Characteristics of Hypovascular versus Hypervascular Well-Differentiated Hepatocellular Carcinoma Smaller Than 2 cm - Focus on Tumor Size, Markers and Imaging Detectability

Sugimoto, Kumiko; Kim, Soo Ryang; Imoto, Susumu; Tohyama, Madoka; Kim, Soo Ki; Matsuoka, Toshifumi; Yano, Yoshihiko; Kudo, Masatoshi; Hayashi, Yoshitake

doi:10.1159/000439078

Cited by 20 publications

(16 citation statements)

References 27 publications

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“…Nineteen studies reported true‐positive, false‐positive, false‐negative, and true‐negative values, while 14 studies reported only detection rate (sensitivity rate). Table describes the detailed baseline characteristics of the included studies.…”

Section: Resultsmentioning

confidence: 99%

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

Roberts¹,

et al. 2017

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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 ...

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Section: Resultsmentioning

confidence: 99%

“…Fourteen studies compared MRI versus CT and reported only detection/sensitivity rate. Pooled analysis (Fig.…”

Section: Resultsmentioning

confidence: 99%

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

Roberts¹,

et al. 2017

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“…Up to now, the reported sensitivity of MR with gadoxetic acid‐enhanced MR (EOB‐MR) for the diagnosis HCC ranges between 70% and 100% . However, the retrospective design of the studies may overestimate the sensitivity and impedes the evaluation of specificity.…”

Section: Introductionmentioning

confidence: 99%

“…However, the retrospective design of the studies may overestimate the sensitivity and impedes the evaluation of specificity. In addition, some authors have considered the finding of hypo‐signal intensity (SI) in the HBP as equivalent to portal washout or even diagnostic of HCC regardless of the presence of arterial contrast enhancement in patients with cirrhosis . Furthermore, in some reports the final HCC diagnosis was based on not validated criteria such as tumour growth or increased alpha‐fetoprotein (AFP) .…”

Section: Introductionmentioning

confidence: 99%

Prospective evaluation of gadoxetic acid magnetic resonance for the diagnosis of hepatocellular carcinoma in newly detected nodules ≤2 cm in cirrhosis

Ayuso

Forner

Darnell

et al. 2019

Liver International

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Background and Aims Most of the published studies about the diagnostic accuracy of gadoxetic acid‐enhanced magnetic resonance (EOB‐MR) for the non‐invasive diagnosis of hepatocellular carcinoma (HCC) have had a retrospective design. Thus, we aimed to prospectively evaluate the diagnostic accuracy of EOB‐MR for the non‐invasive diagnosis of HCC in nodules ≤2 cm detected by screening ultrasound (US) in patients with cirrhosis. Methods Between July 2012 and October 2015, 62 consecutive asymptomatic Child‐Pugh A‐B cirrhotic patients with newly US‐detected solitary nodules between 1 and 2 cm were prospectively included in the study. Hepatic extracellular contrast‐enhanced MR (ECCE‐MR) followed by EOB‐MR were obtained in less than 1‐month interval. Two independent radiologists blindly reviewed the EOB‐MR studies, and the diagnosis of HCC was assigned when the lesion showed arterial enhancement followed by portal venous phase washout and/or hypointensity on the hepatobiliary phase (HBP). The final HCC diagnosis was made by ECCE‐MR according to the accepted non‐invasive criteria, or by biopsy in lesions with atypical vascular profile. Results Final diagnoses were as follows: HCC (n = 41), intrahepatic cholangiocarcinoma (n = 2), colorectal metastases (n = 1) and benign conditions (n = 18). The sensitivity and specificity of EOB‐MR for HCC diagnosis were 56.1% (95% CI: 39.7‐71.5) and 90.5% (95% CI: 69.6‐98.8), respectively, while sensitivity of ECCE‐MR was 63.4% (95% CI: 46.9‐77.9). The low rate of hypointense HCCs in the HBP and suboptimal liver uptake of contrast agent justify the low sensitivity of EOB‐MR for HCC diagnosis. Conclusion EOB‐MR does not surpass the diagnostic accuracy of ECCE‐MR for non‐invasive diagnosis of HCC in nodules ≤2 cm in cirrhotic patients.

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“…Regrettably, in all these studies the imaging criteria for HCC diagnosis was not uniform, as some authors considered the finding of hypo-intensity in the hepatobiliary phase to be equivalent to portal washout 17,21,25 or even diagnostic of HCC, regardless of the presence of arterial contrast enhancement in patients with cirrhosis. 21,28,29 In addition, the retrospective design of the studies 19,20,22 may lead to an overestimation of the sensitivity of the technique since the population included in those analyses might be biased by excluding those with non-typical or technically suboptimal imaging. Finally, most of the studies evaluating the accuracy of MR with gadoxetic acid were conducted in Eastern Asia, where HCC frequently arises in patients with chronic HBV infection without advanced cirrhosis.…”

Section: Diagnosis Of Hcc: Any Room For Improvement?mentioning

confidence: 99%

Controversies in the management of hepatocellular carcinoma

et al. 2019

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The management of hepatocellular carcinoma (HCC) has evolved considerably over the last decade. Surveillance of cirrhotic patients and refinements to imaging techniques have enabled a relevant proportion of patients to be diagnosed at an early stage, when effective therapies are feasible. Resection, transplantation and ablation are all options in patients with early stage HCC. Thus, there is some controversy regarding which is the best treatment approach in challenging scenarios. There have also been major developments in locoregional therapies, particularly in intraarterial approaches. Finally, the systemic treatment for HCC has changed dramatically following the demonstration of a survival benefit with sorafenib; there are currently several firstline (sorafenib and lenvatinib) and second-line (regorafenib, cabozantinib and ramucirumab) treatments that have shown a survival benefit. Expectations for immune checkpoint inhibitors are high, with the results of the ongoing phase III trials eagerly awaited. In this review we discuss some of the controversies in the management of HCC, focussing in particular on systemic therapy.

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Characteristics of Hypovascular versus Hypervascular Well-Differentiated Hepatocellular Carcinoma Smaller Than 2 cm - Focus on Tumor Size, Markers and Imaging Detectability

Cited by 20 publications

References 27 publications

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

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

Prospective evaluation of gadoxetic acid magnetic resonance for the diagnosis of hepatocellular carcinoma in newly detected nodules ≤2 cm in cirrhosis

Controversies in the management of hepatocellular carcinoma

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