Association between ultrasound quality and test performance for HCC surveillance in patients with cirrhosis: a retrospective cohort study

Abstract

Background: Ultrasound visualisation is limited in approximately 20% of patients with cirrhosis undergoing hepatocellular carcinoma (HCC) surveillance; however, it is unknown if impaired visualisation directly impacts test performance. We aimed to evaluate the association between ultrasound visualisation and surveillance test performance. Methods:We performed a retrospective cohort study among patients with cirrhosis, with or without HCC, who underwent ultrasound-based surveillance at two large health systems between July 2016 and July 2019. Ultrasound visualisation assessment was recorded by interpreting radiologists using the ultrasound LI-RADS Visualisation score. We performed logistic regression analyses to evaluate the association between ultrasound visualisation and diagnostic test performance. We assessed sensitivity for HCC detection among ultrasounds performed in the year prior to HCC diagnoses and specificity using ultrasounds in those without HCC.Results: Among 186 patients with HCC, severely limited visualisation (Vis Score C) on ultrasound prior to HCC diagnosis was associated with increased odds of falsenegative results, that is lower sensitivity (OR 7.94, in multivariable analysis. Ultrasound sensitivity with visualisation scores A or B exceeded 75%, compared to only 27.3% with visualisation score C. Among 2052 cirrhosis patients without HCC, moderate visualisation limitations (Vis score B) were associated with increased odds of false-positive results (OR 1.60, 1.13-2.27), although specificity exceeded 95% across all visualisation scores. Conclusions: Impaired ultrasound visualisation is associated with worse surveillance test performance. Alternative blood-based biomarkers and imaging strategies are needed for patients at risk for ultrasound-based surveillance failure.

Comparison of a multitarget blood test to ultrasound and alpha‐fetoprotein for hepatocellular carcinoma surveillance: Results of a network meta‐analysis

“…This gap is not surprising given ultrasound in the United States is conducted by technicians with frozen images subsequently interpreted by radiologists, whereas ultrasound is typically conducted and interpreted concurrently by clinicians in Europe and Asia. [ 29 ] Therefore, the need for alternative strategies, such as biomarkers, may vary by site and be driven by local performance of ultrasound‐based surveillance rather than pooled global estimates. Further, issues with ultrasound‐based surveillance will likely become more prevalent as cirrhosis etiologies shift from being viral hepatitis predominant to an increasing proportion related to alcohol and nonalcoholic steatohepatitis‐related cirrhosis.…”

Physician- and patient-reported barriers to hepatocellular carcinoma surveillance: A nationwide survey

“…Our finding was in line with a finding from a previous research reporting that inadequate US training programs were a potential barrier to proper usage of US for HCC surveillance in developing countries. [16] Additionally, we found that the AFP test was unavailable in 72.4% of community hospitals. This high unavailability rate might be due to the outweighed benefits and versatility of the US machine compared to the AFP test.…”

Emerging liquid biopsy techniques for early detection of hepatocellular carcinoma, prognostication, and disease monitoring

“…Its poor prognosis is partly driven by frequent late‐stage detection due to suboptimal sensitivity of current surveillance tests—abdominal ultrasound and alpha fetoprotein—which miss over one‐third of HCC cases at an early stage 1 . Ultrasound‐based surveillance is particularly subject to failure in obese patients and those with non‐viral etiologies of liver disease, highlighting a clear need for alternative strategies 2 …”