multivariate logistic regression tests were used to analyze the data.

RESULTS

We received 777 responses (6.2% response rate); 656 were eligible for analysis. 92% place cirrhotic patients under surveillance independent of etiology, 79% exclusively use a 6-month interval, and 77% use alpha-fetoprotein. While 93% use US, only 36% use US exclusively and 60% use two or more imaging modalities. Providers from transplant centers favor using additional imaging modalities, instead of only US. Multivariate analysis showed transplant center providers who allocate more time to patient care (OR 1.96, p = 0.004) and see more cirrhotic patients (OR 2.07, p = 0.033) have increased odds of using additional imaging modalities.

CONCLUSIONS

Participating providers reported very high rates of surveillance utilization and use of a biannual interval. It is likely that the sample is composed of providers who are very engaged and informed about HCC surveillance. However, their surveillance imaging practices largely deviated from practice guidelines, which all recommend only using US. Providers affiliated with transplant centers tend to use additional imaging modalities such as computed tomography and MRI, instead of US only.

Non-alcoholic fatty liver disease: a practical approach to treatment

Non-alcoholic fatty liver disease (NAFLD) affects up to a third of the population in many developed countries. Between 10% and 30% of patients with NAFLD have non-alcoholic steatohepatitis (NASH) that can progress to cirrhosis. There are metabolic risk factors common to both NAFLD and cardiovascular disease, so patients with NASH have an increased risk of liver-related and cardiovascular death. Management of patients with NAFLD depends largely on the stage of disease, emphasising the importance of careful risk stratification. There are four main areas to focus on when thinking about management strategies in NAFLD: lifestyle modification, targeting the components of the metabolic syndrome, liver-directed pharmacotherapy for high risk patients and managing the complications of cirrhosis.

DNA markers in molecular diagnostics for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the one of the leading causes of cancer mortality in the world, mainly due to the difficulty of early detection and limited therapeutic options. The implementation of HCC surveillance programs in well-defined, high-risk populations were only able to detect about 40-50% of HCC at curative stages (Barcelona Clinic Liver Cancer stages 0 & 1) due to the low sensitivities of the current screening methods. The advance of sequencing technologies has identified numerous modifications as potential candidate DNA markers for diagnosis/surveillance. Here we aim to provide an overview of the DNA alterations that result in activation of cancer pathways known to potentially drive HCC carcinogenesis and to summarize performance characteristics of each DNA marker in the periphery (blood or urine) for HCC screening.

Serum peptide pattern that differentially diagnoses hepatitis B virus-related hepatocellular carcinoma from liver cirrhosis

BACKGROUND

Although alpha-fetoprotein (AFP) is a useful serologic marker of hepatocellular carcinoma (HCC), it is not sufficiently sensitive to differentiate HCC and liver cirrhosis (LC) caused by hepatitis B virus (HBV) infection.

AIMS

The aim is to discover novel noninvasive specific serum biomarkers for the differential diagnosis of HBV-related HCC and LC.

METHODS

With a highly optimized peptide extraction and matrix-assisted laser desorption/ionization time of flight/time of flight mass spectrometric approach, we investigated serum peptide profiles of 80 HCC and 67 LC patients. Three supervised machine learning methods were employed to construct classifiers. Receiver operator curves were plotted to evaluate the performance of classifiers.

RESULTS

With a support vector machine-based strategy, we picked nine peaks with m/z ratios of 819.49, 1076.14, 1341.72, 2551.44, 3156.44, 3812.88, 4184.26, 4465.92, and 4776.41 to construct the classifier. We proposed a novel method for distinguishing HCC from cirrhosis, based on a multilayer perceptron (MLP) method. We obtained a sensitivity of 90.0%, specificity of 79.4%, and overall accuracy of 85.1% on an independent test set. The combination of the MLP model and serum AFP level outperformed serum AFP marker alone in distinguishing HCC patients from LC patients. In this experience, sensitivity increased from 62.5% to 87.5%, and specificity increased from 79.4% to 88.2%.

CONCLUSIONS

Our results indicate that the MLP model is a novel and useful serum peptide pattern for distinguishing HCC and LC. The peptidome signature alone or together with serum AFP determination may be a more effective method for early diagnosis of HCC in patients with HBV-related LC.

Solid liver masses: approach to management from the standpoint of a radiologist

Solid liver masses are being discovered at increasing rates due to the widespread use of medical imaging. Ultrasound, computed tomography, and magnetic resonance imaging play important and often complementary roles in detecting and diagnosing solid liver masses. Morphologic and enhancement characteristics as well as clinical history frequently allow a confident imaging diagnosis. Still, diagnosing liver masses with imaging alone remains a challenge, and masses that do not meet specific diagnostic criteria may require biopsy. Newly developed standardized terminology and imaging criteria have facilitated the imaging diagnosis of hepatocellular carcinoma (HCC) in patients with cirrhosis. Hepatobiliary-secreted MRI contrast agents have improved the ability to diagnose focal nodular hyperplasia and may also improve the detection and imaging diagnosis of HCC. These exciting new contrast agents are the subject of active investigation.

Predicting coverage of transverse subcostal sonography with the use of previous computed tomography before a sonographic liver examination: a prospective study

OBJECTIVES

The purpose of this study was to assess the coverage of transverse subcostal sonography in the supine position by using computed tomography (CT) performed before a sonographic liver examination as a predictor of sonographic coverage.

METHODS

A total of 124 patients (87 men and 37 women; mean age, 55.55 years; range, 24-79 years) who underwent abdominal CT and subsequent liver sonography were enrolled. All patients were assessed for the coverage of transverse subcostal sonography in the supine position by consensus of 2 radiologists. We evaluated the correlation between the level of the posterior rib against the liver dome on axial CT and a sonographic coverage scoring system using Spearman partial correlation analysis. The optimal cutoff value of the liver position and other potential factors associated with sonographic coverage were analyzed.

RESULTS

Among age, sex, body mass index, interposition of bowel around the gallbladder fossa, atrophic changes from cirrhotic liver, and liver position, liver position was the only independent factor associated with sonographic coverage (P < .001). Liver position and the sonographic coverage score were moderately negatively correlated, with statistical significance (r = -0.44; P < .001). The optimal cutoff value for the level of the hepatic dome was at the 10th posterior rib on axial CT.

CONCLUSIONS

Liver position is the only independent factor associated with the coverage of transverse subcostal sonography in the supine position. If it is above the 10th posterior rib level, we can predict difficulty in adequate sonographic coverage of the liver.

Treatment options and surveillance strategies after therapy for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and the third leading cause of cancer death worldwide. Recurrence rates after curative intent treatment for HCC are high; 5-year disease-free survival ranges from only 19 to 81 %. There is no direct evidence to guide the optimal frequency and method of surveillance for recurrent HCC after curative intent treatment. In contrast, there is strong evidence supporting both primary screening for HCC in patients with chronic liver disease. After resection, HCC tends to recur locally, whereas the pattern after transplantation is more at extrahepatic sites. In theory, if an HCC recurrence is discovered early, more therapeutic options are available for treatment of the recurrent HCC. As such, close surveillance after curative intent therapy may have the potential to prolong survival. We herein review the available literature derived from primary surveillance of patients with cirrhosis, as well as data on postoperative surveillance of HCC patients. In aggregate, although data remain scarce, close surveillance with α-fetoprotein and cross-sectional imaging every 3-4 months for 3 years after curative intent therapy, followed by surveillance every 6-12 months thereafter, seems the most prudent approach to follow-up of patients with HCC in the postsurgical setting.

Review article: the management of autoimmune hepatitis beyond consensus guidelines

BACKGROUND

Consensus guidelines aid in the diagnosis and management of autoimmune hepatitis, but they are frequently based on low-quality clinical evidence, conflicting experiences and divergent opinions. Recommendations may be weak, discrepant or non-existent at critical decision points.

AIMS

To identify the decision points where guidelines are weak or non-existent and review the evidence essential in the decision process.

METHODS

Full-text articles published in English using the keyword 'autoimmune hepatitis' were identified by PubMed from 1972 to 2013. Personal experience and investigations in autoimmune hepatitis also identified important contributions.

RESULTS

Seventy per cent of the guidelines developed by the American Association for the Study of Liver Diseases and 48% of those proposed by the British Society of Gastroenterology are based on low-quality evidence, conflicting experiences or divergent opinions. The key uncertainties in diagnosis relate to the timing of liver biopsy, recognising acute severe (fulminant) disease, interpreting coincidental nonclassical histological changes, accommodating atypical or deficient features in non-White patients, differentiating drug-induced from classical disease and identifying overlap syndromes. The key uncertainties in management relate to pre-treatment testing for thiopurine methyltransferase activity, treating asymptomatic mild disease, determining treatment end points, managing suboptimal responses, incorporating nonstandard medications as front-line and salvage agents, using azathioprine in pregnancy and instituting surveillance for hepatocellular carcinoma.

CONCLUSIONS

Consensus guidelines are fraught with uncertainties in the diagnosis and management of autoimmune hepatitis. Each decision point must counterbalance the current available evidence and tailor the application of this evidence to the individual patient.

Predictors of dysplastic nodule diagnosis in patients with liver cirrhosis on unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase

OBJECTIVE

The purpose of this article is to assess whether unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase may predict the diagnosis of dysplastic nodules in patients with liver cirrhosis.

MATERIALS AND METHODS

We retrospectively analyzed 75 cirrhotic patients (47 men and 28 women; mean [± SD] age, 55 ± 12 years) with 82 hepatocellular nodules, including histology-proven dysplastic nodules (n = 25; diameter, 1-3 cm) and hepatocellular carcinomas (n = 57; diameter, 2-3 cm) scanned by MRI before and after gadobenate dimeglumine injection during hepatic arterial phase (HAP), portal venous phase (PVP), equilibrium phase, and hepatobiliary phase. Nodule T1 and T2 intensities before contrast agent injection and nodule HAP, PVP, equilibrium phase, and hepatobiliary phase intensities were compared with the adjacent liver. Univariate and multivariate logistic regression analysis was conducted to assess how the nodule could predict dysplastic nodule diagnosis.

RESULTS

Some imaging findings were independent predictors of dysplastic nodule diagnosis-namely, nodule T2 isohypointensity (odds ratio [OR], 12.28; 95% CI, 3.88-38.82), T1 isohyperintensity (OR, 26.74; 95% CI, 7.53-94.90), HAP isohypointensity (OR, 97.16; 95% CI, 20.06-470.49), PVP-equilibrium phase isohyperintensity (OR, 20.53; 95% CI, 5.36-78.62), and hepatobiliary phase isohyperintensity (OR, 119.6; 95% CI, 21.59-662.40). Nodule T2 and HAP isohypointensity (OR 31.47; 95% CI, 7.88-125.58), nodule T2 isohypointensity and hepatobiliary phase isohyperintensity (OR, 28.77; 95% CI, 7.79-106.19), nodule T1 isohyperintensity and HAP isohypointensity (OR, 17.22; 95% CI, 4.85-61.14), and nodule T1 and hepatobiliary phase isohyperintensity (OR, 19.39; 95% CI, 5.38-69.90) were also predictors of dysplastic nodule diagnosis.

CONCLUSION

The combination of nodule appearance on T2-weighted MRI and nodule enhancement after gadobenate dimeglumine injection may predict dysplastic nodule diagnosis in patients with liver cirrhosis.

Epidermal growth factor gene polymorphism and risk of hepatocellular carcinoma: a meta-analysis

BACKGROUND

Hepatocarcinogenesis is a complex process that may be influenced by many factors, including polymorphism in the epidermal growth factor (EGF) gene. Previous work suggests an association between the EGF 61*A/G polymorphism (rs4444903) and susceptibility to hepatocellular carcinoma (HCC), but the results have been inconsistent. Therefore, we performed a meta-analysis of several studies covering a large population to address this controversy.

METHODS

PubMed, EMBASE, Google Scholar and the Chinese National Knowledge Infrastructure databases were systematically searched to identify relevant studies. Data were abstracted independently by two reviewers. A meta-analysis was performed to examine the association between EGF 61*A/G polymorphism and susceptibility to HCC. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Eight studies were chosen in this meta-analysis, involving 1,304 HCC cases (1135 Chinese, 44 Caucasian and 125 mixed) and 2,613 controls (1638 Chinese, 77 Caucasian and 898 mixed). The EGF 61*G allele was significantly associated with increased risk of HCC based on allelic contrast (OR = 1.29, 95% CI = 1.16-1.44, p<0.001), homozygote comparison (OR = 1.79, 95% CI = 1.39-2.29, p<0.001) and a recessive genetic model (OR = 1.34, 95% CI = 1.16-1.54, p<0.001), while patients carrying the EGF 61*A/A genotype had significantly lower risk of HCC than those with the G/A or G/G genotype (A/A vs. G/A+G/G, OR = 0.66, 95% CI = 0.53-0.83, p<0.001).

CONCLUSION

The 61*G polymorphism in EGF is a risk factor for hepatocarcinogenesis while the EGF 61*A allele is a protective factor. Further large and well-designed studies are needed to confirm this conclusion.

Planning ultrasound for percutaneous radiofrequency ablation to treat small (≤ 3 cm) hepatocellular carcinomas detected on computed tomography or magnetic resonance imaging: a multicenter prospective study to assess factors affecting ultrasound visibility

PURPOSE

To assess factors affecting tumor visibility on planning ultrasound (US) for percutaneous radiofrequency (RF) ablation to treat small hepatocellular carcinomas (HCCs) primarily detected on computed tomography (CT) or magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Patients referred for planning US for percutaneous RF ablation between September 2008 and June 2009 were prospectively enrolled from nine institutions in Korea. The first small (≤ 3 cm) single HCC or new single HCC after treatment was included. The study enrolled 898 patients (684 men and 214 women, age range 32-86 years). HCCs that were invisible on planning US were compared with visible HCCs with respect to tumor size, distance between the tumor and the diaphragm, subcapsular location, etiology of liver disease, liver cirrhosis, macronodular cirrhosis on US, ascites, Child-Pugh class, serum alpha fetoprotein (AFP) level, body mass index (BMI), previous treatments for HCC, previous chemoembolization treatments for HCC, institutions, and experience of radiologists.

RESULTS

Among 898 HCCs, 671 (74.7%) were visible on the planning US. In multivariate analysis, tumor size, distance between the tumor and the diaphragm, liver cirrhosis, and macronodular cirrhosis were statistically significant factors affecting US detection (each P < .05).

CONCLUSIONS

Smaller tumors, subphrenic location of the tumor, liver cirrhosis, and macronodular cirrhosis were independent predictors of invisible tumors on planning US.