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.

Keywords: early detection; hepatocellular carcinoma; sectional imaging; ultrasound surveillance.

Figure 1

Small hypoechoic hepatocellular carcinoma (HCC) in a cirrhotic liver. US evaluation.

Figure 2

Small isoechoic HCC, with a subcapsular location. US evaluation.

Figure 3

Inadequate US examination. Posterior and superior part of the right lobe could not be visualized due to extensive steatosis and rib shadowing.

Figure 4

Proposal for a multiparametric personalized hepatocellular carcinoma screening in patients with cACLD. HBV—hepatitis B virus; HCV—hepatitis C virus; ALD—alcoholic liver disease; aMAP—hepatocellular carcinoma risk score, as described by Fan R et al. [68]; LSM—liver stiffness measurement; US—ultrasonography; aMRI—abbreviated magnetic resonance imaging; MDCT—multidetector computed tomography; AFP—alpha-fetoprotein; CEUS—contrast-enhanced ultrasonography; ⸸ 20 ng/mL cut-off value to be used for patients with a prior history or ongoing treatment for chronic viral hepatitis or curative-intent treatment for hepatocellular carcinoma; * a liver lesion which is hypo enhanced in the venous and late phase.

Figure 5

Abbreviated magnetic resonance imaging done for HCC surveillance in a 74 years old cirrhotic patient. A newly discovered nodule, in segment 7, is to be seen on the T1 vibe fs tra sequence (A) and T2 haste tra sequence (B). The nodule was later confirmed and classified as LI-RADS 5 by CEUS.