Methods: Between June 2019 and December 2023, patients with high-risk recurrent factors after curative resection from three centers might be enrolled.Patients with tumor staining during TACE procedure were regarded as those who underwent palliative resection.Recurrence-free survival (RFS), overall survival (OS), and adverse events were carefully evaluated in different patient groups.Propensity score matching was used.Results: A total of 1,390 patients were analyzed, with 957 (68.8%) receiving postoperative active surveillance.Among the 433 (31.2%) patients who underwent postoperative TACE, only 315 (72.7%) patients were without intraoperative tumor staining (curative resection).These patients were classified as receiving adjuvant TACE.Patients treated with postoperative TACE (n433) showed significant improvements in both RFS (HR 0.82, 95% CI 0.71-0.93)and OS (HR 0.81, 95% CI 0.67-0.98)compared to patients with active surveillance.However, the RFS (HR 0.92, 95% CI 0.80-1.08)and OS (HR 0.86, 95% CI 0.70-1.06)were virtually identical between patients receiving adjuvant TACE (n315) and those who under active surveillance, and these findings remained similar after propensity score matching.Subgroup analyses found that only patients with microvascular invasion were likely to benefit from adjuvant TACE (RFS: HR 0.75, 95% CI 0.61-0.93;OS: HR 0.62, 95% CI 0.42-0.84).Adjuvant TACE-related adverse events were mostly mild and tolerable, with grade 3 severity predominantly in hepatic impairment, nausea/vomiting, and thrombocytopenia.Grade 4 or 5 adverse event was not observed.Conclusions: Adjuvant TACE does not improve the survival of most HCC patients with high-risk recurrent factors after curative resection.

PURPOSE: To evaluate the added value of contrast-enhanced ultrasonography (CEUS) using Sonazoid in characterizing focal liver lesions (FLLs) with indeterminate findings on gadoxetic acid-enhanced liver MRI in patients without risk factors for hepatocellular carcinoma (HCC). METHODS: Patients who underwent CEUS using Sonazoid for characterizing indeterminate FLLs on gadoxetic acid-enhanced liver MRI were. The indeterminate FLLs were classified according to the degree of malignancy on a 5-point scale on MRI and combined MRI and CEUS. The final diagnosis was made either pathologically or based on more than one-year follow-up. The diagnostic performance was assessed using a receiver operating characteristic (ROC) curve analysis, and the net reclassification improvement (NRI) was calculated. RESULTS: A total of 97 patients (mean age, 49 years ± 16, 41 men, 80 benign and 17 malignant lesions) were included. When CEUS was added to MRI, the area under the ROC curve increased, but the difference was not statistically significant (0.87 [95% confidence interval {CI}, 0.77-0.98] for MRI vs 0.93 [95% CI, 0.87-0.99] for CEUS added to MRI, P = 0.296). The overall NRI was 0.473 (95% CI, 0.100-0.845; P = 0.013): 33.8% (27/80) of benign lesions and 41.2% (7/17) of malignant lesions were appropriately reclassified, whereas 10.0% (8/80) of benign lesions and 17.6% (3/17) of malignant lesions were incorrectly reclassified. CONCLUSIONS: Although performing CEUS with Sonazoid did not significantly improve the overall diagnostic performance in characterizing indeterminate FLLs on gadoxetic acid-enhanced liver MRI in patients without risk factors for HCC, it may increase radiologist's confidence in classifying FLLs.

Microvascular imaging is a new ultrasound technique aiming to image and quantify the microvasculature, comprising arterioles, venules, and maybe even capillaries. The technique uses an advanced clutter filter to eliminate artifacts caused by breathing and movement and retains the low-speed blood signals in microvessels. The great advantage of microvascular imaging in ultrasonography is that it allows a physician intuitively to detect very slow blood signals in microvessels, providing additional information about flow distribution in the target area without the use of contrast media. This technical advance in ultrasonography will improve diagnosis in various clinical situations. In this review, we focus on microvascular imaging in the liver.

Methods: Between June 2019 and December 2023, patients with high-risk recurrent factors after curative resection from three centers might be enrolled.Patients with tumor staining during TACE procedure were regarded as those who underwent palliative resection.Recurrence-free survival (RFS), overall survival (OS), and adverse events were carefully evaluated in different patient groups.Propensity score matching was used.Results: A total of 1,390 patients were analyzed, with 957 (68.8%) receiving postoperative active surveillance.Among the 433 (31.2%) patients who underwent postoperative TACE, only 315 (72.7%) patients were without intraoperative tumor staining (curative resection).These patients were classified as receiving adjuvant TACE.Patients treated with postoperative TACE (n433) showed significant improvements in both RFS (HR 0.82, 95% CI 0.71-0.93)and OS (HR 0.81, 95% CI 0.67-0.98)compared to patients with active surveillance.However, the RFS (HR 0.92, 95% CI 0.80-1.08)and OS (HR 0.86, 95% CI 0.70-1.06)were virtually identical between patients receiving adjuvant TACE (n315) and those who under active surveillance, and these findings remained similar after propensity score matching.Subgroup analyses found that only patients with microvascular invasion were likely to benefit from adjuvant TACE (RFS: HR 0.75, 95% CI 0.61-0.93;OS: HR 0.62, 95% CI 0.42-0.84).Adjuvant TACE-related adverse events were mostly mild and tolerable, with grade 3 severity predominantly in hepatic impairment, nausea/vomiting, and thrombocytopenia.Grade 4 or 5 adverse event was not observed.Conclusions: Adjuvant TACE does not improve the survival of most HCC patients with high-risk recurrent factors after curative resection.

PURPOSE: To evaluate the added value of contrast-enhanced ultrasonography (CEUS) using Sonazoid in characterizing focal liver lesions (FLLs) with indeterminate findings on gadoxetic acid-enhanced liver MRI in patients without risk factors for hepatocellular carcinoma (HCC). METHODS: Patients who underwent CEUS using Sonazoid for characterizing indeterminate FLLs on gadoxetic acid-enhanced liver MRI were. The indeterminate FLLs were classified according to the degree of malignancy on a 5-point scale on MRI and combined MRI and CEUS. The final diagnosis was made either pathologically or based on more than one-year follow-up. The diagnostic performance was assessed using a receiver operating characteristic (ROC) curve analysis, and the net reclassification improvement (NRI) was calculated. RESULTS: A total of 97 patients (mean age, 49 years ± 16, 41 men, 80 benign and 17 malignant lesions) were included. When CEUS was added to MRI, the area under the ROC curve increased, but the difference was not statistically significant (0.87 [95% confidence interval {CI}, 0.77-0.98] for MRI vs 0.93 [95% CI, 0.87-0.99] for CEUS added to MRI, P = 0.296). The overall NRI was 0.473 (95% CI, 0.100-0.845; P = 0.013): 33.8% (27/80) of benign lesions and 41.2% (7/17) of malignant lesions were appropriately reclassified, whereas 10.0% (8/80) of benign lesions and 17.6% (3/17) of malignant lesions were incorrectly reclassified. CONCLUSIONS: Although performing CEUS with Sonazoid did not significantly improve the overall diagnostic performance in characterizing indeterminate FLLs on gadoxetic acid-enhanced liver MRI in patients without risk factors for HCC, it may increase radiologist's confidence in classifying FLLs.

Microvascular imaging is a new ultrasound technique aiming to image and quantify the microvasculature, comprising arterioles, venules, and maybe even capillaries. The technique uses an advanced clutter filter to eliminate artifacts caused by breathing and movement and retains the low-speed blood signals in microvessels. The great advantage of microvascular imaging in ultrasonography is that it allows a physician intuitively to detect very slow blood signals in microvessels, providing additional information about flow distribution in the target area without the use of contrast media. This technical advance in ultrasonography will improve diagnosis in various clinical situations. In this review, we focus on microvascular imaging in the liver.

PURPOSE: This study aimed to compare the clinical and imaging features of hepatocellular carcinomas (HCCs) detected versus undetected on surveillance ultrasound (US), based on a prospective cohort. METHODS: This post-hoc subgroup study analyzed data from MAGNUS-HCC trial, a prospective multicenter study evaluating both biannual US and annual non-contrast abbreviated magnetic resonance imaging (NC-AMRI) for HCC surveillance in high-risk patients. Among 34 HCCs, 16 tumors were detected and 18 tumors were undetected on US. We compared clinical features such as sex, age, body mass index (BMI), liver disease etiology, α-fetoprotein (AFP) level, and Child-Pugh class between participants who were diagnosed on US and those who were not. Imaging features including size, hemiliver distribution, anatomical section, subcapsular location, blind spot location, the presence of hepatic steatosis, and the presence of poor sonic window were also compared. NC-AMRI features were also assessed. RESULTS: No significant differences were observed between US-detected and US-undetected groups in terms of sex, age, liver disease etiology, AFP level, or Child-Pugh class. Patients with US-undetected HCCs had higher BMI (25.7 vs. 23.8 kg/m2, P=0.049). Lesions in blind spots were significantly more common in the US-undetected group (55.6% vs. 18.8%, P=0.039), as were lesions in the left hemiliver (38.9% vs. 6.3%, P=0.043). No significant differences were found in tumor size, anatomical section, subcapsular location, presence of poor sonic window, presence of hepatic steatosis, or magnetic resonance imaging characteristics. Of the 16 US-detected tumors, 62.5% were hypoechoic and 37.5% were hyperechoic. CONCLUSION: US is less effective in detecting HCCs in patients with a higher BMI and tumors located in the blind spots or left hemiliver. These limitations should be considered in planning and interpreting surveillance strategies.

PURPOSE: This study evaluated the 3-year safety and efficacy of microwave ablation (MWA) as an alternative to radiofrequency ablation in Korean patients with hepatocellular carcinoma (HCC). METHODS: In this prospective single-center study, 33 adults with a single HCC lesion (2-5 cm; Barcelona Clinic Liver Cancer stage A) were enrolled between December 2017 and May 2020. All underwent ultrasound-guided MWA using the NEUWAVE system. One patient did not complete post-treatment evaluation and two had protocol deviations, yielding a full analysis set of 30 patients and a safety analysis set of 33 patients. Study endpoints included technical success (TS), technique efficacy (TE), local tumor progression (LTP), overall survival (OS), and adverse events (AEs) over a 3-year follow-up period. RESULTS: All 33 patients were included in the safety analysis, while 30 were included in the efficacy analysis. Most patients were male (83.3%), with a median age of 64 years and a mean tumor size of 2.5±0.6 cm. Median follow-up was 36.2 months. TS and TE were achieved in all cases. The 3-year cumulative LTP rate was 7.3%, and the 3-year OS rate was 90.0%. Minor AEs occurred in 54.5% of patients, most commonly post-ablation pain and fever. Two patients (6.1%) experienced major AEs, including pyrexia and duodenal thermal injury. No procedure- or device-related deaths occurred. CONCLUSION: MWA appears to be a safe and effective treatment for early-stage HCC, demonstrating durable tumor control and a low incidence of major complications over 3 years.

BACKGROUND: Radiofrequency ablation (RFA) of subphrenic hepatocellular carcinomas (HCCs) using ultrasound (US) guidance presents a challenge. PURPOSE: To evaluate local tumor progression (LTP) and overall survival (OS) after RFA of right posterior subphrenic HCCs, and to identify the risk factors for LTP and OS after RFA. MATERIAL AND METHODS: We screened patients who underwent US-guided RFA for a single HCC <3 cm in the right posterior subphrenic area. Cumulative rates of LTP and OS were compared between multiple- and single-electrode treatments and artificial pleural effusion versus no-effusion groups using Kaplan-Meier curves and the log-rank test. The risk factors for LTP and OS were assessed. RESULTS: = 0.020). CONCLUSION: US-guided RFA with multiple electrodes and artificial pleural effusion tends to be linked with lower LTP rates. The ALBI grade and serum albumin level are risk factors for LTP and OS, respectively.