VICT2 Trait: Prognostic Alternative to Peritumoral Hepatobiliary Phase Hypointensity in HCC
Hanyu Jiang, Hong Wei, Ting Yang, Yun Qin, Yuanan Wu, Weixia Chen, Yujun Shi, Maxime Ronot, Mustafa R. Bashir, Bin Song
Radiology. 2023. DOI: 10.1148/radiol.221835
Hepatocellular carcinoma (HCC) is the most common primary liver cancer, it has been recognized as a leading cause of death among patients with cirrhosis, and its incidence is expected to increase in the future .
MRI plays a key role in the management of HCC. To improve long-term survival in patients with HCC, in recent years several studies have been performed to detect imaging features with prognostic value.
Prior studies developed and validated preoperative models based on hepatobiliary (HBP) MRI features for predicting microvascular invasion (MVI) , which is one of the main histopathological factors associated with recurrence during the first 2 years after curative treatment . Peritumoral hypointensity on HBP has been identified as the MRI feature most suggestive of MVI [4,5]. However, the assessment of peritumoral HBP hypointensity needs hepatobiliary contrast agent MRI, which is associated to some drawbacks, such as suboptimal arterial phase quality, higher cost, and deteriorated imaging quality in patients with conditions like cirrhosis or biliary obstruction.
To overcome these problems, Jiang and colleagues  have recently proposed an accurate non-hepatobiliary-specific imaging alternative to peritumoral HBP hypointensity named the “VICT2 trait”, including four non-hepatobiliary-specific MRI features:
- Peritumoral portal venous phase (PVP) hypoenhancement;
- Incomplete capsule;
- Corona enhancement;
- Peritumoral mild-moderate T2 hyperintensity.
By the application of the inclusion and exclusion criteria, this study enrolled 660 patients (551 males with a median age of 53 years) who underwent preoperative extracellular or hepatobiliary contrast-enhanced MRI for HCC assessment between December 2011 and November 2021. In this study, the most common etiology of the chronic liver disease was hepatitis B virus in 610 (92%) patients.
The predictive values of this non-hepatobiliary-specific MRI alternative for MVI and postoperative recurrence-free survival (RFS) were compared with peritumoral HBP hypointensity for patients with a solitary tumor with adequate documentation of the MVI status and follow-up information. The authors involved two liver pathologists who evaluated the margin resections by classifying tumors as positive or negative for MVI but they were aware of the clinical and imaging data.
The preoperative MRI exams were analyzed retrospectively by two blinded abdominal radiologists which considered the “VICT2 trait” for each patient as positive when peritumoral PVP hypoenhancement was present or if all three other features were present or negative if these features are absent.
Univariate and multivariate logistic regression analysis was employed to determine the association between ECA/EOB features and MVI, and postoperative RFS was estimated by using the Kaplan-Meier curves.
Results demonstrate that both peritumoral HBP hypointensity (OR for MVI = 2.5, P = .02; hazard ratio for RFS = 2.5, P < .001) and the VICT2 trait (OR for MVI = 5.1, P < .001; hazard ratio for RFS = 2.3, P < .001) were significantly correlated to MVI and RFS. These values of the VICT2 trait were confirmed in the extracellular contrast agent group (OR for MVI = 4.0; hazard ratio for RFS = 1.7; both P < .001). Particularly, in the gadoxetate disodium-MRI group, the “VICT2 trait” showed a stronger association with MVI compared to peritumoral hypointensity on HBP. The study clinical impact suggests that “VICT2 trait”, identifying a high-risk area for MVI, could improve the preoperative management of patients with hepatocellular carcinoma for the selection of appropriate medical and/or surgical therapy.
However, the authors acknowledge a few limitations, especially the following:
- high prevalence of chronic hepatitis B virus infection (92%) in the study cohort;
- selection bias due to retrospective study design;
- use of subjective features with suboptimal interobserver agreement;
- not-blinded assessment of MVI status and uncertain correlations between those imaging and pathologic features.
The “VICT2 trait” could be considered a simple and non-invasive imaging tool useful to identify microvascular invasion and predict postoperative recurrence in patient with HCC treated with curative intent resection with the aim to improve their management by customizing the therapeutic modalities for each patient. These results should be confirmed in multi-center studies with patients without hepatitis B virus who undergo both extracellular and hepatobiliary MRI.
1. Forner A, Reig M, Bruix J. Hepatocellular carcinoma. Lancet. 2018 Mar 31;391(10127):1301-1314. doi: 10.1016/S0140-6736(18)30010-2.
2. Zhang S, Huo L, Zhang J, Feng Y, Liu Y, Wu Y, Jia N, Liu W. A preoperative model based on gadobenate-enhanced MRI for predicting microvascular invasion in hepatocellular carcinomas (≤ 5 cm). Front Oncol. 2022;12:992301. doi: 10.3389/fonc.2022.992301.
3. Baleato-González S, Vilanova JC, Luna A, Menéndez de Llano R, Laguna-Reyes JP, Machado-Pereira DM, Bermúdez-Naveira A, Osorio-Vázquez I, Alcalá-Mata L, García-Figueiras R. Current and Advanced Applications of Gadoxetic Acid-enhanced MRI in Hepatobiliary Disorders. Radiographics. 2023;43:e220087. doi: 10.1148/rg.220087.
4. Hong SB, Choi SH, Kim SY, Shim JH, Lee SS, Byun JH, Park SH, Kim KW, Kim S, Lee NK. MRI Features for Predicting Microvascular Invasion of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis. Liver Cancer. 2021;10:94-106. doi: 10.1159/000513704.
5. Erstad DJ, Tanabe KK. Prognostic and Therapeutic Implications of Microvascular Invasion in Hepatocellular Carcinoma. Ann Surg Oncol. 2019;26:1474-1493. doi: 10.1245/s10434-019-07227-9.
6. Jiang H, Wei H, Yang T, Qin Y, Wu Y, Chen W, Shi Y, Ronot M, Bashir MR, Song B. VICT2 Trait: Prognostic Alternative to Peritumoral Hepatobiliary Phase Hypointensity in HCC. Radiology. 2023;307(2):e221835. doi: 10.1148/radiol.221835.
Dr. Giulia Pilato is a second-year young radiology resident at the University of Palermo (Italy). She graduated in Medicine and Surgery at the University of Palermo in July 2021 with a dissertation on the Outcome of LI-RADS observations identified after anti-HCV therapy with direct-acting antivirals (DAA). Her main interest is abdominal radiology, with focus on hepatobiliary disease.
Comments may be sent to pilato.giulia(at)yahoo.it