51-year-old man with hepatitis B-related cirrhosis, undergoing HCC surveillance: (A,B) Images from initial ultrasound examination. No suspicious lesion was identified, and examination received consensus ultrasound category of US-1. Nearly entire liver is visualized, with minimal shadowing (“s”, A and B), and examination received consensus result of VIS-A. AFP level was 7.1 ng/mL on assessment 6 months before ultrasound examination, 9.1 ng/mL on assessment 3 months before examination, and 14.2 ng/mL on assessment on day of examination. AFP result was thus assessed as positive based on progressive increase on two consecutive tests. Patient was considered to have negative surveillance result according to LI-RADS Ultrasound Surveillance version 2017, but positive surveillance result according to LI-RADS Ultrasound Surveillance version 2024. (C-D) Axial arterial-phase (C) and portal-venous phase (D) T1-weighted images from subsequent gadoxetic acid-enhanced MRI. MRI shows 2.0-cm arterial-phase hyperenhancing observation (arrow, C) with portal-venous washout (arrow, D) in segment 7. This observation was classified on MRI as LR-5, thus meeting present study’s reference standard for diagnosis of HCC. Mass is located in periphery of liver, an anatomic area where ultrasound visualization can be challenging due to shadowing.


Jan. 24, 2025 — According to an accepted manuscript published in the American Journal of Roentgenology (AJR), the ACR’s LI-RADS Ultrasound Surveillance v2024 (compared with v2017) had higher sensitivity, albeit lower specificity, for detecting hepatocellular carcinoma (HCC)—related primarily to increasing, rather than elevated, alpha-fetoprotein (AFP).

Noting that the only independent predictor of limitations that significantly reduce the ability to detect observations (VIS-C) on subsequent ultrasound was initial VIS-C result, “the findings support a multidisciplinary surveillance framework that integrates ultrasound findings and AFP values to guide management recommendations in at-risk patients,” wrote corresponding author Sang Hyun Choi, MD, PhD, from the Research Institute of Radiology at Ulsan College of Medicine and Asan Medical Center in Seoul, Korea.

Choi et al.’s accepted AJR manuscript included 407 patients (median age, 56 years; 230 male, 177 female) with cirrhosis who underwent rounds of semi-annual surveillance ultrasound as part of a prospective trial (November 2011–December 2012). Two radiologists independently assigned ultrasound categories to round-1 examinations and visualization scores to round-1 and round-2 examinations; then, a third radiologist adjudicated disagreements. AFP was considered positive if elevated or increasing from pre-enrollment values (per v2024 criteria). Reference standard for HCC was positive biopsy or LR-5 observation on MRI. Diagnostic performance was compared between v2017 and v2024.

Ultimately, LI-RADS Ultrasound Surveillance v2024, versus v2017, demonstrated higher sensitivity for HCC (reader 1: 64.3% vs. 42.9%; reader 2: 64.3% vs. 39.3%) but lower specificity (reader 1: 82.0% vs. 92.6%; reader 2: 82.3% vs. 92.9%). Importantly, the only independent predictor of VIS-C on subsequent ultrasound was VIS-C on initial ultrasound (adjusted OR=21.0).

“This study is the first to my knowledge to compare v2024 to the earlier algorithm,” Kathryn McGillen, MD, radiologist at Penn State Health’s Milton. S Hershey Medical Center, replied in her AJR editorial comment. Noting that definitive risk factors for predicting repeat VIS-C scores remain elusive, “such predictive ability would help guide decisions regarding how and when follow-up after VIS-C scores should occur,” added Dr. McGillen.

 

An online supplement to this AJR accepted manuscript is available here.


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