Application Value of Enhanced CT Imaging Features in Predicting Vessels Encapsulating Tumor Clusters (VETC) Positivity in Hepatocellular Carcinoma

Background: VETC-positive has emerged as a novel predictor of HCC for poor prognosis. Enhanced CT is one of the most common diagnostic methods, which can indicate VETC positivity, providing important evidence for the diagnosis and treatment of VETC-positive HCC. Objective: The objective of this study is to investigate the clinical and preoperative enhanced CT imaging characteristics and diagnostic value of VETCpositive hepatocellular carcinoma (HCC) patients. Methods: A retrospective analysis was conducted on the clinical, pathological, and imaging data of 53 HCC patients from the First Affiliated Hospital of Ningbo University between June 2019 and September 2022. According to pathological results, patients were categorized into 11 VETC-positive and 42 VETC-negative cases. Observational parameters included: (1) Clinical indicators: gender, age, history of hepatitis B virus infection, preoperative AFP, TNM staging, and preoperative biochemical and coagulation laboratory tests, including Alb, AST, ALT, TBil, DB, PT, TT, and INR. Additionally, pathological results such as histological grading, microvascular invasion (MVI), satellite nodules, neural invasion, and postoperative recurrence were analyzed. (2) Preoperative enhanced CT observational indicators: maximum tumor diameter, intrahepatic growth, irregular tumor margins, peritumoral hepatic parenchymal enhancement, mosaic structure, non-ring-like arterial phase hyperenhancement, marked heterogeneous enhancement, non-peripheral washout, absence of enhancing capsule, enhancing/clear capsule, intratumoral arteries, intratumoral necrosis, along with measurement of unenhanced CT values and enhanced CT values at various phases, calculating enhancement ratios (enhancement ratio = enhanced CT value - unenhanced CT value / unenhanced CT value). Quantitative data were expressed as mean ± standard deviation (x̅±s), with intergroup comparisons conducted using the t-test; categorical variables were compared using the χ2 test or Fisher's exact test. Multivariate analysis employed stepwise regression for logistic regression, incorporating clinical and imaging characteristics into the logistic regression equation. Based on logistic regression results, receiver operating characteristic (ROC) curves were plotted, calculating the area under the curve (AUC), sensitivity, specificity, and their 95% confidence intervals (CI). Analysis on survival was performed using Kaplan-Meier methods and log-rank tests, aiming survival curves. Results: (1) Clinical characteristics of VETC-positive versus VETC-negative patients: Preoperative AFP levels showed statistical significance (P=0.037), while no significant differences were observed in gender, age, Alb, TB, DB, AST, ALT, PT, TT, and INR between VETC-positive and VETCnegative patients (P>0.05). (2) Enhanced CT imaging features of VETC-positive versus VETC-negative patients: Intratumoral necrosis showed statistical significance (P<0.05), with intratumoral arteries being 63.6% (7/11) in the positive group compared to 42.9% (18/42) in the negative group. No significant differences were found in maximum tumor diameter, irregular tumor margins, peritumoral hepatic parenchymal enhancement, mosaic structure, non-ring-like arterial phase hyperenhancement, marked heterogeneous enhancement, non-peripheral washout, absence of enhancing capsule, enhancing capsule, intratumoral arteries, as well as unenhanced CT values and enhanced CT values at various phases, arterial phase enhancement ratio, portal phase enhancement ratio, and delayed phase enhancement ratio (P>0.05). (3) Multivariate analysis influencing VETC positivity: Arterial phase CT values (HU) (OR=0.937, P=0.029), intratumoral arteries (OR=9.452, P=0.021), and intratumoral necrosis (OR=0.013, P=0.003) were identified as independent risk factors for VETC positivity (Odds Ratio=0.937, 9.452, 0.013, 95% CI=0.883-0.993, 1.4-63.823, 0.001-0.223, P<0.05). The AUC of VETC was 0.863 (95% CI: 0.728-0.997), with a sensitivity of 81.8% and specificity of 88.1%. (4) Postoperative early tumor recurrence in VETC-positive and VETC-negative patients: All 53 patients were followed up, with an average tumor recurrence time of 11 (4-20) months, showing significant differences (P<0.05). Conclusion: As one of the routine and preferred methods for HCC examination, enhanced CT plays a pivotal role in diagnosis, staging, and post-treatment evaluation. Combining preoperative enhanced arterial phase CT values, intratumoral arteries, and intratumoral necrosis can highly indicate VETC positivity.