Failure of hepatocellular carcinoma surveillance: inadequate echogenic window and macronodular parenchyma are potential culprits
Yeun-Yoon Kim1 , Chansik An1 , Do Young Kim2 , Khalid Suliman Aljoqiman1,3 , Jin-Young Choi1 , Myeong-Jin Kim1
1Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Seoul, Korea
2Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
3Department of Radiology, King Faisal University College of Medicine, Al-Ahsa, Saudi Arabia, Al-Ahsa, Saudi Arabia
Corresponding Author: Do Young Kim ,Tel: 82-2-2228-1992, Fax: 82-2-393-6884, Email:
Received: September 17, 2018;  Accepted: January 17, 2019.  Published online: January 17, 2019.
To examine the associations between ultrasound (US) quality and the clinical outcomes in patients undergoing surveillance for hepatocellular carcinoma (HCC).
Between 2008 and 2013, 155 patients were diagnosed with liver cancer during regular surveillance by positive US results (US group; n = 82) or by alternative CT or MRI scanning (CT/MRI group; n = 73). The quality of echogenic window, macronodularity of liver parenchyma, as well as occurrence of surveillance failure (initial tumor diagnosis beyond Milan criteria or at Barcelona Clinic Liver Cancer [BCLC] stage B or C) were evaluated. Overall survival was compared according to the presence or absence of surveillance failure.
Patients in CT/MRI group who had obtained negative US results had a higher proportion of parenchymal macronodularity on US than patients in US group (79.5% vs. 63.4%; P = 0.028). The surveillance failure tended to be more common in US group than in CT/MRI group (40.2% vs. 26.0% by BCLC staging system [P = 0.061]). In US group, surveillance failure occurred more frequently when the echogenic window was inadequate (50.0% vs. 19.4% by Milan criteria [P = 0.046]). Five-year overall survival of patients with surveillance failure was significantly worse than that of patients without surveillance failure (P ≤ 0.001).
Parenchymal macronodularity can hinder detection of early-stage tumors during US surveillance. Use of alternative imaging modality may help prevent surveillance failure in patients with macronodular parenchyma on US. Better surveillance strategies than US may also be necessary when the echogenic window is inadequate.
Keywords: Surveillance; Ultrasound; Hepatocellular carcinoma
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