Editorial
Diagnostic efficacy of ultrasound in hepatocellular carcinoma diagnosis
Kwong-Ming Kee & Sheng-Nan Lu
Pages 277-279 | Received 02 Sep 2016, Accepted 03 Feb 2017, Accepted author version posted online: 06 Feb 2017, Published online: 15 Feb 2017
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third leading cause of cancer-related death. Surviving HCC is mainly influenced by the stages of disease at the time of diagnosis [1 European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908–943.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar],2 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–1022.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. Ultrasound (US) is a simple, noninvasive tool with no risk of radiation exposure. The advantages of US include being inexpensive, safe, and having high accessibility. Conventional US is usually used as the first choice for the surveillance of HCC. The development of contrast-enhanced US (CEUS) has promise in increasing the diagnostic accuracy of HCC. Based on current evidence, the authors review the diagnostic efficacy of US in HCC diagnosis.
2. The role of US in HCC surveillance
US has been used as the standard of care in high-risk groups for HCC surveillance every 6 months [1 European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908–943.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar],2 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–1022.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. The major risk factors for HCC include chronic viral hepatitis B and C infection, nonalcoholic steatohepatitis, and liver cirrhosis. Some limitations could influence the sensitivity of US, such as quality of the US machine and experience of the operator, coarseness of liver parenchyma due to underlying cirrhosis, severe fatty liver background, and lesions located at the subdiaphragmatic area. A systematic review showed that the accuracy of US to detect HCC for patients with chronic hepatitis and cirrhosis with pooled sensitivity and specificity was 60% (95% confidence interval [CI]: 44–76) and 97% (95% CI: 95–98), respectively [3 Colli A, Fraquelli M, Casazza G. et al. Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006;101(3):513–523.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. Another meta-analysis demonstrated that pooled sensitivity and specificity of US for cirrhotic patients was 94% and 94%, respectively. However, the sensitivity decreases to 63% for early-stage HCC [4 Singal A, Volk ML, Waljee A. et al. Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis. Aliment Pharmacol Ther. 2009;30(1):37–47.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]].
The combination of US and alpha-fetoprotein (AFP) as surveillance modality increases the detection rate of HCC and has been widely used as a surveillance guideline in Asia-Pacific countries. The sensitivity of HCC detection has been increased to 90–99% with acceptable decreasing specificity [5 Chang TS, Wu YC, Tung SY. et al. Alpha-fetoprotein measurement benefits hepatocellular carcinoma surveillance in patients with cirrhosis. Am J Gastroenterol. 2015;110(6):836–844. quiz 845.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. AFP for HCC surveillance is not recommended by the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) practice guidelines [1 European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908–943., 2 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–1022.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. The drop of AFP from the AASLD and EASL recommendations for HCC was the consequence of both suboptimal accuracy and a lack of standardized policy to treat AFP-positive patients lacking US detection of a nodule. In fact, the increasing AFP levels might signal the risk of developing HCC clinically. For patients with regular surveillance, HCC survival has significantly improved due to increased detection rates of early-stage HCC and treatments. 作者: StephenW 时间: 2017-3-14 21:25
社论
超声在肝细胞癌诊断中的诊断功效
广明基和盛南路
第277-279页收到日期：02九月2016，接受日期：2017年2月，接受作者版本在线发布：06 Feb 2017，在线发布：2017年2月15日
美国已被用作高风险组的HCC监测的标准，每6个月一次[1欧洲肝脏研究协会，欧洲癌症研究和治疗组织。 EASL-EORTC临床实践指南：肝细胞癌的管理。 J Hepatol。 2012; 56（4）：908-943。[CrossRef]，[PubMed]，[Web Sc Science]，[Google Scholar]，2 Bruix J，Sherman M.Management of hepatocellular carcinoma：an update。肝脏病学。 2011; 53（3）：1020-1022。[CrossRef]，[PubMed]，[Web of Science]，[Google Scholar]]。 HCC的主要危险因素包括慢性病毒性乙型和丙型肝炎感染，非酒精性脂肪性肝炎和肝硬化。一些限制可能影响美国的敏感性，例如美国机器的质量和操作者的经验，由于基础肝硬化引起的肝实质的粗糙度，严重的脂肪肝背景和位于膈下区域的病变。系统综述显示，美国以慢性肝炎和肝硬化患者的合并敏感性和特异性检测HCC的准确性为60％（95％置信区间[CI]：44-76）和97％（95％CI：95- 98）[3 Colli A，Fraquelli M，Casazza G.et al。超声检查，螺旋CT，磁共振和甲胎蛋白在诊断肝细胞癌中的准确性：系统综述。 Am J Gastroenterol。 2006; 101（3）：513-523。[CrossRef]，[PubMed]，[Web of Science]，[Google Scholar]]。另一项荟萃分析显示，美国肝硬化患者的合并敏感性和特异性分别为94％和94％。然而，早期HCC的灵敏度降低到63％[4 Singal A，Volk ML，Waljee A.et al。 Meta分析：用肝硬化患者的早期肝细胞癌超声监测。 Aliment Pharmacol Ther。 2009; 30（1）：37-47。[CrossRef]，[PubMed]，[Web of Science]，[Google Scholar]]。
美国和甲胎蛋白（AFP）作为监测模式的组合提高了HCC的检出率，并已被广泛用作亚太国家的监测指南。 HCC检测的灵敏度已增加到90-99％，可接受的特异性降低[5 Chang TS，Wu YC，Tung SY。 et al。甲胎蛋白测量有利于肝硬化患者的肝细胞癌监测。 Am J Gastroenterol。 2015; 110（6）：836-844。测验845. [CrossRef]，[PubMed]，[Web of Science]，[Google Scholar]]。美国肝脏疾病研究协会（AASLD）和欧洲肝脏研究协会（EASL）实践指南[1欧洲肝脏研究协会，欧洲肝脏研究组织和治疗癌症。 EASL-EORTC临床实践指南：肝细胞癌的管理。 J Hepatol。 2012; 56（4）：908-943。，2 Bruix J，Sherman M.Management of hepatocellular carcinoma：an update。肝脏病学。 2011; 53（3）：1020-1022。[CrossRef]，[PubMed]，[Web of Science]，[Google Scholar]]。 AFP从AASLD和EASL建议对HCC的下降是由于缺乏美国检测结节的AFP阳性患者的次最佳精度和缺乏标准化策略的结果。事实上，增加的AFP水平可能表明临床发展HCC的风险。对于定期监测的患者，由于早期HCC和治疗的检测率增加，HCC存活显着改善。作者: StephenW 时间: 2017-3-14 21:37
Contrast-enhanced US (CEUS).
4. Perspectives and conclusions
In the near future, efforts for the development of new contrast agents such as HCC molecular target-oriented microbubble shall certainly improve the diagnostic efficacy of HCC diagnosis. New technology of US instrumentation such as new nonlinear mode of US, faster US imaging, and high resolution and 3D US imaging can also increase HCC diagnostic rates. US elastography is a good noninvasive method in assessing the degree of liver fibrosis; it was currently used to predict the development of HCC in patients with chronic liver disease, as well as to predict the risk of HCC recurrence after curative therapies such as RFA and tumor resection [15 Park MS, Han KH, Kim SU. Non-invasive prediction of development of hepatocellular carcinoma using transient elastography in patients with chronic liver disease. Expert Rev Gastroenterol Hepatol. 2014;8(5):501–511.[Taylor & Francis Online], [Web of Science ®], [Google Scholar]]. Additionally, three-dimensional CEUS has been demonstrated to provide good depiction of tumors and vessels, high efficacy in evaluating post-ablating HCC, and is comparable with contrast-enhanced CT [16 Wang Y, Jing X, Ding J. Clinical value of dynamic 3-dimensional contrast-enhanced ultrasound imaging for the assessment of hepatocellular carcinoma ablation. Clin Imaging. 2016;40(3):402–406.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]].
In conclusion, CEUS has high diagnostic efficacy for HCC diagnosis. It could also be used as treatment guidance for inconspicuous tumors and for evaluating local recurrence for posttreatment HCC. CEUS is highly recommended as the diagnostic algorithm and to be reintroduced in Western HCC guidelines. In addition, a study of HCC surveillance in cirrhotic patients showed that CEUS surveillance is a cost-effective strategy and gains the longest additional life-years [17 Tanaka H, Iijima H, Nouso K, et al. Cost-effectiveness analysis on the surveillance for hepatocellular carcinoma in liver cirrhosis patients using contrast-enhanced ultrasonography. Hepatol Res. 2012;42(4):376–384.[CrossRef], [PubMed], [Web of Science ®], [Google Scholar]]. CEUS should be considered as a surveillance tool in the near future to improve HCC survival, and is especially indicated for patients with cirrhosis and coarse hepatic parenchyma.作者: StephenW 时间: 2017-3-14 21:38
CEUS :对比增强US
4.观点和结论
在不久的将来，努力开发新的造影剂如HCC分子靶向微泡将肯定地提高HCC诊断的诊断功效。美国仪器的新技术，如美国的新的非线性模式，更快的美国成像，以及高分辨率和3D美国成像也可以增加HCC诊断率。美国弹性成像是评估肝纤维化程度的一种很好的非侵入性方法;它目前用于预测慢性肝病患者的HCC发展，以及预测治疗后如RFA和肿瘤切除术后HCC复发的风险[15 Park MS，Han KH，Kim SU。非侵入性预测肝细胞癌的发展使用瞬态弹性成像在慢性肝病患者。专家Rev Gastroenterol Hepatol。 2014; 8（5）：501-511。[Taylor＆Francis Online]，[Web of Science®]，[Google Scholar]]。此外，三维CEUS已经被证明提供肿瘤和血管的良好描绘，在评估后消融HCC中的高功效，并且与对比度增强的CT相当[16 Wang Y，Jing X，Ding J. Clinical value of dynamic 3维对比增强超声成像用于评估肝细胞癌消融。临床成像。 2016; 40（3）：402-406。[CrossRef]，[PubMed]，[Web of Science®]，[Google Scholar]]。