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The role of contrast enhanced ultrasound in HCC diagnosis
I am in New Orleans right now, attending DDW (digestive disease week) meeting.
For those who are not familiar with HCC (hepatocellular carcinoma) surveillance/diagnosis recommendation from AASLD (Americal Society for the Study of Liver Disease): patients who are at risk of developing HCC are recommended to have ultrasound every 6months to detect HCC. If there is any lesion detected, contrast study will be performed. If one (when the lesion >2cm) or two ( 1 to 2cm) contrast studies show typical enhancement pattern (arterial ehnacement and washout in portal venous phase), you can diagnose the lesion as HCC without biopsy. In AASLD practice guideline, CEUS is one of the 3 modalities (CT, US, MRI) for the diagnosis. However, in the United States, CEUS is not in daily practice, not yet approved by the FDA. In today's session about HCC surveillance & diagnosis, there was not a word of "CEUS", only some discussion about CECT, CEMRI, which was quite shocking to me...Oh, well..
CEUS will be available in the United States, hopefully soon.
Anybody interested in a case study in this community discussion? I can post some cases if anybody is interested.
Yuko
Views: 122
Replies to This Discussion
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Permalink Reply by Dr MM Nurus shafi on -
Thanks Doctor Kono .I think CEUS should have edge over CECT, though non approval from FDA is a matter of concern. In many countries CEUS is done to exclude HCC routinely. And we should also know that FNAC has a big role to play. Even if CEUS confirms HCC we need a histo-diagnosis.As you said we need some study in this context.
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Permalink Reply by Yuko Kono on -
Dear Dr. Nurus,
Thank you for your comment. However, I disagree with you on the role of FNAC on the diagnosis of HCC. AASLD published a practice guideline on HCC management in 2005. Please see below for the details:
http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Prac...
These are patients with cirrhosis (and/or HBV which can cause HCC without cirrhosis) who has much higher risk to develop HCC, many study supports no need for biopsy if the imaging shows typical findings (hypervascular in the hepatic arterial phase and washout in the later phase). This is an evidence based medicine. We rarely recommend biopsy for HCC. The only cases we do biopsy are those with atypical imaging features and not quite sure if HCC or other lesion.
In this guideline, they recommend the use of two imaging for lesions 1-2cm in diameter and one imaging for the lesions greater than 2cm to diagnose HCC, either CEUS, CECT or CEMRI.
Thanks!
Yuko -
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Permalink Reply by Dr Md Azizul Islam on -
Thanks Yuko Kono.
I have attended two workshop of "CEUS" this year in India.
Gone through several papers on it.
Going to start this update part of ultrasound in my country.
Within the last 6 month I believe you did a number of cases!
You can post some cases which will be beneficial for me. -
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Permalink Reply by mobark abdallah abdelhafeez on -
HELLOW YUKO KONO YOU MENTION IN CEUS IN DIGNOSIS HCC PATIENT AT RISK SHOULD HAVE ULTRASOUND EVERY 6MONTH IWANT TO KNOW WHOM PATIENT AT RISK
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Permalink Reply by Dr.Muhammad Bashir Malik on -
Hello forum fellows
Realy its very good to diagnose HCC by CEUS but as concerned for treatment Oncologists/physcians dnt start treatment untill unless proved with histopathology.
Second thing as we find any focal hepatic lesion mostly in known HCV patients we think about HCC but many a time in diffuse HCC we dnt find any focal lesion rather diffusely heterogeneous hepatic parenchyma even no history of hepatitis rather with negative viral markers and smooth hepatic margins, i requested alfa fetoprotien it was highly raised than biopsy done and it proved HCC.
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Permalink Reply by Yuko Kono on
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Hi Dr. Malik,
We have to educate oncologists/physicians regarding HCC diagnosis. It is widely accepted among hepatologists and radiologists that HCC can be diagnosed solely by combination of clinical information and radiology imaging in most of the cases. There are cases of course imaging is not typical, then biopsy is required. Risk of fine needle biopsy is not so big, needle dissemination is ~1% (varies), but is significant when it is likely at curable stage. We should avoid biopsy if patient is T1/T2 stages/surgical, transplant candidates.
Even among our practice, though, I often get referral by outside facilities with HCC proven by biopsy, but often not necessary.
In AASLD updated guideline for HCC, CEUS was eliminated from the diagnosis modality (they now put only CEMRI/CECT) which is totally wrong in my opinion. The reason was that CEUS is not available in the US, and non specific for HCC diagnosis as it may be confused with cholangiocarcinoma. Is it really? Yes, there are rare cases which you could be wrong, but CECT/CEMRI can also be wrong.
http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Prac...
I agree that diffuse HCC is challenging for all imaging modalities. In my experience, there were several cases which AFP was not increased (remember, sensitivity of AFP is only 60%), CECT, CEMRI was not conclusive, but CEUS could diagnose infiltrative HCC as it could diagnose tumor portal venous thrombus (PVT). Tumor PVT is often difficuult to diagnose with CT or MRI and CEUS is the best modality to diagnose.
I will try to upload cases, one case a month! Next would be HCC diagnosis with CEUS.
Thanks!
Yuko
Dr.Muhammad Bashir Malik said:
Hello forum fellows
Realy its very good to diagnose HCC by CEUS but as concerned for treatment Oncologists/physcians dnt start treatment untill unless proved with histopathology.
Second thing as we find any focal hepatic lesion mostly in known HCV patients we think about HCC but many a time in diffuse HCC we dnt find any focal lesion rather diffusely heterogeneous hepatic parenchyma even no history of hepatitis rather with negative viral markers and smooth hepatic margins, i requested alfa fetoprotien it was highly raised than biopsy done and it proved HCC.
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