Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jun 8, 2016; 8(16): 685-690
Published online Jun 8, 2016. doi: 10.4254/wjh.v8.i16.685
Hepatocellular carcinoma after locoregional therapy: Magnetic resonance imaging findings in falsely negative exams
David Becker-Weidman, Jesse M Civan, Sandeep P Deshmukh, Christopher G Roth, Steven K Herrine, Laurence Parker, Donald G Mitchell
David Becker-Weidman, Sandeep P Deshmukh, Christopher G Roth, Laurence Parker, Donald G Mitchell, Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107, United States
Jesse M Civan, Steven K Herrine, Division of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, United States
Author contributions: Becker-Weidman D designed the study, collected the data, and drafted the manuscript; Civan JM developed the concept, collected the data and drafted the manuscript; Deshmukh SP and Roth CG interpreted MRI images and edited the manuscript; Herrine SK developed the concept and edited the manuscript; Parker L performed statistical analysis and edited the manuscript; Mitchell DG developed the concept, interpreted MRI images, and edited the manuscript.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Thomas Jefferson University.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Donald G Mitchell, MD, Department of Radiology, Thomas Jefferson University, 132 S 10th St, Main Building, Room 1094, Philadelphia, PA 19107, United States.
Telephone: +1-215-9554809 Fax: +1-215-9558270
Received: March 2, 2016
Peer-review started: March 2, 2016
First decision: March 22, 2016
Revised: April 7, 2016
Accepted: May 10, 2016
Article in press: May 11, 2016
Published online: June 8, 2016

AIM: To elucidate causes for false negative magnetic resonance imaging (MRI) exams by identifying imaging characteristics that predict viable hepatocellular carcinoma (HCC) in lesions previously treated with locoregional therapy when obvious findings of recurrence are absent.

METHODS: This retrospective institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study included patients who underwent liver transplantation at our center between 1/1/2000 and 12/31/2012 after being treated for HCC with locoregional therapy. All selected patients had a contrast-enhanced MRI after locoregional therapy within 90 d of transplant that was prospectively interpreted as without evidence of residual or recurrent tumor. Retrospectively, 2 radiologists, blinded to clinical and pathological data, independently reviewed the pre-transplant MRIs for 7 imaging features. Liver explant histopathology provided the reference standard, with clinically significant tumor defined as viable tumor ≥ 1.0 cm in maximum dimension. Fisher’s exact test was first performed to identify significant imaging features.

RESULTS: Inclusion criteria selected for 42 patients with 65 treated lesions. Fourteen of 42 patients (33%) and 16 of 65 treated lesions (25%) had clinically significant viable tumor on explant histology. None of the 7 imaging findings examined could reliably and reproducibly determine which treated lesion had viable tumor when the exam had been prospectively read as without evidence of viable HCC.

CONCLUSION: After locoregional therapy some treated lesions that do not demonstrate any MRI evidence of HCC will contain viable tumor. As such even patients with a negative MRI following treatment should receive regular short-term imaging surveillance because some have occult viable tumor. The possibility of occult tumor should be a consideration when contemplating any action which might delay liver transplant.

Keywords: Hepatocellular carcinoma, Transarterial chemoembolization, Tumor recurrence, Locoregional therapy, Imaging surveillance

Core tip: Hepatocellular carcinoma (HCC) is often treated with locoregional therapy such as transarterial chemoembolization as a bridge to transplantation. Detecting residual or recurrent tumor within these treated lesions is challenging and some treated lesions that do not demonstrate any magnetic resonance imaging (MRI) evidence of HCC will contain foci of viable tumor. Regular, short-term imaging surveillance is clinically important for patients being considered for liver transplantation even when prior MRIs have been negative and the possibility of a false negative MRI exam needs to be considered when managing these patients.