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de Santis et al. Hepatoma Res 2019;5:1 I http://dx.doi.org/10.20517/2394-5079.2018.65 Page 13 of 16

Table 2. Comparison between Response Evaluation Criteria In Solid Tumors and Modified Response Evaluation Criteria In
Solid Tumors for target lesions [41]
RECIST mRECIST for HCC
CR = Disappearance of all target lesions CR = Disappearance of any intratumoral arterial enhancement in all
target lesions
PR = At least a 30% decrease in the sum of diameters of all target PR = At least 30% decrease in the sum of diameters of viable
lesions, taking as reference the baseline sum of the diameters of (enhancement in the arterial phase) target lesions, taking as
target lesions reference the baseline sum of the diameters of target lesions
SD = Any cases that do not qualify for either partial response or SD = Any cases that do not qualify for either partial response or
progressive disease progressive disease
PD = An increase in 20% in the sum of diameters of target lesions, PD = An increase in 20% in the sum of diameters of viable
taking as reference the smallest sum of the diameters of target (enhancing) target lesions, taking as reference the smallest sum of
lesions recorded since treatment started the diameters of target lesions recorded since treatment started

RECIST: Response Evaluation Criteria In Solid Tumors; mRECIST: Modified Response Evaluation Criteria In Solid Tumors; HCC:
hepatocellular carcinoma; CR: complete response; PR: partial response; SD: stable disease; PD: progressive disease

known “non target lesions”. After having assigned a definition for each category of lesions (target/non target)
it will be possible to define the “overall response according to mRECIST” by cross-referencing each response
obtained in the two categories of lesions as shown in Table 3.

Subsequent publications have reported a good correlation between the objective response evaluated with
[42]
mRECIST and overall survival, both after the application of loco-regional treatments and also after
[43]
systemic therapies . However, the application of mRECIST criteria in clinical practice is sometimes
challenging due to their complexity and also because it is not rare to find an HCC represented exclusively
by “non target lesions” or by nodular hepatic lesions which do not exhibit the traditional post-contrast
“HCC hallmark”. As such, their use is contraindicated. Finally, it remains to be established that mRECIST
[44]
is superior to RECIST and a comparative evaluation is therefore required . A recent analysis of two phase
II trials in patients treated with sorafenib or nintedanib showed that both RECIST and mRECIST response
[45]
were correlated with overall survival, with similar discriminative abilities in multivariate analysis . It was
also shown that mRECIST and RECIST are equivalent in the evaluation of progression, which is the most
important endpoint in regards to therapeutic decisions.

IN THE FUTURE
The development of artificial intelligence will probably allow in the future to improve the interpretation
of images obtained with the ultrasound, MDTC or MRI with contrast medium limiting diagnostic errors
computer-aided diagnosis (CAD) is one of the most important research topics in radiology and medicine.
A software based on the recognition of the contrast features of the lesions calculates the probability that
[46]
they are benign or malignant. Moga et al. developed a CAD prototype used to analyze 97 videos of
good quality CEUS [34% HCC, 12.3% hypervascular metastases, 11.3% hypovascular metastases, 24.7% of
hemangiomas, 17.5% of focal nodular hyperplasia (FNH)]. The authors evaluated the diagnostic performance
of two young doctors, two experts and CAD in the diagnosis of benign vs. malignant lesions. The CAD was
useful in improving the diagnostic skills of young doctors, especially when integrated with clinical data, but
was lower than the skills of experienced doctors. The most frequently misdiagnosed lesions were FNH and
[46]
HCC .
[47]
Kim et al. developed and evaluated a CAD program for hepatic lesions on MRI for the classification of
HCC risk according to the LI-RADS criteria. MRI images of the livers of 41 patients with hyperenhancing
liver lesions classified as LR 3, 4 and 5 were evaluated by two radiologists. The agreement on the classification
of lesions by radiologists and CAD was 76%-83%, while the agreement between radiologists was 78%.