Comparative diagnostic accuracy of ultrasound elastography and MRI for hepatocellular carcinoma: A systematic review and meta-analysis

ORIGINAL ARTICLE

MALLMANN, Marielle Malucelli ^[1], PEREIRA, Fernando Linhares ^[2], DUARTE, Márcio Luís ^[3], ANDRADE, Ana Maria Machado de ^[4], LIMA JUNIOR, Emilton ^[5], RAMOS JUNIOR, Odery ^[6] 

MALLMANN, Marielle Malucelli et al. Comparative diagnostic accuracy of ultrasound elastography and MRI for hepatocellular carcinoma: A systematic review and meta-analysis. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 11, Ed. 04, Vol. 01, pp. 186-212. April 2026. ISSN: 2448-0959. Available at: https://www.nucleodoconhecimento.com.br/nutrition/ultrasound-elastography, DOI: 10.32749/nucleodoconhecimento.com.br/nutrition/ultrasound-elastography

ABSTRACT

Introduction: Hepatocellular Carcinoma (HCC) is a primary liver neoplasm and the fastest-growing cause of cancer-related deaths, and the third leading cause globally. The risk of HCC varies with liver fibrosis, increasing significantly in cirrhotic patients.  This study aimed to identify, systematically analyze, and summarize the best available evidence on the cutoff value in kPa for diagnostic yield of ultrasound liver elastography compared to MRI, CT, or liver biopsy. Material and methods: A systematic review of studies which analyses elastography and MRI for HCC. A systematic search of the relevant literature was conducted in the PubMed, EMBASE, Cochrane Library, Web of Science, Scopus and LILACS databases, for articles published up to April, 30 2024, relating studies comparing kPa results from ultrasound hepatic elastography (TE, SWE, and 2D-SWE) to MRI for HCC detection were included. Results: Out of the 1,723 studies reviewed, 11 met the established quality criteria. Among these, only the study by Imai et al. (2015) adhered to the PICO framework, demonstrating high sensitivity and specificity in diagnosing hepatocellular carcinoma (HCC) using shear wave elastography (ROC-AUC 0.963; sensitivity and specificity of 83.3% for SWE ≥ 6.5 kPa) when compared to MRI.  Conclusion: SWE shows potential as a low-cost, accessible, non-invasive diagnostic tool for early HCC detection, especially in resource-limited settings. However, further high-quality studies are needed to conduct a meta-analysis and establish a standardized kPa threshold for diagnosing HCC. 

Keywords: Carcinoma, Hepatocellular, Elasticity Imaging Techniques, Magnetic Resonance Image. 

REGISTRATION NUMBER: CRD42022383148, PROSPERO DATABASE.

1. INTRODUCTION

Hepatocellular Carcinoma (HCC) is a primary neoplasm of the liver and is currently the fastest growing cause of cancer-related deaths in the United States1,2 and worldwide the third leading cause of cancer deaths (8.3%), according Global Cancer Observatory (GLOBOCAN).3 The known risk of HCC varies according to the degree of liver fibrosis: less than 1% per year in patients with chronic hepatitis without fibrosis and 3-7% per year when the patient develops cirrhosis,4 this being the main risk factor associated with development of HCC present in 90% of patients in Western countries.5

Known risk factors for the development of HCC are viral liver diseases, Hepatitis B Virus (HBV) and hepatitis C Virus (HCV) depending on duration and genotyping, advanced age, male gender, concomitant exposure to alcohol or aflatoxin.6 These risk factors when associated with Metabolic dysfunction-Associated Fatty Liver Disease (MAFLD), characterized by hepatic steatosis in addition to obesity, Type-2 Diabetes Mellitus (T2DM), or metabolic syndrome, represent an even greater risk in the incidence of HCC and related deaths.7,8

It is estimated that less than one-third of patients with HCC undergo regular screening8. Furthermore, as many patients are asymptomatic in the early stages, it is common for them to be diagnosed only after the disease has reached an advanced stage, leading to less favorable prognoses9. The five-year survival rate is estimated to be just 18%5,10. To reduce mortality through early intervention, hepatology societies worldwide11, along with multiple cohort studies and cost-effectiveness analyses,12-15 strongly recommend a six-month follow-up interval5. This follow-up should utilize viable options for periodic HCC screening, particularly in cirrhotic patients classified within Child-Pugh functional classes A and B, and in those with viral-related liver diseases and moderate or greater degrees of fibrosis (≥F3)16 as determined by the METAVIR score17.

The choice of diagnostic modality is individualized and currently occurs through magnetic resonance imaging (MRI), Computed Tomography (CT) or Ultrasound (US), all with contrast, the latter not characterizing unsuspected lesions throughout the liver volume, unable to stage the tumor burden.18 These are categorized as LR-5 in the Liver Imaging Reporting and Data System (LI-RADS) for high-risk patients.19 Although non-invasive, due to the high cost and complexity of these tests, they may have limited access in some health services, making periodic screening of patients at risk of HCC difficult20. Furthermore, cases of claustrophobia are common, which prevent the examination from being carried out due to the difficulty of patients in remaining lying down in the scanner for 30 to 40 minutes, in addition to the need to voluntarily contribute to inhaling and exhaling air for 20 to 25 seconds according to the guidelines.21 Some patients may also have contraindications to contrast administration, such as renal failure (estimated glomerular filtration rate [eGFR] <30mL/min/1.73m).22 In inconclusive cases there is still the possibility of a biopsy, however, the risks involve immediate complications to the procedure such as the dissemination of the tumor, sampling errors, false negative diagnoses, in addition to death.23

Currently, the method capable of predicting the malignancy of lesions and detecting HCC, useful in determining the amount of fibrosis, is through ultrasound hepatic elastography.18 The liver stiffness value obtained by elastography is an important imaging method obtained non-invasively, with greater accessibility compared to MRI or CT exams and safety compared to liver biopsy.24,25 Liver elastography allows periodic monitoring of at-risk patients as recommended, as it is capable of assessing the presence or risk of developing HCC.18,24

The exam can be performed using three platforms: the most common vibration-controlled Transient Elastography TE (FibroScan, Echosens); Point Shear-wave Elastography p-SWE (Aixplorer, Supersonic Imagine/Sandhill Scientific) or 2D-SWE acoustic radiation force impulse elastography.24 The liver stiffness value can be estimated in meters per second (m/s) or converted to Young’s modulus and expressed in kilo Pascals (kPa), easily performed automatically and this mechanical property represents the elasticity and viscosity of the tissue.20,24,25 Evidence indicates that in cirrhotic patients, each kPa increases in liver stiffness measurement raised the risk of HCC by 4%.18

With the increase in studies reporting the worsening of the prognosis of patients with HCC,18 considering the high cost of MRI and CT scans25 and the lack of quantification of the viral load obtained by US with contrast22 in addition to the risks of biopsy,23 there is a need for evaluation periodic monitoring in a non-invasive way and capable of preventing malignancy and detecting HCC as recommended by the Hepatology Societies in the detection of HCC at an early stage. This diagnosis will improve the treatment of these patients, especially those with liver cirrhosis.20,25

The objective of this study was to identify, systematically analyze and summarize the best available evidence on the cut-off value in kPa for diagnostic yield of the ultrasound liver elastography exam compared to the MRI. Furthermore, we did not find any accurate systematic review on the use of elastography in the diagnosis of HCC.

2. OBJECTIVES

This study aims to identify, systematically analyze and summarize the best available evidence on the cut-off value in kPa for diagnostic yield of the ultrasound liver elastography exam compared to the MRI.

3. METHODS

3.1 STUDY MODEL

This study is a systematic review.  The review was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42022383148) and was exempt from a free and informed consent form. The study design followed the model outlined in the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy, version 5.1.26 There was no funding or support provided for this study.

3.2 INCLUSION CRITERIA

The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)27 guidelines and the question was defined following the PICO strategy28 outlined as follows: P (Population), I (Intervention), C (Comparison) and O (Outcome)29-31, as below: 

P = Patients diagnosed with HCC

I = Patients who underwent SWE exams during the study: TE, p-SWE or 2d-SWE

C = Using the MRI as standard

O = Biopsy

Therefore, this acronym is fundamental for the elaboration of the guiding question for the scientific investigation32 of this systematic review: “What is the diagnostic standard value of the hepatic elasticity obtained in kPa by ultrasound elastography, which can predict the risk of HCC diagnosis using MRI as a standard?”. We included Studies that compared results in kPA in the detection of HCC obtained through ultrasound hepatic elastography (TE, SWE and 2D-SWE) in comparison with MRI.

Concerning the type of studies, given that only a limited number of studies have been published so far, the purpose of this review was to map the knowledge of the subject and identify the designs of these studies according to their level of evidence. There was no restriction on the patient age, origin or publication status of the study. Studies were analyzed only in English, Portuguese and Spanish. In the case of missing information, the authors were contacted by e-mail.

To develop this systematic review, the following steps were carried out: elaboration of the research question; definition of databases and search period; detailing search strategies; identification of descriptors; broad and systematic search in databases; definition of inclusion criteria for original articles; data collect; selection of evidence; critical assessment of the eligibility of original articles; exclusion of articles outside the search criteria; analysis of the quality of eligible studies; analysis synthesis; discussion about the limitations of the study and evidence33-37.

3.3 PARTICIPANTS

Men and women of all ages with HCC suspicion or diagnosis, regardless of severity and time of disease, that performed elastography and MRI with biopsy as gold-standard method.

3.4 SELECTION OF STUDIES AND DATA EXTRACTION

A thorough systematic literature search performed in August, 30th of 2023 with an updated in April, 30th of 2024 was conducted on PubMed, EMBASE, Cochrane Library, Web of Science, Scopus and LILACS databases for original publications by using Medical Subject Headings (MeSH) terms included the following: Carcinoma, Hepatocellular; Elasticity Imaging Techniques; Magnetic Resonance Imaging.; Biopsy. Additional references were searched by cross-checking bibliographies of relevant eligible studies and the main review articles on the subject. A full search strategy is provided in Supplemental Table 1.

Eligible studies with a control group were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool.38 In all eligible studies the questionnaire RTI Item Bank was used (a tool focused on the evaluation of biases and precision).39 

The selected publications were those potentially eligible for inclusion in terms of relevant articles or abstracts from reference journals. Two authors performed an independent selection for eligibility. In cases of disagreement, a third author was consulted. The final selection of full texts was then reviewed in the same manner to confirm eligibility. Data extraction was performed with a standardized form including design of the study, author, year of publication, country, participants, participants with HHC, participants without HCC, patients diagnosed by US, patients diagnosed by MRI, patients confirmed by biopsy.

4. RESULTS

4.1 STUDIES SELECTED

The systematic review yielded 1723 papers; 734 duplicate studies were excluded. This left 1,005 studies for detailed analysis through the reading of titles and abstracts, with 989 articles excluded for the following reasons: different proposed topic (n = 406); review articles (n = 312); no ultrasound elastography (n = 85); letter to the editor (n = 36); no MRI (n = 29); conference presentations (n = 29); guidelines (n = 20); editorials (n = 18); case reports (n = 15); animal studies (n = 14); state-of-the-art articles (n = 10); no HCC (n = 9); comments (n = 2); author reflections (n = 2); seminar presentations (n = 1); in vitro studies (n = 1). 

4.2 CHARACTERISTICS OF THE STUDIES

Of the 16 studies that remained in the analysis, the databases of the studies were read and researched in full, and 5 articles were excluded due to inaccessible language (Chinese, n = 4; Korean, n = 1), with no response after requesting information. Thus, 11 studies met the quality assessment criteria. The PRISMA flowchart is in Figure 1. Finally, the 11 eligible studies were carefully analyzed using the RTI Item Bank evaluation and the QUADAS-2 (Figure 2), with only one study, Imai et al. (2009),40 considered adequate for inclusion in this systematic review. Among the main limitations and low scores in QUADAS-2, the following studies will be discussed.

Abdel-Latif et al. (2020),41 in their prospective study, evaluated 75 Focal Liver Lesions (FLL) and divided them into two groups, specifying only benign or malignant lesions, without specifying HCC. Thus, it has sensitivity and specificity to differentiate malignant and benign lesions, but not specifically HCC from other nodules. Similarly, Shahid et al. (2022)42 presented the main limitation of sensitivity, specificity, and ROC curve results, which characterize lesions with the terms benign or malignant, without differentiating HCC from other lesions.

Gallotti (2012),43 according to the description of results, did not specify whether the HCC diagnosis was made by MRI as per the inclusion criteria of this study, as it could also occur by CT or Contrast-Enhanced Ultrasound (CEUS) before comparing with elastography. Therefore, we cannot compare how many were diagnosed using only the gold standard method established by our study.

In the studies of Ghiuchici et al. (2021),44 Grgurevic et al. (2017),45 and Hasab-Allah et al. (2017),46 there was no description of whether the HCC diagnosis was by MRI or CT, and therefore, without the description of the nodules diagnosed by MRI as the gold standard, it was not possible to compare the nodules diagnosed by elastography as established in our study.

Li et al. (2016)47 did not specify which lesion was confirmed by MRI. This article states that the lesions were confirmed by Contrast-Enhanced Ultrasound (CEUS), contrast-enhanced CT, or MRI. Therefore, we cannot affirm that all HCC cases were confirmed by the gold standard determined by the current study. Ronot (2014),48 in their study, evaluated various types of tumors; however, the only confirmed case of HCC (n=1) was not confirmed by MRI but by liver biopsy. Part of the article states that malignant diseases were confirmed by biopsy, but it does not describe whether it was only biopsy or also involved imaging.

Yu et al. (2011)49 did not specify whether only MRI was used: HCC diagnosis in the article was given by MRI, CT, contrast-enhanced ultrasound, or other nuclear medicine imaging for later comparison with elastography. It does not state how many of these diagnoses were made by MRI, so we cannot compare how many were diagnosed purely by the gold standard method established by our study. Zhang et al. (2013)50 also did not specify if only MRI was used for HCC diagnosis, or was given by CT, CEUS or histopathology for later comparison with SWE. And therefore, it did not allow the comparison of how many were diagnosed purely by the gold standard method established by our study.

Finally, Imai et al. (2015)40 was the only study that defined MRI as the reference standard for HCC diagnosis. The study provided specific sensitivity and specificity values, clearly distinguished between HCC and non-HCC patients, and reported statistically significant results with a p-value <0.05. Moreover, Imai et al. (2015)40 was the sole study to adhere to the PICO framework outlined in this systematic review, making it the only one deemed suitable according to the PRISMA guidelines. Consequently, this systematic review was unable to conduct a meta-analysis. In such instances, the selected studies are evaluated using the Synthesis Without Meta-analysis (SWiM) approach51. Imai et al. (2015)40 was a retrospective study designed to investigate the presence or absence of HCC in patients following a sustained virological response. The study included 42 patients, six with HCC and 36 without this malignant tumor. The article shows that of the six with HCC, four were diagnosed by MRI, which was the control established in the PICO question of this systematic review. Thus, after detecting these four HCC cases by MRI, the study analyzed these malignant tumors using SWE.

For this reason, the study by Imai et al. (2015)40 was deemed suitable, as it provided detailed descriptions of patients with HCC diagnosed by MRI, enabling the evaluation of SWE’s diagnostic accuracy based on MRI findings. In contrast, other studies excluded from this systematic review did not specify the number of HCC patients who underwent both MRI and SWE simultaneously, making direct comparison impossible. The clarity of the data in Imai’s study facilitated the understanding of SWE’s sensitivity and specificity when compared to MRI.

The SWE measurements, expressed in kPa, were found to be higher in patients with HCC than in those without. To assess the diagnostic capability of SWE in distinguishing between HCC and non-HCC patients, the ROC-AUC was reported as 0.963, with sensitivity and specificity values of 83.3% for patients with SWE ≥ 6.5 kPa, according to ROC analysis. This study thus identified a potential link between liver elasticity, as measured by SWE, and the presence of HCC, while also establishing a comparison between MRI and SWE for HCC diagnosis.

All studies are summarized in Supplemental Table 2.

5. DISCUSSION

Elastography has revolutionized the non-invasive assessment of liver diseases by providing quantitative measures of liver stiffness, expressed in kPa. Techniques such as SWE are crucial for diagnosing and monitoring liver fibrosis.6,17 Recent studies have explored the relationship between liver stiffness values and HCC, highlighting the importance of understanding this relationship for early detection and management of HCC.6

Liver stiffness, reflecting the degree of fibrosis, increases with fibrosis progression. HCC often develops in the context of advanced fibrosis or cirrhosis, conditions associated with elevated liver stiffness.5,6 Studies have shown strong correlations between increased liver stiffness and the presence of HCC. Specifically, liver stiffness values greater than 12-14 kPa are generally associated with advanced fibrosis (F3) and cirrhosis (F4), significantly increasing the risk of HCC.5

Research has identified specific liver stiffness thresholds predictive of HCC, with a large cohort study showing that patients with liver stiffness values above 12 kPa have a significantly higher incidence of HCC.16 Stasi and Brillanti (2024)52 reported a cutoff of 20 kPa with high sensitivity and specificity for predicting HCC in cirrhotic patients. Longitudinal monitoring indicates that increases in liver stiffness are strongly associated with HCC development, emphasizing the importance of regular liver stiffness measurement (LSM).12 Studies by Chammas et al. (2013)53 demonstrated that SWE can detect changes in liver stiffness associated with HCC development, corroborated by research showing higher stiffness in tumor regions. Hamada et al. (2018)54 and Gotoh et al. (2022)55 highlighted that SWE can predict HCC risk after HCV eradication, suggesting that SWE aids in early detection and continuous monitoring of HCC risk in patients with chronic liver infections.

The relationship between liver stiffness values and HCC is well-established, with higher kPa values indicating greater risk.2 SWE techniques, including p-SWE and 2D-SWE, offer reliable, non-invasive assessments of liver stiffness, aiding in early HCC detection and management. Continued research and refinement of these methods will enhance their integration into clinical practice, improving HCC prediction, diagnosis, and monitoring, ultimately benefiting patient outcomes.1

The assessment of liver fibrosis is critical in managing chronic liver diseases, including HCC. Non-invasive methods have gained traction due to their simplicity and reduced risk compared to liver biopsy.11 The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and the World Federation for Ultrasound in Medicine and Biology (WFUMB) endorse several ultrasound-based elastographic techniques.56 These include SWE methods like TE, p-SWE and 2D-SWE, which provide reliable measurements of liver stiffness, crucial for assessing HCC risk.57

Initially, TE was the standard method for evaluating liver fibrosis. While effective, TE has limitations, particularly in patients with ascites or obesity, and lacks real-time ultrasound guidance.4 These limitations prompted the development of newer techniques such as pSWE and 2D-SWE, which are integrated into conventional ultrasound machines, offering significant advantages. These techniques provide real-time B-mode imaging, allowing precise ROI selection and avoiding large blood vessels or the liver capsule, enhancing measurement accuracy and reducing failure rates.7

Numerous studies validate the accuracy of p-SWE and 2D-SWE in assessing liver fibrosis, often showing results comparable or superior to liver biopsy29. These studies demonstrate a linear relationship between shear wave velocity and fibrosis extent in hepatic tissue. For instance, a study involving over 300 chronic liver disease patients showed significant correlations between SWE methods and liver biopsy results (r = 0.79 for SWE and r = 0.70 for TE).45 The Area Under the Curve (AUC) for diagnosing significant fibrosis was 0.88 for SWE and 0.84 for TE, while for cirrhosis, the AUC was 0.93 and 0.90, respectively. Another study found the AUC of p-SWE to be 0.84 for significant fibrosis (F > 3) and 0.94 for cirrhosis, indicating high diagnostic accuracy.48

The European Association for the Study of the Liver (EASL) guidelines highlight that p-SWE and 2D-SWE perform equivalently to TE in diagnosing significant fibrosis or cirrhosis.17 These techniques also evaluate patients with ascites effectively, a challenge for TE.11

The practical application of SWE techniques is guided by consensus algorithms such as the Rule of 4, which provides clear cutoffs for interpreting liver stiffness measurements. According to this rule, liver stiffness less than 5 kPa indicates a normal liver, less than 9 kPa rules out significant fibrosis, values between 9-13 kPa suggest advanced fibrosis, and more than 17 kPa indicates clinically Significant Portal Hypertension (CSPH). These guidelines simplify the clinical use of SWE techniques, ensuring consistent and reliable result interpretation.57

Repeated LSM provides enhanced insights into liver disease progression, facilitating personalized treatment strategies. While TE remains the best-validated prognostic marker for liver-related morbidity and mortality in compensated liver disease, p-SWE and 2D-SWE also show promise as reliable prognostic tools. However, variability in cutoff values and equipment differences present challenges for broader clinical application.58. Nacif et al. (2018)59 found that higher elastography values correlate with increased mortality on the liver transplant waiting list, emphasizing the prognostic value of liver stiffness measurements. Similarly, Ajmera et al. (2023)58 highlighted the prevalence of non-alcoholic fatty liver disease (NAFLD), advanced fibrosis, and HCC in patients with type 2 diabetes, validating the importance of periodic monitoring through non-invasive techniques.

The evolution of elastographic techniques, particularly the integration of p-SWE and 2D-SWE into clinical practice, represents a significant advancement in non-invasive liver fibrosis and stiffness assessment. These techniques enhance the ability to manage and detect HCC early, providing clinicians with robust tools for evaluating liver health52,53. Continued research and refinement of these methods will solidify their role in comprehensive liver disease management, improving patient outcomes.6

Currently, SWE offers significant potential for enhancing early detection of HCC in cirrhotic patients due to its affordability, accessibility, and non-invasive nature. However, there remains a shortage of studies directly comparing its sensitivity and specificity to those of MRI, the established gold standard known for its high diagnostic accuracy in detecting HCC. The study by Imai et al. (2015) highlighted the diagnostic value of SWE, reporting high sensitivity and specificity (ROC-AUC 0.963; sensitivity and specificity of 83.3% for SWE ≥ 6.5 kPa), suggesting that SWE can be a reliable tool for HCC detection40. Despite its utility, LSM has limitations, as factors such as acute inflammation, cholestasis, and hepatic congestion can transiently increase liver stiffness, potentially leading to false positives. Therefore, LSM should be interpreted alongside other clinical findings and diagnostic modalities.17

This systematic review did not allow for a meta-analysis. Therefore, the final study was evaluated using the SWiM (Synthesis Without Meta-analysis) guidelines, as outlined51. Imai et al. (2015) investigated the presence of HCC in patients following a sustained virological response, including 42 patients, of whom 6 had HCC and 36 did not. Among the 6 HCC patients, 4 were diagnosed by MRI, which enabled an assessment of SWE’s diagnostic performance based on MRI findings. SWE measurements, expressed in kPa, were notably higher in patients with HCC. The ROC-AUC analysis yielded a value of 0.963, with sensitivity and specificity of 83.3% for patients with SWE ≥ 6.5 kPa. This study demonstrated a clear association between liver elasticity, as measured by SWE, and the presence of HCC, while also providing a comparison between SWE and MRI for diagnostic purposes40. Therefore, this systematic review emphasizes the potential of SWE as a viable and non-invasive diagnostic tool for HCC, especially in resource-limited settings where MRI and CT may be inaccessible.

The main limitation of this systematic review was the heterogeneity among the included studies, preventing a meta-analysis. Many studies did not perform a methodological comparison between MRI and SWE, limiting the generalization of results.31 Additionally, the small sample sizes and lack of data standardization limited direct comparisons between studies and consequently, the establishment of a standardized cutoff value for diagnosing HCC through SWE. There were also five studies with inaccessible language, and after attempts to contact the authors via email, no response was received.

Future research should focus on standardizing SWE methodologies and cutoff values for diagnosing HCC. Integrating SWE into routine clinical practice could improve early HCC detection, enhance patient outcomes, and reduce healthcare costs associated with more invasive diagnostic methods. Continuous investigation into the prognostic value of liver stiffness measurements to enable the detection and treatment of HCC patients is essential for better outcomes and increased survival rates for HCC patients.

6. CONCLUSION

The significance of this systematic review lies in demonstrating SWE as a promising tool for the diagnosis of HCC, eliminating the need for high-cost imaging techniques such as CT and MRI, or invasive procedures like biopsies. Elastography is a low-cost, accessible, non-invasive, and portable diagnostic method, making it feasible for use in remote or resource-limited settings.

However, only one study met the inclusion criteria proposed by this systematic review, involving forty-two patients. Despite the promising results, the small sample size limits the generalizability of the findings. Therefore, further studies with high methodological quality are needed to conduct a meta-analysis and to define the kPa threshold for estimating patients with HCC.

Figure 1. Flowchart of the Study

Figure 2. Risk of Bias

Supplemental table 1: Search strategy according to the correspondent database

Supplemental table 2. Basic characteristics of included patients

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INFORMATION ABOUT THE AUTHORS

^[1] PhD in Internal Medicine and Health Sciences from the Federal University of Paraná (UFPR), Master’s degree in Internal Medicine and Health Sciences from the Federal University of Paraná (UFPR), Bachelor’s degree in Nutrition from the State University of the Midwest (UNICENTRO). ORCID: https://orcid.org/0000-0002-9072-4963. 

^[2] Medicine, Ultrasound Specialist. ORCID: https://orcid.org/0000-0002-5135-2829.

^[3] Doctor of Health from the Federal University of São Paulo, Master in Evidence-Based Health from the Federal University of São Paulo, Title in Radiology and Diagnostic Imaging from the Brazilian College of Radiology, Fellowship in musculoskeletal radiology from Hospital São Camilo, Residency in Radiology from Santa Casa de Misericórdia de Santos, Medical degree from the Faculty of Medical Sciences of Santos. ORCID: https://orcid.org/0000-0002-7874-9332. Currículo Lattes: http://lattes.cnpq.br/1842227342641417.

^[4] Medical student at the Federal University of Paraná (UFPR). ORCID: 0009-0000-5695-1022.

^[5] Master’s degree in Cardiology from UFPR; PhD in Social Psychology from USP. ORCID: 0000-0002-6887-9387.

^[6] Physician, PhD in Sciences and Gastroenterology and Hepatology from the Federal University of Rio Grande do Sul (2009). ORCID: https://orcid.org/0000-0002-9730-6860.

Authors’ contribution:

Marielle Malucelli Mallmann: Conception, planning, analysis, interpretation, and writing of the work..

Fernando Linhares Pereira: Work analysis.

Márcio Luís Duarte: Analysis and interpretation of the work.

Ana Maria Machado de Andrade: Interpretation of the work.

Emilton Lima Junior: Interpretation of the work.

Odery Ramos Junior: Interpretation of the work.

INFORMATION ABOUT THE MATERIAL

Conflict of interest:

It does not have.

Acknowledgments:

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Note:

Registration Number: CRD42022383148, PROSPERO DATABASE.

AI presence note:

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• ISSN (electronic version): 2448-0959
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Publication History:

Material received: October 8, 2024.

Material approved by peers: October 15, 2024.

Edited material approved by authors: April 13, 2026.