Predictors of Ultrasound Failure to Detect Hepatocellular Carcinoma

Abstract

Current guidelines recommend ultrasound (US) for hepatocellular carcinoma (HCC) surveillance in cirrhosis. We assess predictors of decreased US sensitivity for detecting HCC. At a single center in the United States, all HCC patients evaluated for liver transplantation (LT) received an abdominal US. From 2007-2015, consecutive patients presenting for untreated lesions found on computed tomography (CT) or magnetic resonance imaging (MRI) within 3 months of US were compared with US findings. Multivariate logistic regression models compared US sensitivities by patient characteristics. Of 1007 patients completing LT evaluation, 47.5% had indeterminate or previously treated nodules and were excluded; 10.4% had imaging that was too far apart or nondiagnostic. Median Model for End-Stage Liver Disease (MELD) of the cohort (n= 352) was 11 (interquartile range [IQR], 9-14), median body mass index (BMI) was 28 kg/m (IQR, 25-32 kg/m ), 39% had received locoregional therapy, and 10% had moderate/large ascites. Per-patient sensitivity of US compared with CT/MRI was 0.82 (95% confidence interval, 0.76-0.86). Patients with BMI ≥ 30 kg/m had a US sensitivity of 0.76 versus 0.87 for BMI < 30 kg/m (P = 0.01). MELD and ascites did not affect sensitivity. US sensitivity was decreased in patients with nonalcoholic steatohepatitis (NASH) versus other etiologies (0.59 versus 0.84; P = 0.02). Relative to CT/MRI, US is significantly less sensitive in patients with NASH or BMI ≥ 30 kg/m . Further study is necessary to examine the added value of cross-sectional imaging for patients with NASH or obesity.

A young patient with type 2 diabetes associated non-alcoholic steatohepatitis, liver cirrhosis, and hepatocellular carcinoma

“…It highlights the importance of surveillance of NAFLD/NASH patients with liver cirrhosis for HCC. Even though ultrasound was shown to be less sensitive than computed tomography (CT) or MRI in detecting HCC in patients with NASH or obesity (BMI > 30 kg/m²) [32], it is the most cost-effective measure at this time. A specific challenge in obese patients is the loss of diagnostic accuracy in this population.…”

Effect of Nonalcoholic Fatty Liver Disease and Metabolic Risk Factors on Waitlist Outcomes in Patients With Hepatocellular Carcinoma

“… 9 Possible explanations for this include biological factors, such as more aggressive tumor biology, but also systematic factors, such as less referral to specialists, 35 decreased HCC screening rates, 35 , 36 and screening methods that are less effective in this population. 37 , 38 Even in NAFLD-HCC patients eligible for curative therapies, increased comorbidities, and relatively preserved liver function may lead to a preference for LRT over referral for transplant evaluation. Similarly, NAFLD-HCC patients undergoing LT evaluation are less likely to be listed than other HCC patients due to increased medical comorbidities, although these patients still die from their liver disease.…”

<p>Identifying High-Risk NASH Patients: What We Know so Far</p>

“… 122 Nevertheless, in selected cohorts such as severely obese patients, MRI or CT can have a role in HCC surveillance. 125 The recent best practice advices on HCC screening in NAFLD patients by the American Gastroenterological Association (AGA) recommend MRI or CT in case of suboptimal quality of screening ultrasound. 118…”