Imaging for the diagnosis of hepatocellular carcinoma: A systematic review and meta‐analysis

Abstract

Multiphasic computed tomography (CT) and magnetic resonance imaging (MRI) are both used for noninvasive diagnosis of hepatocellular carcinoma (HCC) in patients with cirrhosis. To determine if there is a relative diagnostic benefit of one over the other, we synthesized evidence regarding the relative performance of CT, extracellular contrast-enhanced MRI, and gadoxetate-enhanced MRI for diagnosis of HCC in patients with cirrhosis. We also assessed whether liver biopsy versus follow-up with the same versus alternative imaging is best for CT-indeterminate or MRI-indeterminate liver nodules in patients with cirrhosis. We searched multiple databases from inception to April 27, 2016, for studies comparing CT with extracellular contrast-enhanced MRI or gadoxetate-enhanced MRI in adults with cirrhosis and suspected HCC. Two reviewers independently selected studies and extracted data. Of 33 included studies, 19 were comprehensive, while 14 reported sensitivity only. For all tumor sizes, the 19 comprehensive comparisons showed significantly higher sensitivity (0.82 versus 0.66) and lower negative likelihood ratio (0.20 versus 0.37) for MRI over CT. The specificities of MRI versus CT (0.91 versus 0.92) and the positive likelihood ratios (8.8 versus 8.1) were not different. All three modalities performed better for HCCs 2 cm. Performance was poor for HCCs <1 cm. No studies examined whether adults with cirrhosis and an indeterminate nodule are best evaluated using biopsy, repeated imaging, or alternative imaging. Concerns about publication bias, inconsistent study results, increased risk of bias, and clinical factors precluded support for exclusive use of either gadoxetate-enhanced or extracellular contrast-enhanced MRI over CT. Conclusion: CT, extracellular contrastenhanced MRI, or gadoxetate-enhanced MRI could not be definitively preferred for HCC diagnosis in patients with cirrhosis; in patients with cirrhosis and an indeterminate mass, there were insufficient data comparing biopsy to repeat crosssectional imaging or alternative imaging. (HEPATOLOGY 2018;67:401-421).H epatocellular carcinoma (HCC) is unique among malignancies in having tumor characteristics on cross-sectional multiphasic contrast computed tomography (CT) or magnetic resonance imaging (MRI) that allow for a highly accurate diagnosis of HCC without an invasive biopsy. (1-4) The ability of cross-sectional imaging studies to reliably detect and diagnose HCCs in the cirrhotic liver rests primarily on characterizing the enhancement of a suspected tumor relative to background liver in the hepatic arterial, portal venous, and subsequent phases. (5) The differences in blood flow and extracellular volume between HCC tissues and non-neoplastic cirrhotic liver tissue lead to hallmark imaging characteristics during the multiphasic flow of contrast, including arterial phase hyperenhancement, subsequent washout appearance, and capsule appearance. (6,7) The pathophysiological underpinnings of arterialphase hyperenhancement, washout appearance, and capsule appearance are ...

Risk assessment of hepatocellular carcinoma development by magnetic resonance elastography in chronic hepatitis C patients who achieved sustained virological responses by direct‐acting antivirals

“…When tumour marker levels rose abnormally and/or abdominal ultrasonography suggested a lesion suspicious of HCC, contrast‐enhanced computed tomography, magnetic resonance imaging or angiography were performed. HCC was diagnosed for tumours displaying vascular enhancement at the early phase and washout at the later phase according to guidelines by the American Association for the Study of Liver Diseases, and the Japan Society of Hepatology . Tumour biopsy was used to diagnose tumours with nontypical imaging findings.…”

Prospective Intraindividual Comparison of Magnetic Resonance Imaging With Gadoxetic Acid and Extracellular Contrast for Diagnosis of Hepatocellular Carcinomas Using the Liver Imaging Reporting and Data System

“…Therefore, hypointensity on TP or HBP is not considered to be an alternative to washout of ECA‐MRI but is an ancillary feature . Although a few studies have compared computed tomography with either conventional dynamic ECA‐MRI or HBA‐MRI, no studies have compared ECA‐MRI and HBA‐MRI with regard to diagnostic performance based on LI‐RADS for HCC diagnosis. Thus, the goal of this prospective study was to compare the efficacy of HBA‐MRI and ECA‐MRI in the diagnosis of HCC with LI‐RADS v2017 in an intraindividual, crossover manner.…”

Hepatocyte‐Specific Magnetic Resonance Imaging–Based Assessment of Indeterminate Hepatic Nodules in the Liver Transplant Evaluation of Patients With Cirrhosis

“…The Milan model was originally proposed based on pathological findings of tumors from explanted livers . Unfortunately, approximately 10% of hepatic lesions radiologically typical of HCC were falsely diagnosed in our explant series and in previous ones . However, given the realistic difficulty of performing a biopsy on every nodule in patients with cirrhosis and the risk of malignant seeding, the evaluation of tumor stage before LT inevitably depends on the imaging criteria in most clinical practice .…”

“…This could have led to underestimating the malignancy rate of IDNs. However, most of the relevant reports evaluated tumors smaller than 3 cm, as we did in our study . In contrast, more advanced cirrhosis with greater malignant potential may have been included in our LT set than in prior surveillance series.…”

“…Multiple studies have shown that dynamic MRI enhanced with hepatobiliary contrast agents has greater overall sensitivity and specificity than various other protocols involving CT and MRI in detecting and diagnosing HCC in patients with cirrhosis, and more to the point, it appears to improve survival outcomes . However, little is known about the efficacy of liver‐specific MRI in establishing the identities of IDNs seen in the cirrhotic livers of potential recipients and in assessing LT eligibility and priority …”