Visual perceptual strengths and weaknesses in adults with intellectual disabilities compared with a birth year-matched norm.

BACKGROUND: The ventral and dorsal streams are considered to be the brain substrates of vision for perception and action, respectively. Using the Developmental Test of Visual Perception (DTVP), the current study examined whether visual perceptual strengths and weaknesses in adults with intellectual disabilities (ID) were attributable to the dichotomy of the visual streams. METHOD: In study 1, DTVP performance was compared among mild, moderate and severe adult ID groups; study 2 contrasted adult ID groups with and without Down syndrome (DS). To prevent possible contamination by the Flynn effect, participants were matched by birth year with the norm of the DTVP original edition. RESULTS: Independent of the extent of ID among the three groups in study 1 and the aetiological group difference in study 2, relative strength was found for two DTVP tasks: eye-hand coordination and distinguishing target figures from interference background. Relative weakness was obtained in identifying a figural category. Participants with DS demonstrated exceptional weakness in discerning a target from either mirror-imaged or rotated alternatives, in addition to figural-category detection. CONCLUSIONS: Visual perceptual strengths and weaknesses in persons with ID were difficult to explain on the basis of two visual streams. An interpretation originating in a different research context (e.g. frontal-lobe dysfunction) appears to be required for explaining visual perceptual weaknesses in persons with ID. For persons with DS, strong frontal-lobe dysfunction with atypical lateralisation might be the pathological determinant of visual perceptual weaknesses.

Outcome of 51 nonmalignant nodules in the liver: usefulness of aspiration cytology for diagnosis of dysplastic nodules.

Pathologic diagnostic criteria for intrahepatic nonmalignant nodules using needle biopsy are controversial. To evaluate the cytodiagnostic criteria for dysplastic nodules using aspiration biopsy, a follow-up study of nonmalignant nodules was performed. Fifty-one intrahepatic nodules diagnosed histologically and cytologically as nonmalignant using an aspiration biopsy in 39 patients were followed up without treatment. The outcomes of the nodules were investigated using the Kaplan-Meier method and Cox's multivariate analysis. The cumulative rates of development to HCC at the 2nd year were 0%, 18%, and 53% in the non-dysplastic nodules, the low-grade dysplastic nodules, and the high-grade dysplastic nodules, respectively; and significant differences were seen among them (P= 0.0001). Multivariate analysis showed that cytologic grade was a significant risk factor for development to HCC (P=0.020). In conclusion, aspiration cytology was useful for diagnosis of the dysplastic nodules to predict risks of development to HCC.

Inhibition by d-limonene of experimental hepatocarcinogenesis in Sprague-Dawley rats does not involve p21(ras) plasma membrane association.

The effects of d-limonene on hepatocarcinogenesis induced by N-nitrosomorpholine (NNM) and on membrane-associated p21(ras) and labeling and apoptotic indices of the liver were investigated in male Sprague-Dawley rats. Rats were given drinking water containing NNM for 8 weeks, and from the beginning of experimental week 9, they received chow pellets containing 1% or 2% limonene. The preneoplastic and neoplastic liver lesions (cellular alteration foci, neoplastic nodules and hepatocellular carcinomas), and hepatic foci staining positive for glutathione-S-transferase, placental type (GST-P) were examined microscopically and histochemically. At week 16, quantitative histologic analysis showed that oral administration of 1% or 2% limonene resulted in significant reductions in the number and mean area of GST-P-positive hepatic foci and the number of cellular alteration foci, neoplastic nodules and hepatocellular carcinomas. Limonene, at both doses, also caused significant decreases in the labeling indices and significant increases in the apoptotic indices of cellular alteration foci, neoplastic nodules, hepatocellular carcinomas and adjacent liver. However, limonene, at both doses, had no significant influence on the production of membrane-associated p21(ras) in the visible liver white nodules. These findings indicate that limonene inhibits hepatocarcinogenesis and suggest that this effect may be clearly related to its effect in inhibiting cell proliferation and in enhancing apoptosis, but not through ras oncoprotein plasma membrane association.

Multicenter prospective analysis of newly diagnosed hepatocellular carcinoma with respect to the percentage of Lens culinaris agglutinin-reactive alpha-fetoprotein.

BACKGROUND AND AIM: The Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) has been reported to be a highly useful marker for hepatocellular carcinoma (HCC) compared with a conventional serum AFP concentration, which allows earlier detection of HCC compared with using other imaging modalities and predicting prognosis after therapy. A collaborative prospective study involving nine Japanese hospitals was conducted to analyze the relationships between the tumor characteristics of a HCC patient and the percentage of AFP-L3/AFP total at the initial detection. METHODS: Between 1 October 1996 and 30 September 1997, a total of 388 patients with newly diagnosed HCC were registered. RESULTS: The cut-off level of the percentage of AFP-L3 was altered from 15 to 10%. The AFP-L3-positive HCC patients demonstrated the characteristics of having an advanced tumor, such as the number of tumors, maximum diameter, tumor spread, portal vein invasion, tumor stage, and tumor classification. With the conventional cut-off level of 15% of the percentage of AFP-L3, the malignant characteristics were more definite than that of 10%. However, no significant differences of serum AFP concentration were observed for malignant characteristics such as maximum diameter and histopathological grading. CONCLUSION: Serum AFP concentration does not reveal a malignancy of HCC, however, the AFP-L3-positive HCC has biologically malignant characteristics, especially portal vein invasion and lower tumor classification, and is an advanced tumor regardless of small tumor size and lower serum AFP concentration. As AFP-L3 shows the tumor characteristics, its presence should be an important factor in the determination of therapy and prognosis of patients.

Usefulness of diagnostic criteria for aspiration cytology of hepatocellular carcinoma.

OBJECTIVE: To establish new criteria for cytodiagnosis of hepatocellular carcinoma by comparing cytologic findings of hepatocellular carcinoma with those of liver cirrhosis. STUDY DESIGN: Review of cytologic findings of hepatocellular carcinoma on preoperative aspiration biopsy of 31 lesions from 27 patients who underwent surgical resection and comparison of these findings with those of liver cirrhosis in 17 patients. RESULTS: In the 11 lesions of moderately and poorly differentiated hepatocellular carcinoma, significant cytologic findings included monotonous and abundant cytoplasm, thick cytoplasm, increased nuclear/cytoplasmic ratio, irregular nuclear contours, increased chromatin density, intranuclear vacuoles and naked nuclei. In the 20 lesions demonstrating well-differentiated hepatocellular carcinoma, significant cytologic findings included monotonous and scant cytoplasm, well-defined cytoplasmic borders, thick cytoplasm, eccentric nuclei, increased nuclear/cytoplasmic ratio, thick nuclear membranes and increased chromatin density. We established the criteria for moderately and poorly differentiated hepatocellular carcinoma as including three cytologic parameters: increased nuclear/cytoplasmic ratio, irregular nuclear contours and increased chromatin density. We also established the criteria for well-differentiated hepatocellular carcinoma as including six cytologic parameters: monotonous cytoplasm, scant cytoplasm, well-defined cytoplasmic borders, thick cytoplasm, eccentric nuclei and increased nuclear/cytoplasmic ratio. For all 31 hepatocellular carcinoma lesions, including 27 lesions that were < or = 2 cm in diameter, both sensitivity and specificity were 100% by concurrently employing both criteria. CONCLUSION: The new criteria for cytodiagnosis we established were useful for differentiating hepatocellular carcinoma from liver cirrhosis. In particular, our criteria ensured appropriate diagnostic accuracy for well-differentiated hepatocellular carcinoma.

Indications for hepatectomy for hepatocellular carcinoma - what stage of the disease is the best indication for surgery?

To determine the clinical and tumor stage of hepatocellular carcinoma (HCC) that is the best indication for surgery, the postoperative long-term outcomes of patients who underwent hepatic resection were examined retrospectively. Of 975 patients with HCC who underwent regional therapy, 384 patients (39%) received hepatic resection (HR), 534 (55%) had transcatheter arterial chemoembolization (TACE), and the remaining 57 (6%) received percutaneous ethanol injection (PEI) into the tumor. The criteria defined by liver Cancer Study Group of Japan was used for staging and liver functional reserve (i.e., clinical staging). In the 133 patients with stage I HCC, there were no significant differences among the survivals of the HR, TACE, and PEI groups. In the 314 patients with stage II HCC, the 5- and 7-year survival rates were 51% and 46% in the HR group, 23% and 10% in the TACE group, and 0% and 0% in the PEI group. The survival of the HR group was significantly better than the survivals of the TACE and PEI groups (P < 0.001). The 5- and 10-year survivals of the stage II HCC patients who had HR were 64% and 47% in the clinical stage I (i.e., good liver function) group, significantly better than the 5; and 10-year survivals (32% and 23%) in the clinical stage II (i.e., bad liver function) group (P < 0.0001). Patients with good liver function in stage II are expected to have better survival and are considered to be the most suitable for HR.

Common bile duct stones: management strategies in the laparoscopic era.

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.

[Our initial experience with SMANCS in TAE for liver cancer].

To evaluate the efficacy and adverse reaction of SMANCS, we reviewed 10 cases treated by TAE with SMANCS among 896 cases treated by TAE for liver cancer during the past three years at our institute. Our criteria for using SMANCS were as follows: a) reduced effectiveness of past TAE with Lipiodol, hydrophilic drugs and gelatin sponge; b) sufficient caliber and blood flow in the hepatic artery; and c) good hepatic function. The 1- and 2-year survival rates after treatment with SMANCS were 50% and 25%, respectively. The 3- and 5-year survival rates after initial treatment (first TAE, etc.) were 40% and 20%, respectively. There were no significant complications in clinical course, however, subsequent hepatic arteriogram often showed arterial change that may interfere with further regional therapy for the liver.

Association of granular exocytosis with Ca(2+)-activated K+ channels in human eosinophils.

We studied the mechanism of degranulation caused by Ca(2+)-activated K+ channels (KCa channels) in eosinophils isolated from mildly atopic donors using negative immunoselection. Stimulation of eosinophils with 0.1 microM platelet-activating factor (PAF) caused activation of single channels as recorded by the cell-attached patch-clamp technique. These channels were selectively permeable to K+ because the reversal potential was close to the equilibrium potential for K+. However, the channels were not permeable to Na+ or Cl- as demonstrated by ion substitution experiments. The calcium ionophore A-23187, at 1 microM, increased the K+ channel activity in the presence of Ca2+ in the external perfusate but did not induce channel activity in the absence of Ca2+. Similar results were obtained with another calcium ionophore, ionomycin (1 microM), and the Ca(2+)-releasing agent thapsigargin (10 microM). K+ channels activated by PAF and A-23187 had similar characteristics: two levels of single-channel conductances were observed, 10 +/- 1.5 and 22 +/- 1.7 pS as induced by PAF and 11 +/- 1.3 and 24 +/- 1.9 pS by A-23187; the mean open times of the large-conductance channels were 1.45 +/- 0.3 ms as induced by PAF and 1.26 +/- 0.5 ms by A-23187. These results indicate that PAF activates KCa channels. Both KCa currents and major basic protein release caused by A-23187 were blocked by quinidine. It is suggested that KCa channels are associated with granule secretion in human eosinophils.

[Hepatic resection with "wrapping therapy" for advanced hepatocellular carcinoma uncontrolled by arterial embolization].

We report a 70-year-old male patient who had successful hepatic resection with "Wrapping therapy" for advanced hepatocellular carcinoma (HCC) uncontrolled by arterial embolization. His laboratory tests were as follows: Alb: 4.7 (g/dl), T. Bil:0.9 (mg/dl), ICG R15:26.8 (%), PT: > 100%, AFP:33 (ng/ml), HCV-Ab:(-), HBs-Ag:(-). Hepatic angiogram showed a 20 cm sized tumor in the left lobe and many large and small tumors in the right lobe. He received chemoembolization (TAE) five times during seven months. At the time of the fifth hepatic angiogram, TAE was assessed as ineffective because of the resulting collateral feeding arteries. Thus, he underwent left lobectomy, partial resection of the right lobe, and partial "Wrapping therapy" for the regions including foci supplied with parasitic branch. Afterwards, he had TAE two times. One year and five months after the procedure, he is still alive without signs of recurrence.

Clinical features of small hepatocellular carcinomas as assessed by histologic grades.

BACKGROUND: Ninety-seven patients with small hepatocellular carcinomas (HCCs) measuring 3 cm or less in size and three patients with adenomatous hyperplasia who underwent radical hepatic resection were examined in this study. METHODS: The lesions were classified into four groups according to the following histologic grading criteria: group A, adenomatous hyperplasia (n = 3); group B, early HCC (n = 6); group C, well-differentiated HCC (wHCC) (n = 32); and group D, moderately or poorly differentiated HCC (n = 59). The involvement factors that seemed to be important or to characterize the progression of HCC and the survival rates were compared among the four histologic groups. RESULTS: The frequency of patients with tumors larger than 2.0 cm in size and that of patients with 200 or more ng/ml serum alpha-fetoprotein increased with the progression of histologic malignancy. Tumor staining on the angiogram, capsular formation, and extranodular invasion were never seen in groups A and B, but they began to appear in group C and increased remarkably in group D. The 5-year survival rates of the patients in groups B, C, and D were 100%, 60%, and 27%, respectively, and statistically significant differences were seen among them. In comparative evaluation of the group C patients the lesions that showed no tumor staining had no capsule, and those that had no capsule had no extranodular invasion. The 5-year survival rate of patients with wHCC without extranodular invasion (81%) was significantly higher than that of patients with extranodular invasion (35%) (p < 0.05). CONCLUSIONS: It may be recommended to provide the category of wHCC without extranodular invasion for pathologic classification of clinically early HCC (i.e., HCC of high curability).

[Usefulness of spiral CT in the detection of hypovascular, well-differentiated hepatocellular carcinoma].

Whole liver scanning during artery-dominant phase using spiral CT was performed in 14 patients with 17 histologically proven well-differentiated HCCs, which were not depicted by hepatic digital subtraction angiography but by CT during arterial portography. The density of HCC relative to the liver was evaluated with conventional precontrast CT, spiral CT, and following conventional CT during the equilibrium phase. Comparison between spiral CT and magnetic resonance (MR) imaging of dynamic contrast studies was also investigated. Four tumors of 17 HCCs (24%) were shown as a high-density area by the artery-dominant phase using spiral CT. Consequently, the total sensitivity of these three kinds of CT techniques was elevated to 82%. The sensitivity of dynamic MR imaging was slightly greater than that of spiral CT. However, spiral CT sometimes made the diagnosis more conspicuous by it's good spatial resolution. Our results indicate that spiral CT has a potential benefit in the detection of hypovascular well-differentiated HCC, and MR imaging and spiral CT may be complement each other.

[A case report of far advanced gastric cancer with multiple liver metastasis (H3) treated with transarterial intermittent chemotherapy and intradermal administration of low molecular lipopolysaccharide (LPSp) extracted from Pantoea agglomerans].

A case of far advanced gastric cancer with multiple liver metastasis (H3) was treated with transarterial intermittent chemotherapy (5-FU: 250 mg/week, Farmorubicin: 10 mg/4 weeks, MMC: 4 mg/2 weeks) and intradermal administration of low molecular lipopolysaccharide (LPSp) extracted from Pantoea agglomerans. The CT examination and endoscopy showed regression of the tumor and the patient was discharged from the hospital. LPSp was given at the concentration of 0.1 microgram initially, and the dose was gradually increased. Finally, the dose of LPSp was increased up to 70 micrograms. No serious side effect except fever was observed. The serum TNF-alpha levels were elevated and, histologically, CD 8(+) lymphocyte dominantly infiltrated around the tumor. These findings clearly indicated the immunological anticancer effect of LPSp. Intradermal administration of LPSp is a promising new adjuvant therapy to improve QOL without serious side effect.

[Tissue concentration of 5-FU after intra-operative arterial infusion].

The aim of this study was to measure the tissue concentration of anti-cancer agents administered by arterial infusion. After the abdominal cavity was opened, 250 mg of 5-FU diluted in 20 ml saline was infused into the feeding artery in 16 patients with colonic cancer. After the affected lesion was resected, specimens were obtained at the tumor, at sites 5 and 10 cm from the center of the tumor, and at the adjacent nodes. The concentration of 5-FU was higher in the tumor and the adjacent lymph nodes than in the normal colon near the lesion. This suggests that 5-FU has a more favorable distribution profile in tumor tissue than in normal tissue. Patients with a high concentration of 5-FU in the tumor also demonstrated high levels in the other tissue. Blood flow volume and the length of time between the injection of 5-FU and harvest of the specimen may account for differences in the tissue concentration of the agent after administration of the same dose.

Liver with hypoechoic nodular pattern as a risk factor for hepatocellular carcinoma.

BACKGROUND/AIMS: Ultrasonography should be used for screening of hepatocellular carcinoma, but there are few reports on the relationship between liver ultrasonographic findings and the development of hepatocellular carcinoma (HCC). Using prospective follow-up studies, we examined the role of liver with a hypoechoic nodular pattern as a high-risk factor in HCC. METHODS: The study was performed by follow-up on 593 patients with chronic liver disease recorded at our hospital. The ultrasonographic pattern of the liver parenchyma was classified either as a small or large hypoechoic nodular pattern or as a nonnodular pattern. Patients were followed up from the time of initial ultrasonographic examination (1985-1987) until January 1, 1991. RESULTS: During the follow-up period (average, 4.2 years, range, 0.3-6.0 years), 62 patients were found to have HCC (12%). Patients whose livers showed small or large hypoechoic nodular pattern had a significantly higher risk of HCC than did patients whose livers showed a nonnodular pattern (rate ratios were 14.0 and 20.0, respectively, adjusted for age, sex, hepatitis virus markers, ICG R15, alpha-fetoprotein concentration, and ultrasonographic pattern of the liver). CONCLUSIONS: Liver showing a hypoechoic nodular pattern is a major risk factor in HCC.

Prevention of laparoscopic surgeon's thumb.

Laparoscopic surgery is being used in an increasing number of operations today. We have been performing various types of laparoscopic techniques in our department. A problem we sometimes have encountered involves a ring of pressure that develops around the surgeon's thumb at the end of the procedure, which is accompanied by an area of paresthesia in the distribution of the lateral digital nerve. We report our own experience and a small review of the literature.

Comparison between conventional and spiral CT in patients with hypervascular hepatocellular carcinoma.

To determine the usefulness of spiral CT in the detection of hypervascular hepatic lesions, we compared conventional contrast enhanced CT (CECT) with whole liver dynamic scanning during the artery-dominant phase by spiral CT (SDCT), using hypervascular hepatocellular carcinoma (HCC) as a model. Twenty-nine patients with 56 hypervascular nodular type HCCs detected by hepatic digital subtraction angiography were examined by both CT techniques. These nodular type HCCs were divided into three groups according to diameter: < 10 mm (n = 7), 10-20 mm (n = 17), and over 20 mm (n = 32). None of seven lesions less than 10 mm in diameter was seen by either technique. Of 17 lesions 10-20 mm in diameter, four (24%) were detected by precontrast CT plus CECT, whereas 14 (82%) were detected by precontrast CT plus SDCT. There were no lesions detected by CECT only, whereas 10 lesions were detected by SDCT only (P < 0.01 by signed test). For 32 lesions over 20 mm in diameter, there was no significant difference in detection rates between the CT techniques. Our results indicate that spiral CT is useful for the detection of relatively small hypervascular hepatic lesions such as hypervascular HCCs.

Analysis of factors affecting uptake of Tc-99m Sn-N-pyridoxyl-5-methyltryptophan by hepatocellular carcinoma.

We performed Tc-99m PMT imaging in 176 patients with HCC and evaluated factors affecting 99mTc-PMT uptake by HCC with a logistic model. The probability of HCC showing increase in uptake of the radioisotope was 104.6 times higher in patients with the Ed I type than in those with the Ed III type and 12.1 times higher in patients with a tumor diameter of 5.0-7.9 cm than in those with a tumor diameter of 2.0-5.0 cm. Among the other variables, the serum AFP level and sex were suggested to have effects similar to those of the tumor size on Tc-99m PMT uptake by HCC. The grade of morphological differentiation of the tumor was therefore most markedly related to Tc-99m PMT uptake.

Sarcomere dynamics in a spontaneous contraction wave and its effect on the following, electrically triggered twitch in rat myocyte. Comparison with the rested state twitch.

A spontaneous contraction (SC) wave propagates among sarcomeres in heart muscle by the mechanism of Ca(++)-induced release of Ca++ from sarcoplasmic reticulum (SR). In the present study, some characteristics of unloaded shortening during the SC and its effect on a subsequent, electrically triggered twitch (Tsc) were examined at a sarcomere level in isolated rat myocytes. The results were compared with those of a rested state twitch (RS), which was accompanied by an action potential. Average shortening velocity from onset to peak of shortening was 3.74 +/- 1.25 (mean +/- SD, n = 18) and 5.35 +/- 2.30 microns/s per sarcomere (n = 54) in SC and RS, respectively. That the former was smaller than the latter (P < 0.01, t test) suggests that Ca++ are released from the SR more slowly in the SC than the RS. There were no differences in either the extent or area of shortening between SC and RS. The extent of shortening increased significantly as shortening velocity increased in all the SC (P < 0.05), RS, Tsc, and triggered twitch (Trs) after the RS (P < 0.001 in the last three). The slope of the line for the regression of the extent upon the velocity of shortening in the SC was approximately 1.5 times greater than the other three. This suggests that the SC has a different time course of change of myoplasmic [Ca++] and therefore a different mode of the causal SR Ca++ release from the electrically triggered twitches (RS, Trs, Tsc). There were positive correlations between the extent and the area of shortening in each of the RS (P < 0.01), the Trs (P < 0.05), and the Tsc (P < 0.001), but not in SC. The slope of the line for the regression of the extent upon the area of shortening in the Tsc was about three times greater than those in the RS and the Trs, suggesting characteristics of the Tsc from different those of the RS and the Trs. An SC inhibited a Tsc in an interval-dependent manner. The shortening velocity in the Tsc recovered fully at a test interval of approximately 0.6 s between the onsets of the two successive contractions. The velocity increased further with further increasing the test interval (up to 0.9 s). At a test interval of 0.8-0.9 s, the shortening velocity in the Tsc was greater than those in the preceding SC and the corresponding Trs by 1.17- and 1.80-fold, respectively, as compared in the same five sarcomeres.(ABSTRACT TRUNCATED AT 400 WORDS)

[Evaluation of multislice dynamic MR imaging of the whole liver].

In 47 patients with liver cirrhosis, we performed dynamic MRI with a multisection FLASH technique that enabled us to obtain 13 T 1-weighted images of the entire liver within a single breath hold. Computed tomographic arterial portography (CTAP), US, CT, angiography (AOG) and MRI (spin echo [SE] and dynamic MRI) were performed in all 47 patients. Except for cyst, hemangioma and metastatic tumor, 104 focal nodules less than 3 cm in diameter were detected. These 104 focal lesions were divided into three groups according to the pattern of CTAP: 69 portal supply negative, 11 portal supply decreased, and 24 portal supply normal. In the portal supply negative group, 63 lesions (91%) were detected by dynamic MRI, which was superior to other modalities (US 77%, CT 41%, AOG 70%, MRI-SE 61%). The superiority of dynamic MRI resulted from its excellent ability to detect liver lesions less than 1 cm in diameter. We confirmed histologically that dynamic MRI had almost the same ability to detect hepatocellular carcinoma (HCC) as CTAP. Dynamic MRI should be clinically useful as a noninvasive examination for the detection of HCC.