Clinical and economical impact of 2010 AASLD guidelines for the diagnosis of hepatocellular carcinoma

Background & Aims Although contrast-enhanced computed tomography (CT), dynamic magnetic resonance (MRI) and fine needle biopsy (FNB) are the standard of care to diagnose hepatocellular carcinoma (HCC), the clinical and economic benefits of the updated AASLD diagnostic algorithm, including the drop of contrast enhanced ultrasound (CEUS), have not been previously evaluated. Methods 119 de novo liver nodules detected during ultrasound (US) surveillance in 98 cirrhotics, 7 <1 cm, 67 1-2 cm, 45 >2 cm in size, were sequentially examined by CEUS and CT, using MRI as a rescue approach in patients lacking a typical vascular pattern for HCC by one or both contrast techniques in the 1-2 cm nodules and by CT in the >2 cm nodules. A FNB was performed when required to meet both 2005 and 2010 AASLD criteria. Results Eighty-four (70%) nodules were HCC: the radiological diagnosis was done in 38 (88%) of those 1-2 cm and in 38 (95%) for those >2 cm HCCs according to 2010 AASLD criteria. CT or MRI detected 13 HCC nodules that were missed by unenhanced US. Despite an absolute specificity, CEUS failed to identify any HCC uncharacterized by CT or MRI. By updated AASLD criteria, 6 (17%) FNB procedures were spared in patients with 1-2 cm nodules (p = 0.025), as compared to 2005 criteria. The 2010 vs. 2005 AASLD per patient cost was similar in 1-2 cm nodules, 432 € vs. 451 € (p = 0.46), but lower in >2 cm nodules, 248 € vs. 321 € (p <0.001). Conclusions A sequential study with either CT or MRI enhances the radiological diagnosis of HCC and reduces costs and liver biopsy need.