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Competing Interests: Conflict of Interest: Fabio Piscaglia: Speaker fees: Bayer, Bracco; Advisory board: Bayer; Research contract: Esaote. / Stephanie R. Wilson: Research support: Siemens, Philips; Advisory role: Lantheus / Andrej Lyshchik: Industry grant and Research support: GE, Siemens, Toshiba; Advisory Board: BRACCO; Speaker Panel: SonoScape / David Cosgrove: Speaker and MAB: Bracco Spa, Toshiba, Bk Medical, Clearstream / Christoph F. Dietrich: Advisory board: Hitachi, Mindray; Speaker honorarium: Hitachi, Supersonic, Siemens, Mindray, GE, Bracco, Pentax / Juergen K. Willmann: Research grant: Siemens, GE, Philips, Bracco; Consulting fees: Bracco, Triple Ring Technologies; Advisory board: Lantheus, Bracco, SonoVol / Claude B. Sirlin: Industry grant support: Siemens, GE, Gerber; Consulting and service agreements: Bracco / Yuko Kono: Grant and research support: Toshiba, GE, Philips; Advisory board and speaker fees: Bayer, Wako

The lifetime utility of liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) is still controversial. The aim of this study was to ascertain when LT is cost-effective for HCC patients, with a view to proposing new transplant selection criteria. The study involved a real cohort of potentially transplantable Italian HCC patients (n = 2419 selected from the Italian Liver Cancer group database) who received nontransplant therapies. A non-LT survival analysis was conducted, the direct costs of therapies were calculated, and a Markov model was used to compute the cost utility of LT over non-LT therapies in Italian and US cost scenarios. Post-LT survival was calculated using the alpha-fetoprotein (AFP) model on the basis of AFP values and radiological size and number of nodules. The primary endpoint was the net health benefit (NHB), defined as LT survival benefit in quality-adjusted life years minus incremental costs (US $)/willingness to pay. The calculated median cost of non-LT therapies per patient was US $53,042 in Italy and US $62,827 in the United States. On Monte Carlo simulation, the NHB of LT was always positive for AFP model values ≤ 3 and always negative for values > 7 in both countries. A multivariate model showed that nontumor variables (patient's age, Child-Turcotte-Pugh [CTP] class, and alternative therapies) had the potential to shift the AFP model threshold of LT cost-ineffectiveness from 3 to 7. LT proved always cost-effective for HCC patients with AFP model values ≤ 3, whereas the cost-ineffectiveness threshold ranged between 3 and 7 using nontumor variables., (© 2015 American Association for the Study of Liver Diseases.)

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 <1cm, 67 1-2cm, 45 >2cm 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 1-2cm nodules and by CT in the >2cm 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 1-2cm and in 38 (95%) for those >2cm 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 1-2cm nodules (p=0.025), as compared to 2005 criteria. The 2010 vs. 2005 AASLD per patient cost was similar in 1-2cm nodules, 432 € vs. 451 € (p=0.46), but lower in >2cm 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., (Copyright © 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)