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Ultrasound Screening for Hepatocellular Carcinoma (HCC) in Cirrhosis
Clinical Radiology (2000) 55, 161
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instructions to Authors at the back of the Journal. doi:10.1053/crad.1999.0265, available online at http://www.idealibrary. com on I ULTRASOUND SCREENING FOR HEPATOCELLULAR CARCINOMA (HCC) IN CIRRHOSIS SIR – I read with interest the article by Bottelli et al. [1], extolling the virtues of ultrasound screening for hepatocellular carcinoma (HCC) in patients with cirrhosis. The authors suggest that ultrasound is reliable in the early diagnosis of HCC and quote the paper by Rizzi et al. [2], giving a sensitivity for ultrasound of 80%. I fear that this may be a little misleading. That paper indicated an 80% sensitivity for ultrasound in the identification of the main tumour. Where multicentric tumour was demonstrated at histology ultrasound had only prospectively demonstrated it in 30·7% of cases. Rizzi et al. concluded that while ultrasound, CT and hepatic arteriography could identify patients with small (less than 4 cm) or large tumour bulk, the sensitivity of these techniques, especially ultrasound in detecting satellite lesions was poor. Dodd et al. [3] found a lesion sensitivity of 45% for ultrasound in 200 patients who underwent hepatic transplantation and pathological examination of the explanted liver. The authors concluded that ultrasound is highly insensitive for the detection of malignant lesions in end-stage cirrhotic livers. Shapiro et al. [4] showed a sensitivity of 51% for ultrasound in the detection of HCC in 21 patients who underwent liver transplantation. These are, to my knowledge, the only studies that have been performed to assess ultrasound in patients who have subsequently undergone transplantation and careful pathological examination of the explanted liver. Whilst there are several other papers claiming far better results for ultrasound sensitivity [5,6], these are based on limited pathological correlation. Ultrasound examination in end-stage cirrhosis is often difficult. Disorganized liver architecture and regenerative nodules may obscure small hepatocellular carcinoma. The liver is often shrunken and situated high under the right hemidiaphragm, making identification of segment 8 particularly difficult; the liver may be further obscured by the presence of ascites and interposed bowel loops. There may be differences in sensitivity for ultrasound between Asian and non-Asian populations. Patients in the former group often have a more ultrasound-friendly body habitus and often develop hepatocellular carcinoma at an early, pre-cirrhotic stage as there is a higher incidence of Hepatitis B as the aetiological factor in this group. Whilst I would not suggest abandoning ultrasound in screening of highrisk patients, I cannot share the authors’ enthusiasm. CHRISTOPHER FRAZER
Sir Charles Gairdner Hospital Hospital Avenue Nedlands 6009 Western Australia
References 1 Bottelli R, Tibballs J, Hochhauser D, Watkinson A, Dick R, Burroughs AK. Ultrasound screening for hepatocellular carcinoma (HCC) in
0009-9260/00/020161+01 $35.00/0
2 3 4 5 6
cirrhosis: the evidence for an established clinical practice. Clin Radiol 1998;53:713–716. Rizzi PM, Kane PA, Ruder SD, et al. Accuracy of radiology in detection of hepatocellular carcinoma before liver transplantation. Gastroenterology 1994;107:1424–1429. Dodd GD, Miller WJ, Baron RL, Skolnick ML, Campbell WL. Detection of malignant tumours in end-stage cirrhotic livers: efficacy of sonography as a screening technique. Am J Roentgenol 1992;159:727–733. Shapiro RS, Katz R, Mendelson DS, Halton KP, Schwartz ME, Miller CM. Detection of hepatocellular carcinoma in cirrhotic patients: sensitivity of CT and ultrasound. J Ultrasound Med 1996;15:497–502. Takayazu K, Moriyiama N, Muramatsu Y. The diagnosis of small hepatocellular carcinomas: efficacy of various imaging procedure in 100 patients. Am J Roentgenol 1990;155:49–54. Oka H, Kurioka N, Kosyun K, et al. Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis. Hepatology 1990;12:680–687.
doi:10.1053/crad.1999.0419, available online at http://www.idealibrary. com on REPLY TO DR FRAZER SIR – The availability of explanted livers for histological evaluation has significantly improved our knowledge of hepatocellular carcinoma (HCC) in cirrhotic patients. Despite continuous improvement of diagnostic radiological equipment, sensitivity for lesions of less than 1 cm in size and daughter nodules of main tumours is reported to be 50% in comparison to careful histological analysis. The goal of ultrasound screening is to identify neoplastic lesions at an early stage, when therapy can achieve better results. A maximum diameter of 3 cm is considered essential to allow good prognosis after surgical resection, transplantation or ablative therapies. As reported in our paper, ultrasound sensitivity for HCC less than 3 cm in size was over 80% in several series. After ultrasound identification of suspected lesions, further diagnostic definition and staging is performed by spiral CT, fine needle biopsy and MR. Intraoperative ultrasound examination is essential to achieve radical resection and can be useful in the work-up before liver transplant. Moreover, small lesions or daughter nodules not identified by ultrasound are revealed during patient follow-up. We agree that the location of the lesion, an anatomical feature unsuitable for ultrasound or the presence of a coarse liver can hinder correct identification of an early HCC. All the above-mentioned conditions can reduce the sensitivity of ultrasound screening. Alphafetoprotein can be useful in patients with unsuitable habitus for ultrasound. High AFP level is a prompt to complete a full work-up to exclude the diagnosis of HCC. Technological improvement will probably further increase ultrasound sensitivity and specificity for HCC. Liver Transplantation and Hepatobiliary Medicine R. BOTTELLI Royal Free Hospital A. K. BURROUGHS London, U.K.
q 2000 The Royal College of Radiologists
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instructions to Authors at the back of the Journal. doi:10.1053/crad.1999.0265, available online at http://www.idealibrary. com on I ULTRASOUND SCREENING FOR HEPATOCELLULAR CARCINOMA (HCC) IN CIRRHOSIS SIR – I read with interest the article by Bottelli et al. [1], extolling the virtues of ultrasound screening for hepatocellular carcinoma (HCC) in patients with cirrhosis. The authors suggest that ultrasound is reliable in the early diagnosis of HCC and quote the paper by Rizzi et al. [2], giving a sensitivity for ultrasound of 80%. I fear that this may be a little misleading. That paper indicated an 80% sensitivity for ultrasound in the identification of the main tumour. Where multicentric tumour was demonstrated at histology ultrasound had only prospectively demonstrated it in 30·7% of cases. Rizzi et al. concluded that while ultrasound, CT and hepatic arteriography could identify patients with small (less than 4 cm) or large tumour bulk, the sensitivity of these techniques, especially ultrasound in detecting satellite lesions was poor. Dodd et al. [3] found a lesion sensitivity of 45% for ultrasound in 200 patients who underwent hepatic transplantation and pathological examination of the explanted liver. The authors concluded that ultrasound is highly insensitive for the detection of malignant lesions in end-stage cirrhotic livers. Shapiro et al. [4] showed a sensitivity of 51% for ultrasound in the detection of HCC in 21 patients who underwent liver transplantation. These are, to my knowledge, the only studies that have been performed to assess ultrasound in patients who have subsequently undergone transplantation and careful pathological examination of the explanted liver. Whilst there are several other papers claiming far better results for ultrasound sensitivity [5,6], these are based on limited pathological correlation. Ultrasound examination in end-stage cirrhosis is often difficult. Disorganized liver architecture and regenerative nodules may obscure small hepatocellular carcinoma. The liver is often shrunken and situated high under the right hemidiaphragm, making identification of segment 8 particularly difficult; the liver may be further obscured by the presence of ascites and interposed bowel loops. There may be differences in sensitivity for ultrasound between Asian and non-Asian populations. Patients in the former group often have a more ultrasound-friendly body habitus and often develop hepatocellular carcinoma at an early, pre-cirrhotic stage as there is a higher incidence of Hepatitis B as the aetiological factor in this group. Whilst I would not suggest abandoning ultrasound in screening of highrisk patients, I cannot share the authors’ enthusiasm. CHRISTOPHER FRAZER
Sir Charles Gairdner Hospital Hospital Avenue Nedlands 6009 Western Australia
References 1 Bottelli R, Tibballs J, Hochhauser D, Watkinson A, Dick R, Burroughs AK. Ultrasound screening for hepatocellular carcinoma (HCC) in
0009-9260/00/020161+01 $35.00/0
2 3 4 5 6
cirrhosis: the evidence for an established clinical practice. Clin Radiol 1998;53:713–716. Rizzi PM, Kane PA, Ruder SD, et al. Accuracy of radiology in detection of hepatocellular carcinoma before liver transplantation. Gastroenterology 1994;107:1424–1429. Dodd GD, Miller WJ, Baron RL, Skolnick ML, Campbell WL. Detection of malignant tumours in end-stage cirrhotic livers: efficacy of sonography as a screening technique. Am J Roentgenol 1992;159:727–733. Shapiro RS, Katz R, Mendelson DS, Halton KP, Schwartz ME, Miller CM. Detection of hepatocellular carcinoma in cirrhotic patients: sensitivity of CT and ultrasound. J Ultrasound Med 1996;15:497–502. Takayazu K, Moriyiama N, Muramatsu Y. The diagnosis of small hepatocellular carcinomas: efficacy of various imaging procedure in 100 patients. Am J Roentgenol 1990;155:49–54. Oka H, Kurioka N, Kosyun K, et al. Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis. Hepatology 1990;12:680–687.
doi:10.1053/crad.1999.0419, available online at http://www.idealibrary. com on REPLY TO DR FRAZER SIR – The availability of explanted livers for histological evaluation has significantly improved our knowledge of hepatocellular carcinoma (HCC) in cirrhotic patients. Despite continuous improvement of diagnostic radiological equipment, sensitivity for lesions of less than 1 cm in size and daughter nodules of main tumours is reported to be 50% in comparison to careful histological analysis. The goal of ultrasound screening is to identify neoplastic lesions at an early stage, when therapy can achieve better results. A maximum diameter of 3 cm is considered essential to allow good prognosis after surgical resection, transplantation or ablative therapies. As reported in our paper, ultrasound sensitivity for HCC less than 3 cm in size was over 80% in several series. After ultrasound identification of suspected lesions, further diagnostic definition and staging is performed by spiral CT, fine needle biopsy and MR. Intraoperative ultrasound examination is essential to achieve radical resection and can be useful in the work-up before liver transplant. Moreover, small lesions or daughter nodules not identified by ultrasound are revealed during patient follow-up. We agree that the location of the lesion, an anatomical feature unsuitable for ultrasound or the presence of a coarse liver can hinder correct identification of an early HCC. All the above-mentioned conditions can reduce the sensitivity of ultrasound screening. Alphafetoprotein can be useful in patients with unsuitable habitus for ultrasound. High AFP level is a prompt to complete a full work-up to exclude the diagnosis of HCC. Technological improvement will probably further increase ultrasound sensitivity and specificity for HCC. Liver Transplantation and Hepatobiliary Medicine R. BOTTELLI Royal Free Hospital A. K. BURROUGHS London, U.K.
q 2000 The Royal College of Radiologists