Thomas Sersté1,2, Vincent Barrau3, Violaine Ozenne1, Marie Pierre Vullierme3, Pierre Bedossa5,6, Olivier Farges4, Dominique-Charles Valla1,6, Valérie Vilgrain3,6, Valérie Paradis5,6, Françoise Degos1 Hepatology R3 박 소 영

 Hepatocellular carcinoma (HCC)  the sixth most common malignant tumor in the world  its incidence has risen rapidly  Monitoring  in the presence of cirrhosis  the development of a wide spectrum of hepatocellular nodules ranging from benign to malignant  in areas endemic for chronic liver diseases such as hepatitis B (HBV) and/or C viral infection (HCV)  small nodules (≤ 2 cm)  dysplastic nodules (DN), considered to be premalignant  overt HCC recognized as “small HCC”

 early detection of HCC  alpha-fetoprotein (AFP) levels  ultrasound (US)  based on the vascular pattern of the nodules the American Association for the Study of Liver Disease (AASLD) published guidelines in 2005  contrast enhanced CT or MRI  hypervascularization in the arterial phase with portal or delayed washout  Aim  What is the diagnostic accuracy of a single contrast enhanced study?  What is the frequency of disagreement between two contrast enhanced imaging procedures (CT or MRI)?  What is the advantage and the role of biopsy in this context?

 Patients  January 2005 ~ December 2010  Patients with cirrhosis or chronic liver disease and small nodules (diameter between 1 and 2 cm) newly detected by US and without prior HCC  a single centre, case-only, observational study  initial evaluation  systematic contrast enhanced multiphasic CT, MRI  liver biopsy of the nodule  Radiological analysis  multiphasic CT (LightSpeed Plus; General Electric Healthcare, WI)  including arterial, portal venous and delayed phases

 MRI with a 1.5-T unit (Intera, Philips, Netherlands)  read by two radiologists who were blind to biopsy results  Classification of nodules  “conclusive” for HCC  hypervascularity during the arterial phase  Wash-out in later phases  “suspicious” for HCC  hypervascularity during the arterial phase  without washout  Histological analysis  Percutaneous US guided liver biopsies using 18 gauge cutting needles

 read by one pathologist who was unaware of the previous pathological diagnosis and imaging results  based on international criteria for the classification of small liver nodules  HCC  increased cell density more than 2 times that of the surrounding tissue  Increased nuclear/cytoplasm ratio  irregular thin-trabecular pattern  pseudoglandular pattern  Stromal invasion

 High grade DN (HGDN)  nodule displayed architectural and/or cytologic atypias but the atypias were insufficient for a diagnosis of overt HCC  difficult cases between HGDN and HCC  Glypican-3 : immunohistochemical study  positive GPC-3 staining : HCC  Grading of the tumors : Edmonson’s classification  Scoring of the non-tumorous liver lesions : METAVIR  Analyses of sensitivity and specificity  first session : HCC  second session : malignant and premalignant

hypervascula r with washout during the portal or late phase

 unlike other studies, 13% of our patients did not have cirrhosis based on clinical radiological or histological criteria but had various degree of fibrosis from F1 to F4 according to Metavir staging  When a first imaging modality does not provide a conclusive diagnosis,  a sequential imaging strategy  such strategy still miss the diagnosis of HCC in 26%  not cost effective  liver biopsy

 combined contrast enhanced CT and MRI  high specificity and low sensitivity  a single imaging modality  100% specificity  high number of disagreements between contrast enhanced CT and MR  not recommend sequential imaging  suggest to perform a biopsy when the first imaging is inconclusive  biopsy of a nodule and of the adjacent liver  provides an accurate diagnosis  helps in the therapeutic strategy  Identify relevant prognostic factors based on aspect of adjacent liver