Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis

Background: Abdominal ultrasound fails to detect over one-fourth of hepatocellular carcinoma (HCC) at an early stage in patients with cirrhosis. Identifying patients in whom ultrasound is of inadequate quality can inform interventions to improve surveillance effectiveness. Aim: To evaluate and identify predictors of ultrasound quality in patients with cirrhosis. Methods: We performed a retrospective cohort study among patients who underwent ultrasound examination for a cirrhosis-related indication between April 2015 and October 2015. Three fellowship-trained abdominal radiologists collectively reviewed all ultrasound exams and categorised exam quality as definitely adequate, likely adequate, likely inadequate and definitely inadequate to exclude liver lesions. We performed multivariable logistic regression to determine characteristics associated with inadequate ultrasound quality. Results: Among 941 patients, 191 (20.3%) ultrasounds were inadequate for excluding HCC- 134 definitely inadequate and 57 likely inadequate. In multivariable analysis, inadequate quality was associated with male gender (OR 1.68, 95% CI 1.14–2.48), body mass index category (OR 1.67, 95% CI 1.45–1.93), Child–Pugh B or C cirrhosis (OR 1.93, 95% CI 1.32–2.81), alcohol-related cirrhosis (OR 2.11, 95% CI 1.33–3.37), NASH cirrhosis (OR 2.87, 95% CI 1.71–4.80), and in-patient status (OR 1.55, 95% CI 1.01–2.37). Ultrasounds were inadequate in over one-third of patients with Child–Pugh C cirrhosis, BMI >35, or NASH cirrhosis. Conclusions: One in five ultrasounds in patients with cirrhosis are inadequate for exclusion of HCC, which can contribute to surveillance failure. Alternative surveillance modalities are needed in subgroups prone to inadequate ultrasounds including obese patients, those with Child Pugh B or C cirrhosis, and those with alcohol- or NASH-related cirrhosis.