Surveillance Program for Diagnosis of HCC in Liver Cirrhosis: Role of Ultrasound Echo Patterns

Abstract

International guidelines suggest ultrasound surveillance for hepatocellular carcinoma (HCC) early diagnosis in liver cirrhosis (LC) patients, but 40% of nodules <2 cm escape detection. We investigated the existence of an ultrasound pattern indicating a higher risk of developing HCC in patients under surveillance. 359 patients with LC (Child-Pugh A-B8) underwent ultrasound screening (median follow-up 54 months, range 12-90 months), liver function tests, alpha-fetoprotein assay, and portal hypertension evaluation. Echo patterns were homogeneous, bright liver, coarse, coarse small nodular pattern, and coarse large nodular pattern. During follow-up 13.9% developed HCC. At multivariate analysis using Cox's model alpha-fetoprotein, coarse large nodular pattern, portal hypertension, and age were independent predictors of HCC development. Kaplan-Meier estimates of HCC cumulative risk in relation to the baseline echo patterns showed risk of 75% in coarse large nodular pattern patients, 23% coarse small nodular pattern, 21% coarse pattern, 0% homogeneous, and bright liver echo patterns (log-rank test = 23.6, P < 0.001). Coarse large nodular pattern indicates a major risk factor for HCC as 40.7% of patients with this pattern developed HCC. Homogeneous and bright liver echo patterns and the absence of portal hypertension were not related to HCC. This observation could raise the question of possibly modifying the follow-up timing in this subset of patients.

Figure 1

Coarse echo pattern (see text).

Figure 2

Hypoechoic nodules < 5 mm in diameter on the background of the coarse echo pattern.

Figure 3

Hypoechoic nodules > 5 mm in diameter on the background of the coarse echo pattern.

Figure 4

Changes in echo pattern at enrolment and end of follow-up (H, homogeneous; BL, bright liver; C, coarse pattern; CSNP, coarse small nodular pattern; CLNP, coarse large nodular pattern) (χ²_MH = 114,7; P = 0.0001).

Figure 5

Cumulative risk for echo patterns: H/BL (homogeneous/bright liver), C (coarse), CSNP (coarse small nodular pattern), and CLNP (coarse large nodular pattern). A log-rank test showed significant differences (log-rank test = 23.6, P < 0.001).