Optimal Intervals of Ultrasonography Screening for Early Diagnosis of Hepatocellular Carcinoma in Taiwan

Abstract 

IMPORTANCE 

There are different clinical practices regarding ultrasonography screening intervals for hepatocellular carcinoma (HCC) despite recommendations from international guidelines.

 OBJECTIVE

 To evaluate whether ultrasonography screening using intervals suggested by international guidelines is associated with cancer stage shifting, reductions in mortality, and improved quality of life (QoL) for patients with HCC. 

DESIGN, SETTING, AND PARTICIPANT

 This nationwide comparative effectiveness research study estimated lifetime survival functions using interlinkages of 3 databases from Taiwan—the Taiwan National Health Insurance, Taiwan National Cancer Registry, and National Mortality Registry— combined with QoL measurements obtained from National Cheng Kung University Hospital. In total, 114 022 patients listed as having newly diagnosed HCC from 2002 through 2015 in the Taiwan National Cancer Registry were followed up until 2017. The QoL values of 1059 patients with HCC who visited National Cheng Kung University Hospital were prospectively measured with the European QoL-5 dimensions questionnaire from 2011 through 2019. Patients were categorized based on the time between their last ultrasonography screening and the index date (90 days prior to HCC diagnosis) as 1 of 5 subcohorts: 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months (no screening in the previous 3 years). Data were analyzed from April 2020 to April 2021. 

MAIN OUTCOMES AND MEASURES 

Life expectancy, quality-adjusted life expectancy, and loss of life expectancy or loss of quality-adjusted life expectancy compared with age-, sex-, and calendar year–matched cohorts. 

RESULTS 

There were 59 194 patients with Barcelona Clinic Liver Cancer staging information, including 42 081 men (mean [SD] age, 62.2 [12.6] years) and 17 113 women (mean [SD] age, 69.0 [11.2] years). There was a consistent trend showing that the longer the interval between ultrasonography examinations, the higher the loss of life expectancy and loss of quality-adjusted life expectancy for both sexes. Loss of quality-adjusted life expectancy values for male subcohorts were 10.0 (95% CI, 9.1-10.9) quality-adjusted life-years (QALYs) for ultrasonography screening intervals of 6 months, 11.1 (95% CI, 10.4-11.8) QALYs for 12 months, 12.1 (95% CI, 11.5-12.7) QALYs for 24 months, 13.1 (95% CI, 12.6-13.6) QALYs for 36 months, and 14.6 (95% CI, 14.2-15.0) QALYs for longer than 36 months. Loss of quality-adjusted life expectancy values for female subcohorts were 9.0 (95% CI, 8.3-9.6) QALYs for 6 months, 9.7 (95% CI, 9.2-10.2) QALYs for 12 months, 10.3 (95% CI, 9.8-10.7) QALYs for 24 months, 10.7 (95% CI, 10.2-11.1) QALYs for 36 months, and 11.4 (95% CI, 11.0-11.8) QALYs for longer than 36 months. Patients with underlying hepatitis B virus infection or cirrhosis had the greatest improvement in life expectancy with shorter screening intervals.  

Findings 

This comparative effectiveness research study evaluated 59 194 patients with HCC in Taiwan who were followed up for 14 years, with loss of quality-adjusted life expectancy estimated by comparison with age-, sex-, and calendar year–matched referents simulated from vital statistics data. Compared with  abdominal ultrasonography screening within 36 months before diagnosis, screening 6 months before diagnosis was associated with an additional 4.6 QALYs for men and 2.4 QALYs for women. Meaning In this study, ultrasonography screening using shorter intervals for high-risk patients detected HCC earlier, suggesting that such a screening approach may save more lives and improve quality of life. 

CONCLUSIONS AND RELEVANCE

 Regular ultrasonography screening with intervals less than 6 to 12 months may be associated with early detection of HCC, save lives, and improve the quality of life for patients with HCC from a lifetime perspective. 

Key Points Question What is the optimal interval of ultrasonography screening for early diagnosis of hepatocellular carcinoma (HCC) among high-risk patients? 

JAMA Network Open. 2021;4(6):e2114680. doi:10.1001/jamanetworkopen.2021.14680

POCUS in diagnosis of pediatric transient synovitis

By Amerigo Allegretto, AuntMinnie.com staff writer

July 13, 2021 -- Point-of-care-ultrasound (POCUS) in combination with a decision-support checklist can help accurately diagnose transient synovitis in pediatric patients, according to research published July 13 in JAMA Network Open.

A group led by Marah Zoabi, a research assistant from the Technion-Israel Institute of Technology in Haifa, found that a POCUS decision-support algorithm can help provide more efficient diagnosis of transient synovitis and avoid unnecessary blood tests.

"To our knowledge, this study is the first to suggest a rule-in diagnostic tool for transient synovitis, instead of one of exclusion," Zoabi and colleagues wrote. "The traditional approach advocates the use of laboratory tests to differentiate between transient synovitis and other serious diseases."

Transient synovitis causes acute hip pain and is confirmed by excluding other severe diseases, such as septic arthritis, osteomyelitis, and Legg-Calvé-Perthes disease. Hip effusion, meanwhile, is typically found using ultrasonography.

The team's POCUS decision-support algorithm is used regularly to identify transient synovitis in pediatric patients. It includes a set of five clinical criteria that must be met, followed by bedside ultrasonography of the hip joint. The criteria include the following:

• Age 3-10 years
• Fever less than 38° C
• Pain with weight-bearing movement
• Concerns started seven days ago or earlier
• Absence of paleness, splenomegaly, and generalized lymphadenopathy

The researchers wanted to test the accuracy of the algorithm in diagnosing the disease. To do so, they looked at data gathered from 1,461 children with nontraumatic hip tenderness between October and November 2020.

The POCUS algorithm was applied to 621 patients (429 boys, 192 girls) with an average age of 5.5 years. Out of these patients, 539 were correctly diagnosed as having transient synovitis. Meanwhile, 22 patients were correctly diagnosed as not having synovitis and 54 were misdiagnosed as not having synovitis, but they were correctly diagnosed at follow-up visits.

Six emergency department patients were misdiagnosed as having synovitis, but they were found to have another condition at follow-up visits.

The algorithm showed high sensitivity at 90.9% and high positive predictive value at 98.9%. Specificity, meanwhile, was 78.6% and negative predictive value was 28.9%.

The algorithm's positive likelihood ratio of 4.25 suggests it can be helpful in ruling in the diagnosis of transient synovitis, the authors concluded.

Hip effusion may not always be present when patients present with transient synovitis. This is reflected by the limited specificity and low negative predictive value, suggesting the algorithm cannot reliably rule out synovitis, they added.

Potential limitations of the study included its retrospective nature, the operator-dependent nature of the ultrasonography exam, the absence of an objective reference standard, and the lack of external validation of the algorithm, according to Zoabi and colleagues.

However, "these data provide evidence for the safety of the POCUS decision-support algorithm," they wrote.