The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis

Sangiovanni, A.; Manini, M.A.; Iavarone, M.; Roméo, R.; Forzenigo, L.V.; Fraquelli, Mirella; Massironi, Sara; Corte, C. Della; Ronchi, G.; Rumi, Maria Grazia; Biondetti, Pierpaolo; Colombo, Massimo

doi:10.1136/gut.2009.187286

Cited by 383 publications

(312 citation statements)

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“…Despite similar contrast biodistribution of the contrast agents, and similar acquisition timing between CT and MR, we still observed discrepancies in 39% in assessing tumor vascularity, leading to liver biopsy to solve doubtful cases in a high percentage of the cases, as reported by Leoni et al 21 As recently suggested by the 2011 updated AASLD guidelines, we also evaluated the sensitivity and specificity for a noninvasive diagnosis of HCC or HGDN with a single imaging technique (i.e., CT or MRI). [21][22][23] Our results show that sensitivity ranged between 75% and 79%, with the highest sensitivity for MRI, as also observed by others. 21 Interestingly, we had a specificity of 100% for HCC or HGDN with any of each single imaging modality.…”

Section: Discussionsupporting

confidence: 73%

“…22 One could argue that such a strategy would still miss the diagnosis of HCC in 26% of the cases and is not cost effective. 23 Alternatively, we recommend liver biopsy after a first inconclusive imaging examination. Biopsy remains important in our view, because the information provided both by examination of the nontumoral and tumoral liver should be considered from a prognostic point of view.…”

Section: Discussionmentioning

confidence: 99%

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Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: Role of biopsy

et al. 2012

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Liver macronodules, ranging from benign to low-grade or high-grade dysplastic nodules (LGDNs/HGDNs) and hepatocellular carcinoma (HCC), may develop during chronic liver diseases (CLDs). Current guidelines were recently updated and the noninvasive criteria for the diagnosis of small HCC are based on a single typical radiological pattern and nonconclusive coincidental findings with two techniques. This study aimed to assess the accuracy and disagreements of noninvasive multiphasic examinations for the diagnosis of HCC and dysplastic nodules (DNs) and the role of biopsy. Seventy-four consecutive patients with CLD with ultrasound-detected 1-2-cm nodules underwent, within 1 month, multiphasic computed tomography (CT), magnetic resonance imaging (MRI), and biopsy of the nodule. Median age was 60 years; 33 patients (45%) had hepatitis C virus, 20 (27%) had hepatitis B virus, and 13 (18%) patients had no cirrhosis. Biopsy revealed 47 HCCs, 6 HGDNs, 1 LGDNs, 1 cholangiocarcinoma, and 1 epithelioid hemangioendothelioma. There were no tumors in the other 18 patients. All patients (31 of 31; 100%) who had conclusive coincidental findings (i.e., arterial enhancement and washout) on both examinations had HCC or HGDN (sensitivity, 57%; specificity, 100%). All patients (51 of 51; 100%) who had conclusive findings on at least one of the two examinations had HCC or HGDN (sensitivity, 96%; specificity, 100%). There was a disagreement regarding imaging findings between CT and MRI in 21 of 74 (28%) patients and no washout on both examinations in 23 of 74 patients (31%). In these 44 patients, liver biopsy provided an initial accurate diagnosis. Conclusion : The noninvasive diagnosis of HCC or HGDN can be obtained if arterial enhancement and washout are found in a single dynamic imaging examination. These findings are frequently discordant on both CT and MRI, supporting the place of biopsy for the diagnosis of small HCCs.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: Role of biopsy

et al. 2012

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“…These guidelines have been validated in 3 studies 56,58,59 (Tables 9 and 10). The prospective study by Leoni et al 58 used the EASL guidelines 3 to establish the diagnosis of HCC for 75 consecutive small lesions (10-30 mm) detected by ultrasonography.…”

Section: Question 4 Are There Studies Validating the Current Guidelimentioning

confidence: 99%

“…Recently, another study evaluating the diagnostic and economic impact of contrast imaging techniques in the diagnosis of small HCCs in patients with cirrhosis was published. 59 Using CEUS, CT, MRI, and fine-needle biopsy as the diagnostic standards, the authors investigated 64 patients with 67 de novo liver nodules (44 HCC) (55 of the 67 lesions were between 10-20 mm in size. Of these 34 proved to be HCC).…”

Section: Question 4 Are There Studies Validating the Current Guidelimentioning

confidence: 99%

Is tumor biopsy necessary?

et al. 2011

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“…14,15 Recent prospective studies have reported that up to 67% of new nodules smaller than 2 cm identified during surveillance imaging in patients with cirrhosis are indeed HCC. 16 Although the specificity of contrast enhanced MRI has been reported as high as 96% for hepatic nodules of 1-2 cm in size, a significant proportion of small HCC may appear hypovascular or have atypical features, resulting in a false-negative rate of 20%-38%. 17 Finally, lesions < 1 cm in diameter may be especially difficult to characterize, even with the best imaging techniques.…”

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confidence: 99%

Tissue Diagnosis of Hepatocellular Carcinoma

Jain

2014

Journal of Clinical and Experimental Hepatology

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The current American Association for the Study of Liver Diseases (AASLD) guideline provides strategies for achieving the diagnosis of hepatocellular carcinoma (HCC) based on the size of liver nodules seen on surveillance imaging. For lesions less than 1 cm in size, follow-up surveillance imaging is recommended. Lesions larger than 2 cm require typical radiological hallmark on dynamic imaging. Lesions of 1-2 cm in size require typical imaging features including intense uptake of contrast during arterial phases followed by decreased enhancement during portal venous phases on at least 2 imaging modalities. In cases of atypical radiological features of the suspected lesion, tissue diagnosis either by fine needle aspiration or biopsy should be obtained. Although fine needle aspiration could give a smaller risk of seeding than biopsy, biopsy has been preferred over cytology. Percutaneous biopsy of HCC carries a potential risk of tumor seeding along the needle tract. However the risk is low and there is no clear evidence of post transplant recurrence due to needle tract seeding. Histopathologic assessment can differentiate between premalignant lesions such as dysplastic nodules and early HCC. Atypical variants of HCC can be recognized morphologically which may have associated prognostic value. ( J CLIN EXP HEPATOL 2014;4:S67-S73) H epatocellular carcinoma (HCC) is the sixth most common cancer in the world. 1 Its incidence is expected to rise in the future due to anticipated increase in cirrhosis secondary to viral hepatitis. Over the past 2 decades, the incidence of HCC has tripled, and hepatitis C virus (HCV) related HCC is the fastest-rising cause of cancer-related death in the United States. [2][3][4] Hepatocellular carcinoma develops within an established background of chronic liver disease in 70-90% of all patients. 5 The most frequent risk factor for HCC is chronic hepatitis B virus (HBV) infection in Asia and Africa. However HCV predominates as a risk factor in Europe and Japan. 2 Other well established risk factors are alcoholism, non-alcoholic fatty liver disease and diabetes. [6][7][8] Treatment depends on early diagnosis by screening high-risk patients when HCC is small and remains localized to the liver. Various studies suggest surveillance of HCC in cirrhotic patients irrespective of its etiology. Surveillance of non-cirrhotic patients is also advocated, especially in HBV carriers with serum viral load >10,000 copies/ml 9 or HCV infected patients with bridging fibrosis. Patients with HCV infection and advanced fibrosis remain at risk for HCC even after achieving sustained virological response following antiviral treatment.The preferred imaging method for screening is ultrasonography (USG) which is well tolerated and widely available. However, the sensitivity of USG for HCC detection is low because small nodules can be missed in a cirrhotic liver. 10 Use of contrast-enhanced USG improves the diagnostic performance of USG for HCC.The most used serological test in clinical setting for screening is alpha-fetop...

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The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis

Abstract: In patients with cirrhosis with a 1-2 cm nodule detected during surveillance, a single imaging technique showing a typical contrast pattern confidently permits the diagnosis of HCC, thereby reducing the need for FNB examinations.

Cited by 383 publications

References 20 publications

Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: Role of biopsy

Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: Role of biopsy

Is tumor biopsy necessary?

Tissue Diagnosis of Hepatocellular Carcinoma

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