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SA–CME Information SA-CME SA–CME Information MRI Screening for Hepatocellular Carcinoma Description Target Audience Screening for hepatocellular carcinoma (HCC) has been • Radiologists shown to improve overall survival by detecting earlier stage, • Related Imaging Professionals more treatable disease. For some patients with HCC, liver transplant is the preferred treatment. However, donor livers System Requirements are a scarce resource. Accurate identification and description In order to complete this program, you must have a com- of HCC with MRI is important in the determination of which puter with a recently updated browser and a printer. For as- patients will receive a liver transplant. sistance accessing this course online or printing a certificate, email [email protected]. This article reviews background information about cirrhosis and hepatocellular carcinoma, the role of screening, transplant Instructions priority determination, and diagnostic criteria for HCC. This activity is designed to be completed within the des- ignated time period. To successfully earn credit, participants Learning Objectives must complete the activity during the valid credit period. To After completing this activity, the participant will be able to: receive SA–CME credit, you must: • Explain the Milan criteria and how these criteria impact liver allocation; 1. Review this article in its entirety. • Describe imaging findings of HCC; and, 2. Visit www.appliedradiology.org/SAM2. • Develop appropriate imaging protocols for HCC 3. Login to your account or create an account (new users). screening. 4. Complete the posttest and review the discussion and references. Accreditation/Designation Statement 5. Complete the evaluation. The Institute for Advanced Medical Education is accredited 6. Print your certificate. by the Accreditation Council for Continuing Medical Educa- tion (ACCME) to provide continuing medical education for Estimated time for completion: 1 hour physicians. Date of release and review: July 1, 2020 The Institute for Advanced Medical Education designates this Expiration date: June 30, 2022 journal-based CME activity for a maximum of 1 AMA PRA Cat- egory 1 Credit™. Physicians should only claim credit commen- Disclosures surate with the extent of their participation in the activity. These No authors, faculty, or any individuals at IAME or Applied credits qualify as SA-CME credits. Radiology who had control over the content of this program have any relationships with commercial supporters. Authors Courtney C. Moreno, MD, is an Associate Professor in the Department of Radiology and Imaging Sciences; Thuy-Van P. Hang, MD, is a gastroenterology Fellow in the Division of Di- gestive Diseases; and Joel P. Wedd is an Assistant Professor in the Division of Digestive Diseases; all at the Emory University School of Medicine, Atlanta, GA. © July–August 2020 www.appliedradiology.com APPLIED RADIOLOGY n 9 SA-CME DETAILS ON PAGE 9 MRI Screening for Hepatocellular Carcinoma Courtney C Moreno, MD; Thuy-Van P Hang, MD; Joel P Wedd, MD, MPH rimary liver cancer is the fifth- American Association for the Study of Computed tomography (CT) or leading cause of cancer-related Liver Diseases (AASLD), surveillance magnetic resonance (MR) imaging is death in men and seventh-leading ultrasound imaging should be per- recommended where a nondiagnostic Pcause of cancer-related death in women formed every 6 months.5 Surveillance ultrasound is highly likely, such as in in the U.S.1 Worldwide, the most com- should be offered to cirrhosis patients obese patients. In addition, follow-up mon risk factors for hepatocellular car- when risk of HCC is ≥1.5%/year, and imaging with multiphase abdominal CT cinoma (HCC) are chronic hepatitis B to hepatitis B carriers without cirrhosis or MRI should be pursued when sur- infection (44%) and chronic hepatitis C when HCC risk is ≥0.2%/year.5 Hep- veillance ultrasound is positive for a ≥ infection (21%).2 In North America, the atitis B carriers are at risk of develop- 10 mm lesion or AFP is > 20 ng/mL.5 fraction of cases attributable to major ing HCC even without the presence of HCC risk factors are alcohol (32%), obe- cirrhosis. Therefore, surveillance is Liver Transplant and HCC sity (24%), and chronic hepatitis C infec- recommended for Asian male hepatitis Tumor Size Criteria for Transplant tion (17%).2 All patients with cirrhosis B carriers over age 40, Asian female Most HCCs develop in patients with are at risk for HCC. Patients with smaller carriers over age 50, African and Afri- underlying cirrhosis.6 In such patients, tumors can undergo potentially curative can-Americans with hepatitis B, and tumor resection is typically not pos- surgery, including liver transplantation, hepatitis B carriers with a family history sible, as the patient’s remnant liver whereas patients with larger, unresect- of HCC.5 Although the risk of HCC is would be too poorly functioning to be able tumors or extrahepatic tumor spread reduced in hepatitis C patients who ex- life sustaining. A landmark 1996 pub- have a poor prognosis. perience a sustained virologic response lication by Mazzaferro et al of the Na- with newer antiviral therapy agents, tional Cancer Institute in Milan, Italy, Role of Screening those patients with cirrhosis remain at reported 83% recurrence free survival Surveillance is associated with ear- risk for HCC and should continue imag- at 4 years for patients with unresectable lier HCC detection, higher rates of ing surveillance.5 “small” HCCs, specifically one tumor ≤ cure, and higher overall survival in pa- According to the AASLD, 6-month 5 cm in diameter or up to three tumors ≤ tients with cirrhosis.3,4 According to the imaging surveillance can be performed 3 cm without extrahepatic involvement 2018 guidance document issued by the with or without monitoring of serum al- or macrovascular invasion.7 These pha-fetoprotein (AFP) levels.5 A serum thresholds are now known as the Milan Affiliations: Emory University School of AFP level > 20 ng/mL is considered criteria. Larger tumors can potentially Medicine, Atlanta, GA. Disclosures: Dr. positive and has a sensitivity of approx- be downstaged to within Milan crite- Moreno has a research agreement with imately 60% and a specificity of approxi- ria using locoregional therapy. Other GE Healthcare. mately 90% for HCC.5 classification systems also are utilized, © 10 n APPLIED RADIOLOGY www.appliedradiology.com July–August 2020 MRI SCREENING FOR HEPATOCELLULAR CARCINOMA SA-CME DETAILS ON PAGE 9 A B FIGURE 1. Hepatocellular carcinoma. (A) Late arterial-phase T1 contrast-enhanced (CE) MR image demonstrates a lesion (arrow) with signal intensity greater than background liver parenchyma compatible with arterial phase hyperenhancement. (B) 3-minute delayed image after admin- istration of an extracellular contrast agent demonstrates lower signal intensity in the lesion as compared with the background liver parenchyma compatible with washout. Image also demonstrates enhancing capsule or pseudocapsule (arrow). A B FIGURE 2. Hepatocellular carcinoma. (A) Late arterial-phase T1 CE MR image demonstrates a lesion (arrow) with signal intensity greater than background liver parenchyma, compatible with arterial phase hyperenhancement. (B) 3-minute delayed image after administration of an extra- cellular contrast agent demonstrates lower signal intensity in the lesion compared to background liver parenchyma compatible with washout. Image also demonstrates enhancing capsule or pseudocapsule (arrow). such as the University of California San were performed in the United States in Factors typically considered include the Francisco criteria (one lesion 5 - 6.5 cm 2018 while more than 13,000 candi- patient’s overall health status and non- in diameter, or up to three lesions, each dates were on the liver transplant wait hepatic comorbidities, surgical complex- measuring ≤ 4.5 cm with a total tumor list.9 Eligibility for the transplant list ity, recent or active substance use, and diameter of ≤ 8 cm).8 relies on the judgement of a multidisci- psychosocial barriers. Transplant livers plinary committee, typically consisting are allocated according to the Model of Transplant Priority of hepatologists, transplant surgeons, co- End Stage Liver Disease (MELD) score, Donor livers are a scare resource. ordinators, and social workers who meet which is based upon serum bilirubin, Approximately 8,000 liver transplants regularly to discuss patient candidacy. International Normalized Ratio (INR), © July–August 2020 www.appliedradiology.com APPLIED RADIOLOGY n 11 SA-CME MRI SCREENING FOR HEPATOCELLULAR CARCINOMA DETAILS ON PAGE 9 A B FIGURE 3. Nodule-in-nodule appearance. (A) Late arterial-phase image demonstrates arterial phase hyperenhancement involving the lesion in the posterior segment right hepatic lobe (arrow). (B) Delayed phase CE MR image demonstrates lower signal intensity in the lesion compared to the background liver, compatible with washout, as well as a nodule-in-nodule appearance (arrows). sodium, and creatinine values.10 Donor quiring tissue confirmation. MRI with and Transplantation Network (OPTN) livers go to patients with the highest optimized techniques has high (> 90%) and by the American College of Ra- MELD score; these patients are usually diagnostic sensitivity and specificity for diology-sponsored Liver Imaging Re- gravely ill. HCCs ≥ 2 cm.12 When imaging is con- porting And Data System (LI-RADS) Based on MELD scores, many pa- clusive, treatment (eg, liver transplant group.15,16 Both sets of criteria consider
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