Hepatocellular carcinoma after ablation: the imaging follow-up scheme

Abstract

Percutaneous ablation using thermal or chemical methods has been widely used in the treatment of hepatocellular carcinoma (HCC). Nowadays, contrast-enhanced imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), and contrast-enhanced ultrasound (CEUS) are widely used to evaluate local treatment response after ablation therapies. CEUS is gaining increasing attention due to its characteristics including real-time scanning, easy performance, lack of radiation, wide availability, and lack of allergy reactions. Several studies have documented that CEUS is comparable to CT or MRI in evaluating local treatment efficacy within 1 mo of treatment. However, little information is available regarding the role of CEUS in the follow-up assessment after first successful ablation treatment. Zheng et al found that in comparison with contrast-enhanced computed tomography (CECT), the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of CEUS in detecting local tumor progression (LTP) were 67.5%, 97.4%, 81.8%, 94.4% and 92.3%, respectively, and were 77.7%, 92.0%, 92.4%, 76.7% and 84.0%, respectively for the detection of new intrahepatic recurrence. They concluded that the sensitivity of CEUS in detecting LTP and new intrahepatic recurrence after ablation is relatively low in comparison with CECT, and CEUS cannot replace CECT in the follow-up assessment after percutaneous ablation for HCC. These results are meaningful and instructive, and indicated that in the follow-up period, the use of CEUS alone is not sufficient. In this commentary, we discuss the discordance between CT and CEUS, as well as the underlying mechanisms involved. We propose the combined use of CT and CEUS which will reduce false positive and negative results in both modalities. We also discuss future issues, such as an evidence-based ideal imaging follow-up scheme, and a cost-effectiveness analysis of this imaging follow-up scheme.

Keywords: Computed tomography; Contrast-enhanced ultrasound; Ethanol ablation; Follow-up; Hepatocellular carcinoma; Radiofrequency ablation; Treatment response.

Figure 1

The proposed algorithm combining the strengths of the radiologic techniques of contrast-enhanced ultrasound and contrast-enhanced computed tomography. HCC: Hepatocellular carcinoma; CEUS: Contrast-enhanced ultrasound; CECT: Contrast-enhanced computed tomography; AFP: α fetoprotein; TACE: Transarterial chemoembolization; -: Negative finding; +: Positive finding.