Utility of sonography in diagnosing hepatocellular carcinoma

Viral-related cirrhosis is a leading risk factor for hepatocellular carcinoma (HCC). Mortality due to HCC has not improved because of the poor performance of available tumor markers, leading to delays in diagnosis. Treatment options are limited and often inefficient. Percutaneous ethanol injection therapy appears to be as safe and effective as resection, and both treatments can be considered first-line options for small HCC. Transarterial chemoembolization or percutaneous ethanol injection therapy or both offer a median survival range of 16 to 24 months. A recent study fixed the best cutoff value for -fetoprotein to discriminate between liver cirrhosis and HCC at 30 ng/mL (sensitivity, 65%; specificity, 89%; positive predictive value [PPV], 74%) [1]. With the widespread use of sonography, the usefulness of -fetoprotein assay in the diagnosis of HCC has decreased. Some authors, attempting to assess the diagnostic performance of contrast administration for detection of HCC, use contrast-enhanced sonography to characterize focal hepatic lesions in patients with diffuse liver disease rather than baseline sonography images. These authors obtained a better result for specific diagnosis with contrast-enhanced sonography (sensitivity, 79%; specificity, 75%) than with baseline sonography (sensitivity, 37%; specificity, 48%). These figures cast no doubt on the scarce utility of basic sonography [2]. Although there is no definitive evidence that HCC screening in high-risk groups improves survival, many physicians screen high-risk populations with various strategies. The most widely used techniques are -fetoprotein and liver sonography. When we consider the clinical and economic consequences of a common HCC surveillance strategy in patients with viral-related cirrhosis in this context, we can see that the outcome is poor. HCC remains the fifth most common cancer worldwide. Do we have alternative strategies? Once intrahepatic carcinoma nodules are suspected, sonography-guided fine-needle biopsy should be performed as early as possible for early diagnosis and treatment. Three-dimensional dynamic liver MRI using sensitivity encoding (SENSE) for acquiring double arterial phase images is more efficient than superparamagnetic iron oxide (SPIO)-enhanced MRI for detecting HCC. The mean sensitivity and PPV of 3D dynamic imaging with SENSE were 91.3% and 89.2%, respectively, and those of SPIO-enhanced imaging were 77.3% and 92.6%, respectively [3]. Recently, some radiologists compared the diagnostic accuracy of ferumoxides-enhanced MRI and gadolinium-enhanced dynamic MRI using 3D volume, interpolatric breath-hold examination (VIBE) for the detection of HCC. The mean sensitivity of dynamic MRI (90.7%) was significantly superior to that of ferumoxides-enhanced MRI (80.9%). Furthermore, for lesions smaller than 1.5 cm, the mean sensitivity of dynamic MRI was significantly higher than that of ferumoxides-enhanced MRI (85.2% vs 69.2%). Conclusively, dynamic MRI showed a trend toward better diagnostic accuracy than ferumoxides-enhanced MRI for the detection of HCC [4]. As a matter of fact, those tools, although better than the previous ones for diagnosing HCC, are relatively expensive and invasive, contributing to high and increasing health care costs. We applaud the study of Kim et al. [2] as a strong example of cost-containing measures.