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

Abstract

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.

Current Imaging Diagnosis of Hepatocellular Carcinoma

“…Ultrasound (US) is very-well suited for this purpose, thanks to its wide availability, cost-effectiveness, and accuracy in detecting focal liver lesions (FLL). Once a FLL is detected, US can assist its characterization, particularly using the full spectrum of ultrasonographic techniques, including B-mode, colour, and power Doppler techniques, such as pulsed-wave Doppler, non-Doppler flow-visualization, and, currently, contrast-enhanced ultrasound (CEUS); a wide range of techniques justifies the term, multi-parametric ultrasound [ 7 , 8 ].…”

Repeating Ultrasound for Hepatocellular Carcinoma Detection in Case of Inadequate Liver Visualization: A Matter of Expertise

“…Several factors can explain these disappointing results; they can be related to the patient (male gender, overweight, bowel gas), underlying liver disease (alcohol-related liver disease, liver heterogeneity, impaired liver function), or the pattern of the lesion itself (size, margins, echogenicity, location). 3 A recent quality assessment study conducted in the United States reported that only 66.5% of US examinations performed in the setting of HCC surveillance programs could be considered as "definitely adequate," 4 and identified subgroups prone to inadequate US, namely obese patients, those with Child-Pugh B or C cirrhosis, and those with alcohol-or nonalcoholic steatohepatitis-related cirrhosis. 4 In this situation frequently encountered in clinical practice, physicians in charge of patients have to decide whether they should repeat US examination, or directly switch to an alternative surveillance modality, such as sectional imaging techniques, usually less influenced by the patient status.…”

A multi‐analyte cell‐free DNA–based blood test for early detection of hepatocellular carcinoma

“…This variability is due in part to differences in the skill and training of the ultrasound operator, the quality of the instrument, and confounding factors that reduce ultrasound sensitivity, such as obesity and underlying liver disease. [ 28 ] Interestingly, many of these challenges posed to ultrasound as an HCC surveillance tool may be overcome by the development of a sensitive and easy‐to‐use blood test. Further subgroup analysis of studies comparing the performance of ultrasound with or without AFP indicated that including AFP increases the sensitivity for early HCC lesions from 45% for ultrasound alone to 63% for the combination of ultrasound and AFP.…”