Objectives | Hepatocellular carcinoma (HCC) upon contrast-enhanced ultrasound (CEUS) typically shows arterial phase hyperenhancement (APHE), followed by late (> 60 seconds) and mild contrast washout (WO). Although APHE is considered as the hallmark of HCC, it can be absent in some HCCs. Thus, we explored which sonomorphological and histopathological features of HCC are associated with a lack of APHE upon CEUS. |
Authors | Strobel D, Agaimy A, Jesper D, Zundler S, Schellhaas B. |
Journal | Ultraschall Med. 2023 Dec;44(6):606-613. English. Epub 2023 Feb 13. PMID: 36781161. |
Methods | Focal liver lesions in high-risk patients for HCC were assessed with CEUS following a standardized protocol in a prospective multi-center real-life setting. CEUS patterns in HCC were assessed, and tumour and patient characteristics were compared for HCCs with and without APHE. |
Results | 316 patients with HCC were recruited (cirrhosis, 76.9%). APHE occurred in 271/316 HCCs (85.8%). A lack of APHE was associated with portal vein thrombosis, tumour infiltration of the liver vessels (p<0.001), larger size, multilocularity, and higher depth location upon ultrasound (p<0.01). Histological grading did not differ between HCCs with and without APHE (p=0.39). Histopathological features of HCCs without APHE included cirrhotic stromal reaction, marked tumour cell steatosis and absence of the typical surrounding dilated sinusoidal vascular channels. |
Conclusion | Correlation with histopathological findings support the fact that HCCs with a lack of APHE in CEUS are a heterogeneous group. The examiner has to be aware that particularly HCCs with portal vein thrombosis or macro-invasion of the liver vessels may lack APHE. |
Link (DOI) | https://doi.org/10.1055/a-2034-1911 |
Ultrasound speciality | Focal liver lesions |
Short-Review by Prof. V. Cantisani:
The Authors report a prospective multi-center real-life study in which CEUS HCC patterns were assessed, and tumour and patient characteristics were compared for HCCs with and without APHE.
316 patients with HCC were recruited, 76.9 % of them were cirrhotic. Typical APHE occurred in 271/316 HCCs (85.8 %). Conversely, a lack of APHE was associated with portal vein thrombosis, tumour infiltration of the liver vessels (p < 0.001), larger size, multilocularity, and higher depth location upon ultrasound (p < 0.01). Histological grading did not differ between HCCs with and without APHE (p = 0.39). Histopathological features of HCCs without APHE included cirrhotic stromal reaction, marked tumour cell steatosis and absence of the typical surrounding dilated sinusoidal vascular channels
Correlation with histopathological findings support the fact that HCCs with a lack of APHE in CEUS are a heterogeneous group.
According to this multicenter study a significant proportion of HCCs do not display the characteristic APHE, due to several factors such as:
- portal vein thrombosis and tumour infiltration of the liver vessels;
- the presence of a transjugular intrahepatic portosystemic stent shunt (TIPSS);
- larger tumour size, diffusely infiltrating tumours and multilocular growth, suggesting a different and potentially more aggressive tumour biology in this subtype.
Indeed, considering the large dataset of the present paper, US expert has to be aware that particularly HCCs with portal vein thrombosis or macro-invasion of the liver vessels may lack APHE. Therefore, in these cases, biopsy, especially when emerging drug for targeted therapies in HCC may be considered, is warranted to avoid misdiagnosis.