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Critical review of HCC imaging in the multidisciplinary setting: treatment allocation and evaluation of response

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Abstract

Imaging has not only an established role in screening and diagnosis of hepatocellular carcinoma (HCC) in patients with chronic liver inflammatory diseases, but also a crucial importance for patient stratification and treatment allocation, as well as for assessing treatment response. In the setting of increasing therapeutic options for HCC, the Barcelona Clinic Liver Cancer (BCLC) system still remains the most appropriate way to select candidate cohorts for best treatments. This classification takes into account the imaging information on tumor burden and extension, liver function, and cancer-related symptoms, stratifying patients in five risk categories (Stages 0, A, B, C and D) associated with different treatment options. Still now, there are no clear roles for biomarkers use in treatment allocation. The increasing use of locoregional non-surgical therapies in the different stages is highly dependent on reliable evaluation of treatment response, in particular when they are used with curative intention or for downstaging at liver transplantation re-assessment. Moreover, objective response (OR) has emerged as an important imaging biomarker, providing information on tumor biology, which can contribute for further prognostic assessment. Current guidelines for OR assessment recommend only the measurement of viable tumor according to mRECIST criteria, with further classification into complete response, partial response, stable disease or progressive disease. Either computed tomography (CT) or magnetic resonance (MR) imaging can be used for this purpose, and the Liver Imaging Reporting and Data System (LI-RADS) committee has recently provided some guidance for reporting after locoregional therapies. Nevertheless, imaging pitfalls resulting from treatment-related changes can impact with the correct evaluation of treatment response, especially after transarterial radioembolization (TARE). Volume criteria and emerging imaging techniques might also contribute for a better refinement in the assessment of treatment response and monitoring. As the role of imaging deeply expands in the multidisciplinary assessment of HCC, our main objective in this review is to discuss state-of-the-art decision-making aspects for treatment allocation and provide guidance for treatment response evaluation.

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Abbreviations

AASLD:

American Association for the Study of Liver Diseases

BCLC:

Barcelona Clinic Liver Cancer

CEUS:

Contrast-enhanced ultrasound

CR:

Complete response

CT:

Computed tomography

DCE-MR:

Dynamic contrast-enhanced magnetic resonance

EASL:

European Association for the Study of the Liver

HCC:

Hepatocellular carcinoma

LI-RADS:

Liver Imaging Reporting and Data System

LR-TR:

LI-RADS treatment response

LT:

Liver transplantation

MCA:

Microwave ablation

MR:

Magnetic resonance

mRECIST:

Modified Response Evaluation Criteria in Solid Tumors

OR:

Objective response

PD:

Progressive disease

PR:

Partial response

qEASL:

Quantitative European Association for the Study of the Liver

RECIST:

Response Evaluation Criteria in Solid Tumors

RFA:

Radiofrequency ablation

SD:

Stable disease

SIRT:

Systemic internal radiation therapy

TACE:

Transarterial chemoembolization

TARE:

Transarterial radioembolization

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Authors and Affiliations

  1. Radiology Department, Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal

    J. Amorim & M. França

  2. School of Medicine, University of Minho, Braga, Portugal

    J. Amorim

  3. Radiology Department and Biomedical Imaging Research Group, Hospital Universitario y Politécnico e Instituto Investigación Sanitaria La Fe, Valencia, Spain

    A. Perez-Girbes, A. Torregrosa & L. Martí-Bonmatí

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Amorim, J., França, M., Perez-Girbes, A. et al. Critical review of HCC imaging in the multidisciplinary setting: treatment allocation and evaluation of response. Abdom Radiol 45, 3119–3128 (2020). https://doi.org/10.1007/s00261-020-02470-1

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