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Suboptimal Ultrasound Visualization Impacts Accuracy of HCC Screening in Patients with Cirrhosis

By Amit Singal, M.D., M.S.

While survival rates are low for advanced-stage hepatocellular carcinoma (HCC), screening in patients with cirrhosis can improve early detection and overall survival. Ultrasound is considered the gold-standard screening method, but a recent study showed that, when used alone, ultrasound often has a sensitivity below 50% for detecting early-stage HCC.

UT Southwestern researchers discovered that limited visualization – related to factors such as obesity, liver nodularity, or steatosis – can reduce ultrasound sensitivity and specificity for detecting early-stage HCC in approximately 1 in 5 patients with cirrhosis, who would thereby benefit from alternative exam methods.

About the Research

The investigators used the American College of Radiology Liver Imaging, Reporting Data Systems’ (LI-RADS) visualization scoring system for HCC screening, which classifies ultrasound exams from visualization scores A to C, indicating no visualization limitations to severe limitations.

Researchers from UT Southwestern’s Departments of Internal Medicine, Pathology, and Radiology and Parkland Health performed a retrospective cohort study of 2,238 cirrhosis patients (186 of whom had HCC) with at least one abdominal ultrasound between 2016 and 2019 in two large health systems.

The authors found that up to 20% of patients with cirrhosis can have visualization scores of B to C, indicating suboptimal visualization. Poor visualization was more likely to occur in patients with obesity and non-viral etiologies of cirrhosis, which are increasingly common in patients under HCC screening.

The team then evaluated whether these lower scores resulted in worse test performance for early HCC detection. Visualization score C was associated with significantly lower sensitivity. Patients with visualization score A had sensitivity exceeding 75%, compared to only 27% in patients with visualization score C. Visualization score B (moderate limitations) maintained high sensitivity but was associated with an increased risk of false positives.

What Clinicians Need to Know

Although more research is needed to validate these findings, the results have important implications for determining the optimal screening method of patients with cirrhosis. Our data suggest that patients with suboptimal visualization on ultrasound-based screening may need alternative exams to detect early-stage HCC. Abbreviated MRI could be valuable, and data increasingly suggest that blood-based biomarker panels may also achieve high sensitivity for early-stage HCC detection, although validation of these techniques in patients with cirrhosis is still needed prior to widespread adoption.


Disclosure: Amit Singal has served as a consultant or on advisory boards for FujiFilm Medical Sciences, Exact Sciences, Roche, Glycotest, GRAIL, Freenome, Universal Dx, Genentech, AstraZeneca, Eisai, Bayer, and Exelixis. Dr. Singal’s research is supported by NIH R01 CA256977, R01 MD012565, and U01 CA271888.