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Jahn M, Layer G. [Multiparametric MRI in hepatocellular carcinoma, part 2 : Diffusion-weighted imaging in the primary diagnostics and treatment monitoring]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:587-596. [PMID: 38884639 DOI: 10.1007/s00117-024-01323-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/18/2024]
Abstract
In addition to morphology and tissue perfusion, diffusion-weighted imaging (DWI) is the third pillar of multiparametric diagnostics in oncology. Due to the strong correlation between the apparent diffusion coefficient (ADC) and cell count in hepatocellular carcinoma (HCC), it can be used as a surrogate marker for tumor cell quantity. Therefore, ADC effectively reflects the effects of cytoreductive treatment, such as transarterial chemoembolization (TACE) and systemic chemotherapy and becomes an important clinical marker for treatment response. The DWI should remain an integral part of a magnetic resonance imaging (MRI) protocol in primary HCC diagnostics and treatment monitoring but is of secondary clinical importance compared to contrast-enhanced MRI perfusion sequences and the use of liver-specific contrast agents. For the future, standardization of DWI sequences for better comparability of various study protocols would be desirable.
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Affiliation(s)
- Mona Jahn
- Zentralinstitut für Diagnostische und Interventionelle Radiologie, Klinikum der Stadt Ludwigshafen am Rhein gGmbH, Bremserstraße 79, 67063, Ludwigshafen, Deutschland.
| | - Günter Layer
- Zentralinstitut für Diagnostische und Interventionelle Radiologie, Klinikum der Stadt Ludwigshafen am Rhein gGmbH, Bremserstraße 79, 67063, Ludwigshafen, Deutschland
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Nadarevic T, Colli A, Giljaca V, Fraquelli M, Casazza G, Manzotti C, Štimac D, Miletic D. Magnetic resonance imaging for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease. Cochrane Database Syst Rev 2022; 5:CD014798. [PMID: 35521901 PMCID: PMC9074390 DOI: 10.1002/14651858.cd014798.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and third in terms of cancer deaths. In clinical practice, magnetic resonance imaging (MRI) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-fetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study (computed tomography (CT) or MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is considered valid to diagnose hepatocellular carcinoma. The detection of hepatocellular carcinoma amenable to surgical resection could improve the prognosis. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma may, therefore, be missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of MRI may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of MRI in people with chronic liver disease who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma. OBJECTIVES Primary: to assess the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease. Secondary: to assess the diagnostic accuracy of MRI for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease, and to identify potential sources of heterogeneity in the results. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test of Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, and three other databases to 9 November 2021. We manually searched articles retrieved, contacted experts, handsearched abstract books from meetings held during the last 10 years, and searched for literature in OpenGrey (9 November 2021). Further information was requested by e-mails, but no additional information was provided. No data was obtained through correspondence with investigators. We applied no language or document-type restrictions. SELECTION CRITERIA Studies assessing the diagnostic accuracy of MRI for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up. DATA COLLECTION AND ANALYSIS At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and we tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses. MAIN RESULTS We included 34 studies, with 4841 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time interval between the index test and the reference standard was rarely defined. Regarding applicability, we judged 15% (5/34) of studies to be at low concern and 85% (29/34) of studies to be at high concern mostly owing to characteristics of the participants, most of whom were on waiting lists for orthotopic liver transplantation, and due to pathology of the explanted liver being the only reference standard. MRI for hepatocellular carcinoma of any size and stage: sensitivity 84.4% (95% CI 80.1% to 87.9%) and specificity 93.8% (95% CI 90.1% to 96.1%) (34 studies, 4841 participants; low-certainty evidence). MRI for resectable hepatocellular carcinoma: sensitivity 84.3% (95% CI 77.6% to 89.3%) and specificity 92.9% (95% CI 88.3% to 95.9%) (16 studies, 2150 participants; low-certainty evidence). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results. AUTHORS' CONCLUSIONS We found that using MRI as a second-line imaging modality to diagnose hepatocellular carcinoma of any size and stage, 16% of people with hepatocellular carcinoma would be missed, and 6% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 16% of people with resectable hepatocellular carcinoma would improperly not be resected, while 7% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.
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Affiliation(s)
- Tin Nadarevic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Vanja Giljaca
- Department of Gastroenterology, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Cristina Manzotti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca´ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davor Štimac
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Damir Miletic
- Department of Radiology , Clinical Hospital Centre Rijeka, Rijeka, Croatia
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Zhao J, Li D, Xiao X, Accorsi F, Marshall H, Cossetto T, Kim D, McCarthy D, Dawson C, Knezevic S, Chen B, Li S. United adversarial learning for liver tumor segmentation and detection of multi-modality non-contrast MRI. Med Image Anal 2021; 73:102154. [PMID: 34280670 DOI: 10.1016/j.media.2021.102154] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/13/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023]
Abstract
Simultaneous segmentation and detection of liver tumors (hemangioma and hepatocellular carcinoma (HCC)) by using multi-modality non-contrast magnetic resonance imaging (NCMRI) are crucial for the clinical diagnosis. However, it is still a challenging task due to: (1) the HCC information on NCMRI is insufficient makes extraction of liver tumors feature difficult; (2) diverse imaging characteristics in multi-modality NCMRI causes feature fusion and selection difficult; (3) no specific information between hemangioma and HCC on NCMRI cause liver tumors detection difficult. In this study, we propose a united adversarial learning framework (UAL) for simultaneous liver tumors segmentation and detection using multi-modality NCMRI. The UAL first utilizes a multi-view aware encoder to extract multi-modality NCMRI information for liver tumor segmentation and detection. In this encoder, a novel edge dissimilarity feature pyramid module is designed to facilitate the complementary multi-modality feature extraction. Secondly, the newly designed fusion and selection channel is used to fuse the multi-modality feature and make the decision of the feature selection. Then, the proposed mechanism of coordinate sharing with padding integrates the multi-task of segmentation and detection so that it enables multi-task to perform united adversarial learning in one discriminator. Lastly, an innovative multi-phase radiomics guided discriminator exploits the clear and specific tumor information to improve the multi-task performance via the adversarial learning strategy. The UAL is validated in corresponding multi-modality NCMRI (i.e. T1FS pre-contrast MRI, T2FS MRI, and DWI) and three phases contrast-enhanced MRI of 255 clinical subjects. The experiments show that UAL gains high performance with the dice similarity coefficient of 83.63%, the pixel accuracy of 97.75%, the intersection-over-union of 81.30%, the sensitivity of 92.13%, the specificity of 93.75%, and the detection accuracy of 92.94%, which demonstrate that UAL has great potential in the clinical diagnosis of liver tumors.
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Affiliation(s)
- Jianfeng Zhao
- Shandong Key Laboratory of Medical Physics and Image Processing, Shandong Institute of Industrial Technology for Health Sciences and Precision Medicine, School of Physics and Electronics, Shandong Normal University, Jinan, 250358, China; Digital Imaging Group of London, London, ON, Canada
| | - Dengwang Li
- Shandong Key Laboratory of Medical Physics and Image Processing, Shandong Institute of Industrial Technology for Health Sciences and Precision Medicine, School of Physics and Electronics, Shandong Normal University, Jinan, 250358, China.
| | - Xiaojiao Xiao
- School of Information and Computer, Taiyuan University of Technology, Shanxi, 030000, China; Digital Imaging Group of London, London, ON, Canada
| | - Fabio Accorsi
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Harry Marshall
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Tyler Cossetto
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Dongkeun Kim
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Daniel McCarthy
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Cameron Dawson
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Stefan Knezevic
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada
| | - Bo Chen
- Digital Imaging Group of London, London, ON, Canada
| | - Shuo Li
- Department of Medical Imaging, Western University, London, ON, Canada; Digital Imaging Group of London, London, ON, Canada.
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Shao YY, Wang SY, Lin SM. Management consensus guideline for hepatocellular carcinoma: 2020 update on surveillance, diagnosis, and systemic treatment by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan. J Formos Med Assoc 2021; 120:1051-1060. [PMID: 33199101 DOI: 10.1016/j.jfma.2020.10.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/28/2020] [Accepted: 10/30/2020] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in Taiwan. The Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan had established a management consensus guideline in 2016. The current recommendations focus on updating critical issues regarding the management of HCC, including surveillance, diagnosis, and systemic treatment. For surveillance, the updated guideline suggests the role of dynamic computed tomography or magnetic resonance imaging and contrast-enhanced ultrasound (CEUS) in selected patients. For diagnosis, this update incorporates CEUS and recognizes the role of gadoxetic acid-enhanced magnetic resonance imaging. For systemic therapy, the updated guideline summarizes the multiple choices of targeted therapy, immune checkpoint inhibitors, and the combination of both. Through this update of the management consensus guideline, patients with HCC can benefit from receiving optimal diagnostic and therapeutic modalities.
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Affiliation(s)
- Yu-Yun Shao
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shen-Yung Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shi-Ming Lin
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Medicine, MacKay Memorial Hospital, Taipei, Taiwan.
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Lan H, Lin G, Zhong W. A meta-analysis of the added value of diffusion weighted imaging in combination with contrast-enhanced magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma lesser or equal to 2 cm. Oncol Lett 2020; 20:2739-2748. [PMID: 32782590 PMCID: PMC7400770 DOI: 10.3892/ol.2020.11805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/02/2020] [Indexed: 02/05/2023] Open
Abstract
Diffusion weighted imaging (DWI) has been found to increase the sensitivity in the diagnosis of small hepatocellular carcinoma (HCC), although additional studies are required to confirm its value. The aim of the present study was to explore the diagnostic performance of DWI combined with contrast-enhanced magnetic resonance imaging (MRI) for small HCC by performing a meta-analysis. Literature databases (PubMed, Embase, Web of Science and Cochrane Library databases) were searched to identify studies reporting the sensitivity and specificity of MRI with DWI for the diagnosis of small HCCs. Pooled sensitivity and specificity were generated using a bivariate random effect model. Multilevel mixed-effects logistic regression analysis was used to examine the value of DWI combined with conventional MRI. A total of 837 small HCCs and 545 benign liver lesions from 10 studies were included. The overall sensitivity and specificity of DWI combined with contrast-enhanced MRI was 0.88 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.81-0.95), respectively. Compared with that in contrast-enhanced MRI, DWI with contrast-enhanced MRI had a significantly higher sensitivity for the diagnosis of small HCC (P=0.01) while there was no significant difference in the specificity (P=0.603). The present meta-analysis suggests that DWI combined with contrast-enhanced MRI may increase the sensitivity, whilst maintaining high specificity for the diagnosis of small HCCs with a diameter ≤2 cm.
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Affiliation(s)
- Hailong Lan
- Department of Radiology, Wuchuan People's Hospital, Wuchuan, Guangdong 524500, P.R. China
- Department of Radiology, Xiaolan Hospital Affiliated to Southern Medical University, Zhongshan, Guangdong 528000, P.R. China
- Correspondence to: Dr Hailong Lan, Department of Radiology, Wuchuan People's Hospital, 12 Jiefang North Road, Wuchuan, Guangdong 524500, P.R. China, E-mail:
| | - Guisen Lin
- Department of Radiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515000, P.R. China
| | - Weizhi Zhong
- Department of Radiology, Wuchuan People's Hospital, Wuchuan, Guangdong 524500, P.R. China
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Cha DI, Choi GS, Kim YK, Kim JM, Kang TW, Song KD, Ahn SH. Extracellular contrast-enhanced MRI with diffusion-weighted imaging for HCC diagnosis: prospective comparison with gadoxetic acid using LI-RADS. Eur Radiol 2020; 30:3723-3734. [DOI: 10.1007/s00330-020-06753-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/05/2020] [Accepted: 02/17/2020] [Indexed: 02/08/2023]
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The utility of diffusion-weighted imaging in improving the sensitivity of LI-RADS classification of small hepatic observations suspected of malignancy. Abdom Radiol (NY) 2019; 44:1773-1784. [PMID: 30603882 DOI: 10.1007/s00261-018-01887-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE We investigated the added value of diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC) in the categorization of small hepatic observation (≤ 20 mm) detected in patients with chronic liver disease in reference to LI-RADS (liver imaging reporting and data system) classification system. METHODS We prospectively evaluated 165 patients with chronic liver disease with small hepatic observations (≤ 20 mm) which were previously categorized as LI-RADS grade 3-5 on dynamic contrast-enhanced CT (DCE-CT). All patients were submitted to a functional MRI including DCE and DWI. Using LI-RADS v2017, two radiologists independently evaluated the observations and assigned a LI-RADS category to each observation using DCE-MRI alone and combined DCE-MRI and DWI/ADC. In the combined technique, the radiologists assigned a LI-RADS category based on a modified LI-RADS criteria in which restricted diffusion on DWI was considered a major feature of HCC. We evaluated the inter-reader agreement with Kappa statistics and compared the diagnostic performance of the LI-RADS with two imaging techniques by Fisher's exact test using histopathology as the reference standard. RESULTS Combined technique in LI-RADS yielded better sensitivities (reader 1, 97% [65/67]; reader 2, 95.5% [64/67]) for HCC diagnosis than DCE-MRI alone (reader 1, 80.6% [54/67], p = 0.005; reader 2, 83.6% [56/67], p = 0.04). The specificities were insignificantly lower in combined technique (reader 1, 88.4% [107/121]; reader 2, 77.7% [94/121]) than in DCE-MRI alone (reader 1, 90.9% [110/121], p = 0.67; reader 2, 79.3% [96/121], p = 0.88). The inter-reader agreement of the LI-RADS scores between combined technique and DCE-MRI was good (κ = 0.765). CONCLUSION The use of DWI/ADC as an additional major criterion, improved the sensitivity of LI-RADS in the diagnosis of HCC while keeping high specificity.
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Barua SK, Kaman PK, Baruah SJ, T P R, Bagchi PK, Sarma D, Singh Y. Role of Diffusion-Weighted Magnetic Resonance Imaging (DWMRI) in Assessment of Primary Penile Tumor Characteristics and Its Correlations With Inguinal Lymph Node Metastasis: A Prospective Study. World J Oncol 2018; 9:145-150. [PMID: 30524639 PMCID: PMC6279457 DOI: 10.14740/wjon1138w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022] Open
Abstract
Background Penile cancer is a rare malignancy. The extent of lymph node (LN) metastasis is the most important prognostic factor in penile cancer. However, preoperative prediction of LN involvement in clinically non-palpable LN is still a challenge. In absence of a reliable biomarker, attempts are being made to validate imaging characteristics as a predictive tool. The aim of the present study is to assess the primary penile tumor characteristics with diffusion-weighted magnetic resonance imaging (DWMRI) and its correlations with inguinal LN status and tumor positivity in LN dissection specimen within normal sized LNs. Methods Twenty-six patients with carcinoma penis underwent DWMRI of penis and pelvis. The apparent diffusion coefficient (ADC) values of primary tumor were compared with histological characteristics. Inclusion criteria encompassed all cases of clinically non-palpable inguinal LN and normal sized LN on imaging. All palpable inguinal nodes with pelvic lymphadenopathies were excluded from this study. Results The primary tumor ADC ranged from 0.65 × 10-3 - 1.2 × 10-3 mm2/s (mean: 0.87 × 10-3 ± 0.11 × 10-3 mm2/s). In pT1 and pT3 tumors, mean ADC values were 0.86 × 10-3 ± 0.10 × 10-3 and 0.81 × 103 ± 0.09 × 103 mm2/s, respectively. The mean ADC values for grade 1, grade 2 and grade 3 were 0.89 × 10-3, 0.82 × 10-3 and 0.80 × 10-3 mm2/s, respectively. The ADC value of < 0.95 × 10-3 mm2/s was positively correlated with pathological LN presence within normal sized LN. With mean ADC value of 0.87 × 10-3 ± 0.11 × 10-3 mm2/s, sensitivity and positive predictive values for primary penile cancer were 100% and 84.61%, respectively. The mean ADC value for higher-grade and -stage tumor was low. The sensitivity and specificity of predicting LN metastasis by DWMRI were 87.22% and 80.90%, respectively. Conclusion ADC value of primary tumor can help in prediction of LN metastasis in carcinoma penis with clinically and radiologically normal groin.
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Affiliation(s)
- Sasanka Kumar Barua
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Pranab K Kaman
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Saumar Jyoti Baruah
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Rajeev T P
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Puskal K Bagchi
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Debanga Sarma
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
| | - Yashasvi Singh
- Department of Urology, Gauhati Medical College Hospital, Guwahati, Assam, India
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Kuai ZX, Sang XQ, Yao YF, Chu CY, Zhu YM. Evaluation of non-monoexponential diffusion models for hepatocellular carcinoma using b values up to 2000 s/mm 2 : A short-term repeatability study. J Magn Reson Imaging 2018; 50:297-304. [PMID: 30447032 DOI: 10.1002/jmri.26563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Non-monoexponential diffusion models are being used increasingly for the characterization and curative effect evaluation of hepatocellular carcinoma (HCC). But the fitting quality of the models and the repeatability of their parameters have not been assessed for HCC. PURPOSE To evaluate kurtosis, stretched exponential, and statistical models for diffusion-weighted imaging (DWI) of HCC, using b-values up to 2000 s/mm2 , in terms of fitting quality and repeatability. STUDY TYPE Prospective. POPULATION Eighteen patients with HCC. FIELD STRENGTH/SEQUENCE Conventional and DW images (b = 0, 200, 500, 1000, 1500, 2000 s/mm2 ) were acquired at 3.0T. ASSESSMENT The parameters of the kurtosis, stretched exponential, and statistical models were calculated on regions of interest (ROIs) of each lesion. STATISTICAL TESTS The fitting quality was evaluated through comparing the fitting residuals produced on the average data of ROI between different models using a paired t-test or Wilcoxon rank-sum test. Repeatability of the fitted parameters at the median values on the voxelwise data of ROI was assessed using the within coefficient of variation (WCV), the intraclass correlation coefficient (ICC), and the 95% Bland-Altman limits of agreements (BA-LA). The repeatability was divided into four levels: excellent, good, acceptable, and poor, referring to the values of ICC and WCV. RESULTS Among three models, the stretched exponential model provided the best fit to HCC (P < 0.05), whereas the statistical model produced the largest fitting residuals (P < 0.05). The repeatability of K from the kurtosis model was excellent (ICC 0.915; WCV 8.79%), while the distributed diffusion coefficient (DDC) from the stretched model was just acceptable (ICC 0.477; WCV 27.83%). The repeatability was good for other diffusion-related parameters. DATA CONCLUSION Considering the model fit and repeatability, the kurtosis and stretched exponential models are the preferred models for the description of the DW signals of HCC with respect to the statistical model. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:297-304.
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Affiliation(s)
- Zi-Xiang Kuai
- Imaging Center, Harbin Medical University Cancer Hospital, Harbin, P.R. China
| | - Xi-Qiao Sang
- Division of Respiratory Disease, Fourth Hospital of Harbin Medical University, Harbin, 150001, China
| | - Yuan-Fei Yao
- Imaging Center, Harbin Medical University Cancer Hospital, Harbin, P.R. China
| | - Chun-Yu Chu
- College of Engineering, Bohai University, Jinzhou, P.R. China
| | - Yue-Min Zhu
- CREATIS, CNRS UMR 5220-INSERM U1206-University Lyon 1-INSA Lyon-University, Lyon, France
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Renzulli M, Biselli M, Brocchi S, Granito A, Vasuri F, Tovoli F, Sessagesimi E, Piscaglia F, D'Errico A, Bolondi L, Golfieri R. New hallmark of hepatocellular carcinoma, early hepatocellular carcinoma and high-grade dysplastic nodules on Gd-EOB-DTPA MRI in patients with cirrhosis: a new diagnostic algorithm. Gut 2018; 67:1674-1682. [PMID: 29437912 DOI: 10.1136/gutjnl-2017-315384] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/02/2018] [Accepted: 01/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Many improvements have been made in diagnosing hepatocellular carcinoma (HCC), but the radiological hallmarks of HCC have remained the same for many years. We prospectively evaluated the imaging criteria of HCC, early HCC and high-grade dysplastic nodules (HGDNs) in patients under surveillance for chronic liver disease, using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) MRI and diffusion-weighted imaging. DESIGN Our study population included 420 nodules >1 cm in 228 patients. The MRI findings of each nodule were collected in all sequences/phases. The diagnosis of HCC was made according to the American Association for the Study of Liver Diseases (AASLD) criteria; all atypical nodules were diagnosed using histology. RESULTS A classification and regression tree was developed using three MRI findings which were independently significant correlated variables for early HCC/HCC, and the best sequence of their application in a new diagnostic algorithm (hepatobiliary hypointensity, arterial hyperintensity and diffusion restriction) was suggested. This algorithm demonstrated, both in the entire study population and for nodules ≤2 cm, higher sensitivity (96% [95% CI 93.5% to 97.6%] and 96.6% [95% CI 93.9% to 98.5%], P<0.001, respectively) and slightly lower specificity (91.8% [95% CI 88.6% to 94.1%], P=0.063, and 92.7% [95% CI 88.9% to 95.4%], P=0.125, respectively) than those of the AASLD criteria. Our new diagnostic algorithm also showed a very high sensitivity (94.7%; 95% CI 92% to 96.6%) and specificity (99.3%; 95% CI 97.7% to 99.8%) in classifying HGDN. CONCLUSION Our new diagnostic algorithm demonstrated significantly higher sensitivity and comparable specificity than those of the AASLD imaging criteria for HCC in patients with cirrhosis evaluated using Gd-EOB-DTPA MRI, even for lesions ≤2 cm. Moreover, this diagnostic algorithm allowed evaluating other lesions which could arise in a cirrhotic liver, such as early HCC and HGDN.
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Affiliation(s)
- Matteo Renzulli
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Maurizio Biselli
- Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Stefano Brocchi
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Granito
- Unit of Internal Medicine, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesco Vasuri
- 'F Addarii' Institute of Oncology and Transplantation Pathology, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Francesco Tovoli
- Unit of Internal Medicine, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Elisa Sessagesimi
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fabio Piscaglia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonietta D'Errico
- 'F Addarii' Institute of Oncology and Transplantation Pathology, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luigi Bolondi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Diagnostic Medicine and Prevention, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
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Ippolito D, Inchingolo R, Grazioli L, Drago SG, Nardella M, Gatti M, Faletti R. Recent advances in non-invasive magnetic resonance imaging assessment of hepatocellular carcinoma. World J Gastroenterol 2018; 24:2413-2426. [PMID: 29930464 PMCID: PMC6010944 DOI: 10.3748/wjg.v24.i23.2413] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/27/2018] [Accepted: 05/12/2018] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance (MR) imaging of the liver is an important tool for the detection and characterization of focal liver lesions and for assessment of diffuse liver disease, having several intrinsic characteristics, represented by high soft tissue contrast, avoidance of ionizing radiation or iodinated contrast media, and more recently, by application of several functional imaging techniques (i.e., diffusion-weighted sequences, hepatobiliary contrast agents, perfusion imaging, magnetic resonance (MR)-elastography, and radiomics analysis). MR functional imaging techniques are extensively used both in routine practice and in the field of clinical and pre-clinical research because, through a qualitative rather than quantitative approach, they can offer valuable information about tumor tissue and tissue architecture, cellular biomarkers related to the hepatocellular functions, or tissue vascularization profiles related to tumor and tissue biology. This kind of approach offers in vivo physiological parameters, capable of evaluating physiological and pathological modifications of tissues, by the analysis of quantitative data that could be used in tumor detection, characterization, treatment selection, and follow-up, in addition to those obtained from standard morphological imaging. In this review we provide an overview of recent advanced techniques in MR for the diagnosis and staging of hepatocellular carcinoma, and their role in the assessment of response treatment evaluation.
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Affiliation(s)
- Davide Ippolito
- School of Medicine, University of Milano-Bicocca, Milan 20126, Italy
- Department of Diagnostic Radiology, HS Gerardo Monza, Monza (MB) 20900, Italy
| | - Riccardo Inchingolo
- Division of Interventional Radiology, Department of Radiology, Madonna delle Grazie Hospital, Matera 75100, Italy
| | - Luigi Grazioli
- Department of Radiology, University of Brescia “Spedali Civili”, Brescia 25123, Italy
| | - Silvia Girolama Drago
- School of Medicine, University of Milano-Bicocca, Milan 20126, Italy
- Department of Diagnostic Radiology, HS Gerardo Monza, Monza (MB) 20900, Italy
| | - Michele Nardella
- Division of Interventional Radiology, Department of Radiology, Madonna delle Grazie Hospital, Matera 75100, Italy
| | - Marco Gatti
- Department of Surgical Sciences, Radiology Unit, University of Turin, Turin 10126, Italy
| | - Riccardo Faletti
- Department of Surgical Sciences, Radiology Unit, University of Turin, Turin 10126, Italy
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12
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Does intravoxel incoherent motion reliably stage hepatic fibrosis, steatosis, and inflammation? Abdom Radiol (NY) 2018; 43:600-606. [PMID: 28828711 DOI: 10.1007/s00261-017-1263-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate the usefulness of intravoxel incoherent motion (IVIM) in determining the severity of hepatic fibrosis, steatosis, and inflammation in patients with chronic liver disease. METHODS Forty-nine patients who had liver MRI with IVIM sequence and liver biopsy within three months of MRI were enrolled. A reviewer, blinded to histology, placed regions of interest of 1-2 cm2 in the right liver lobe. In addition, the first twenty patients were assessed with a second reviewer. Perfusion fraction (f), pseudodiffusion coefficient (D fast), true diffusion coefficient (D slow), and apparent diffusion coefficient (ADC) were calculated from normalized signal intensities that were fitted into a biexponential model. Errors in the model were minimized with global stochastic optimization using Simulated Annealing. ANOVA with post hoc Tukey-Kramer test and multivariate generalized linear model analysis were performed, using histological findings as the gold standard. RESULTS The most common etiologies for liver disease were hepatitis C and alcohol, accounting together for 76% (37/49) of patients. Low-grade fibrosis (F0, F1), hepatic steatosis, and inflammation were seen in 24% (12/49), 31% (15/49), and 29% (14/49) of patients, respectively. The interobserver correlation was poor for D fast and D slow (0.105, 0.173) and moderate for f and ADC (0.461, 0.418). ANOVA showed a strong inverse association between D fast and liver fibrosis grade (p = 0.001). A weak inverse association was seen between ADC and hepatic steatosis (p = 0.059). Multivariate general linear model revealed that the only significant association between IVIM parameters and pathological features was between D fast and fibrosis. On ROC curve analysis, D fast < 23.4 × 10-3 mm2/s had a sensitivity of 82.8% and a specificity of 64.3% in predicting high-grade fibrosis. CONCLUSION D fast has the strongest association with hepatic fibrosis but has weak interobserver correlation. IVIM parameters were not significantly associated with hepatic inflammation or steatosis.
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Kim HA, Kim KA, Choi JI, Lee JM, Lee CH, Kang TW, Ku YM, Lee SL, Park YS, Yoon JH, Kim SH, Choi MH. Comparison of biannual ultrasonography and annual non-contrast liver magnetic resonance imaging as surveillance tools for hepatocellular carcinoma in patients with liver cirrhosis (MAGNUS-HCC): a study protocol. BMC Cancer 2017; 17:877. [PMID: 29268722 PMCID: PMC5740703 DOI: 10.1186/s12885-017-3819-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/22/2017] [Indexed: 01/07/2023] Open
Abstract
Background Ultrasonography (US) is recommended as a standard surveillance tool for patients with a high risk of developing hepatocellular carcinoma (HCC). However, the low sensitivity of US for small HCC can lead to surveillance failure, resulting in advanced stage tumor presentations. For the early detection of HCC in high-risk patients and to improve survival and prognosis, a new efficient imaging tool with a high sensitivity for HCC detection is needed. The purpose of this study is to evaluate and compare the feasibility and efficacy of non-contrast magnetic resonance imaging (MRI) with US as a surveillance tool for HCC in patients with liver cirrhosis. Methods MAGNUS-HCC is a prospective, multicenter clinical trial with a crossover design for a single arm of patients. This study was approved by six Institutional Review Boards, and informed consent was obtained from all participants. All patients will undergo liver US every 6 months and non-contrast liver MRI every 12 months during a follow-up period of 3 years. If a focal liver lesion suspected of harboring HCC is detected, dynamic liver computed tomography (CT) will be performed to confirm the diagnosis. After the last surveillance round, patients without suspicion of HCC or who are not diagnosed with HCC will be evaluated with a dynamic liver CT to exclude false-negative findings. The primary endpoint is to compare the rate of detection of HCC by US examinations performed at 6-month intervals with that of yearly non-contrast liver MRI studies during a 3-year follow-up. The secondary endpoint is the survival of the patients who developed HCC within the 3-year follow-up period. Discussion MAGNUS-HCC is the first study to compare the feasibility of non-contrast MRI with US as a surveillance tool for the detection of HCC in high-risk patients. We anticipate that the evidence presented in this study will establish the efficacy of non-contrast MRI as a surveillance tool for HCC in high-risk patients. Trial registration The date of trial registration (NCT02551250) in this study was September 15, 2015, and follow-up is still ongoing.
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Affiliation(s)
- Hyun A Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea
| | - Kyung Ah Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea.
| | - Joon-Il Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, Republic of Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, 148 Urodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Tae Wook Kang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Young-Mi Ku
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271 Cheon bo-ro, Uijeongbu, Gyeonggi-do, Republic of Korea
| | - Su Lim Lee
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271 Cheon bo-ro, Uijeongbu, Gyeonggi-do, Republic of Korea
| | - Yang Shin Park
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, 148 Urodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Seong Hyun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Moon Hyung Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, Republic of Korea
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14
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Shin SK, Kim YS, Choi SJ, Shim YS, Jung DH, Kwon OS, Choi DJ, Kim JH. Characterization of small (≤3 cm) hepatic lesions with atypical enhancement feature and hypointensity in hepatobiliary phase of gadoxetic acid-enhanced MRI in cirrhosis: A STARD-compliant article. Medicine (Baltimore) 2017; 96:e7278. [PMID: 28723741 PMCID: PMC5521881 DOI: 10.1097/md.0000000000007278] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
It is difficult to characterize the nodular lesions in cirrhotic liver if typical enhancement pattern is not present on dynamic contrast-enhanced imagings. Although the signal intensity of the hepatobiliary phase in gadoxetic acid-enhanced magnetic resonance imaging (MRI) is helpful for characterization of the lesions, some dysplastic nodules may also exhibit low signal intensity in the hepatobiliary phase. We aimed to assess the usefulness of gadoxetic acid (Gd-EOB-DTPA)-enhanced MRI including diffusion-weighted imaging (DWI) for differentiation between atypical small hepatocellular carcinomas (HCCs) and dysplastic nodules showing low signal intensity (SI) in the hepatobiliary phase, and to evaluate the MRI findings in determining the histological grade of atypical HCCs in patients with cirrhosis.A total of 43 cirrhotic patients with a small (≤3 cm) liver nodule (n = 25, HCC; n = 18, dysplastic nodule) who underwent Gd-EOB-DTPA-enhanced MRI and pathologic confirmation were retrospectively reviewed. Atypical HCC was defined as not showing arterial hyperenhancement and delayed washout on dynamic MRI.High SI on both T2WI and DWI (sensitivity 80.0%, specificity 100%, positive predictive value 100%, negative predictive value 78.3%) was the most specific feature to differentiate atypical HCCs from dysplastic nodules. High SI on both T2WI and DWI (100% vs 61.5%, P = .039) or low SI on pre-enhanced T1WI (83.3% vs 30.8%, P = .021) was more frequent observed in Edmonson grade II-III HCCs compared with those in grade I HCCs.The combination of DWI and T2WI is most useful for the differentiation of atypical small HCCs from dysplastic nodules showing low SI in the hepatobiliary phase. Combination of DWI and T2WI or pre-enhanced T1WI seems to be useful for predicting the histological grade of atypical HCCs.
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Affiliation(s)
| | | | | | | | - Dong Hae Jung
- Department of Pathology, Gachon University Gil Medical Center, Incheon, Republic of Korea
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15
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Abstract
There is great geographical variation in the distribution of hepatocellular carcinoma (HCC), with the majority of all cases worldwide found in the Asia–Pacific region, where HCC is one of the leading public health problems. Since the “Toward Revision of the Asian Pacific Association for the Study of the Liver (APASL) HCC Guidelines” meeting held at the 25th annual conference of the APASL in Tokyo, the newest guidelines for the treatment of HCC published by the APASL has been discussed. This latest guidelines recommend evidence-based management of HCC and are considered suitable for universal use in the Asia–Pacific region, which has a diversity of medical environments.
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16
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Ramalho M, Matos AP, AlObaidy M, Velloni F, Altun E, Semelka RC. Magnetic resonance imaging of the cirrhotic liver: diagnosis of hepatocellular carcinoma and evaluation of response to treatment - Part 2. Radiol Bras 2017; 50:115-125. [PMID: 28428655 PMCID: PMC5397003 DOI: 10.1590/0100-3984.2015.0140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the second part of this review, we will describe the ancillary imaging features of hepatocellular carcinoma (HCC) that can be seen on standard magnetic resonance imaging (MRI) protocol, and on novel and emerging protocols such as diffusion weighted imaging and utilization of hepatocyte-specific/hepatobiliary contrast agent. We will also describe the morphologic sub-types of HCC, and give a simplified non-invasive diagnostic algorithm for HCC, followed by a brief description of the liver imaging reporting and data system (LI-RADS), and MRI assessment of tumor response following locoregional therapy.
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Affiliation(s)
- Miguel Ramalho
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, and Hospital Garcia de Orta, Almada, Portugal
| | - António P Matos
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, and Hospital Garcia de Orta, Almada, Portugal
| | - Mamdoh AlObaidy
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, and King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fernanda Velloni
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ersan Altun
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Richard C Semelka
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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17
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Choi SH, Byun JH, Lim YS, Yu E, Lee SJ, Kim SY, Won HJ, Shin YM, Kim PN. Diagnostic criteria for hepatocellular carcinoma ⩽3 cm with hepatocyte-specific contrast-enhanced magnetic resonance imaging. J Hepatol 2016; 64:1099-1107. [PMID: 26820629 DOI: 10.1016/j.jhep.2016.01.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 01/13/2016] [Accepted: 01/19/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Current diagnostic imaging criteria for hepatocellular carcinoma (HCC) are dedicated to imaging with nonspecific extracellular contrast agents. This study aimed to evaluate diagnostic criteria for HCC ⩽3 cm on magnetic resonance imaging (MRI) with a hepatocyte-specific contrast agent through an inception cohort study. METHODS Of 291 patients with chronic liver disease and new nodules of 1-3 cm in diameter at surveillance ultrasonography, 295 solid nodules (194 HCCs, 98 benign nodules, and three other malignancies) in 198 patients with a confirmed final diagnosis or ⩾24 months follow-up were evaluated on gadoxetic acid-enhanced MRI. Through univariate and multivariate logistic regression analyses, various diagnostic criteria were developed by combining significant MRI findings for diagnosing HCC. The diagnostic performance of each criterion was compared with that of the European Association for the Study of the Liver (EASL) criteria. RESULTS Four MRI findings (arterial-phase hyperintensity, transitional-phase hypointensity, hepatobiliary-phase hypointensity, and rim enhancement) were independently significant for diagnosis of HCC ⩽3 cm. For whole nodules, EASL criteria showed the best performance for diagnosing HCC (sensitivity, 83.5%; specificity, 81.2%). For nodules ⩽2 cm in diameter, a new criterion (arterial-phase hyperintensity and hepatobiliary-phase hypointensity) showed a significantly higher sensitivity than that of the EASL criteria (83.0% vs. 74.5%, p=0.008), without a significantly different specificity (76.7% vs. 81.1%, p=0.125). CONCLUSIONS EASL criteria exhibit the best diagnostic performance for HCC ⩽3 cm on hepatocyte-specific contrast-enhanced MRI. A newly identified criterion (arterial-phase hyperintensity and hepatobiliary-phase hypointensity) may increase the diagnostic sensitivity of small (⩽2 cm) HCC.
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Affiliation(s)
- Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea.
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Eunsil Yu
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - So Jung Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Hyung Jin Won
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Yong Moon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Pyo Nyun Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Republic of Korea
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18
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Yoon JH, Park JW, Lee JM. Noninvasive Diagnosis of Hepatocellular Carcinoma: Elaboration on Korean Liver Cancer Study Group-National Cancer Center Korea Practice Guidelines Compared with Other Guidelines and Remaining Issues. Korean J Radiol 2016; 17:7-24. [PMID: 26798212 PMCID: PMC4720815 DOI: 10.3348/kjr.2016.17.1.7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Hepatocellular carcinoma (HCC) can be diagnosed based on characteristic findings of arterial-phase enhancement and portal/delayed "washout" in cirrhotic patients. Several countries and major academic societies have proposed varying specific diagnostic criteria for HCC, largely reflecting the variable HCC prevalence in different regions and ethnic groups, as well as different practice patterns. In 2014, a new version of Korean practice guidelines for management of HCC was released by the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC). According to the KLCSG-NCC Korea practice guidelines, if the typical hallmark of HCC (i.e., hypervascularity in the arterial phase with washout in the portal or 3 min-delayed phases) is identified in a nodule ≥ 1 cm in diameter on either dynamic CT, dynamic MRI, or MRI using hepatocyte-specific contrast agent in high-risk groups, a diagnosis of HCC is established. In addition, the KLCSG-NCC Korea practice guidelines provide criteria to diagnose HCC for subcentimeter hepatic nodules according to imaging findings and tumor marker, which has not been addressed in other guidelines such as Association for the Study of Liver Diseases and European Association for the Study of the Liver. In this review, we briefly review the new HCC diagnostic criteria endorsed by the 2014 KLCSG-NCC Korea practice guidelines, in comparison with other recent guidelines; we furthermore address several remaining issues in noninvasive diagnosis of HCC, including prerequisite of sonographic demonstration of nodules, discrepancy between transitional phase and delayed phase, and implementation of ancillary features for HCC diagnosis.
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Affiliation(s)
- Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Joong-Won Park
- Center for Liver Cancer, National Cancer Center, Goyang 10408, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul 03080, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 03080, Korea
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Comparison of Free-Breathing With Navigator-Triggered Technique in Diffusion Weighted Imaging for Evaluation of Small Hepatocellular Carcinoma: Effect on Image Quality and Intravoxel Incoherent Motion Parameters. J Comput Assist Tomogr 2015. [PMID: 26196345 DOI: 10.1097/rct.0000000000000278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the effect on image quality and intravoxel incoherent motion (IVIM) parameters of small hepatocellular carcinoma (HCC) from choice of either free-breathing (FB) or navigator-triggered (NT) diffusion-weighted (DW) imaging. METHODS Thirty patients with 37 small HCCs underwent IVIM DW imaging using 12 b values (0-800 s/mm) with 2 sequences: NT, FB. A biexponential analysis with the Bayesian method yielded true diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) in small HCCs and liver parenchyma. Apparent diffusion coefficient (ADC) was also calculated. The acquisition time and image quality scores were assessed for 2 sequences. Independent sample t test was used to compare image quality, signal intensity ratio, IVIM parameters, and ADC values between the 2 sequences; reproducibility of IVIM parameters, and ADC values between 2 sequences was assessed with the Bland-Altman method (BA-LA). RESULTS Image quality with NT sequence was superior to that with FB acquisition (P = 0.02). The mean acquisition time for FB scheme was shorter than that of NT sequence (6 minutes 14 seconds vs 10 minutes 21 seconds ± 10 seconds P < 0.01). The signal intensity ratio of small HCCs did not vary significantly between the 2 sequences. The ADC and IVIM parameters from the 2 sequences show no significant difference. Reproducibility of D*and f parameters in small HCC was poor (BA-LA: 95% confidence interval, -180.8% to 189.2% for D* and -133.8% to 174.9% for f). A moderate reproducibility of D and ADC parameters was observed (BA-LA: 95% confidence interval, -83.5% to 76.8% for D and -74.4% to 88.2% for ADC) between the 2 sequences. CONCLUSIONS The NT DW imaging technique offers no advantage in IVIM parameters measurements of small HCC except better image quality, whereas FB technique offers greater confidence in fitted diffusion parameters for matched acquisition periods.
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You MW, Kim SY, Kim KW, Lee SJ, Shin YM, Kim JH, Lee MG. Recent advances in the imaging of hepatocellular carcinoma. Clin Mol Hepatol 2015; 21:95-103. [PMID: 25834808 PMCID: PMC4379204 DOI: 10.3350/cmh.2015.21.1.95] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The role of imaging is crucial for the surveillance, diagnosis, staging and treatment monitoring of hepatocellular carcinoma (HCC). Over the past few years, considerable technical advances were made in imaging of HCCs. New imaging technology, however, has introduced new challenges in our clinical practice. In this article, the current status of clinical imaging techniques for HCC is addressed. The diagnostic performance of imaging techniques in the context of recent clinical guidelines is also presented.
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Affiliation(s)
- Myung-Won You
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Department of Radiology, Eulji Hospital, Eulji University School of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Jung Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Moon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; Asan Liver Cancer Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Contrast Enhanced MRI in the Diagnosis of HCC. Diagnostics (Basel) 2015; 5:383-98. [PMID: 26854161 PMCID: PMC4665604 DOI: 10.3390/diagnostics5030383] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/22/2015] [Accepted: 08/28/2015] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the 6th most common cancer worldwide. Imaging plays a critical role in HCC screening and diagnosis. Initial screening of patients at risk for HCC is performed with ultrasound. Confirmation of HCC can then be obtained by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), due to the relatively high specificity of both techniques. This article will focus on reviewing MRI techniques for imaging HCC, felt by many to be the exam of choice for HCC diagnosis. MRI relies heavily upon the use of gadolinium-based contrast agents and while primarily extracellular gadolinium-based contrast agents are used, there is an emerging role of hepatobiliary contrast agents in HCC imaging. The use of other non-contrast enhanced MRI techniques for assessing HCC will also be discussed and these MRI strategies will be reviewed in the context of the pathophysiology of HCC to help understand the MR imaging appearance of HCC.
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Kierans AS, Kang SK, Rosenkrantz AB. The Diagnostic Performance of Dynamic Contrast-enhanced MR Imaging for Detection of Small Hepatocellular Carcinoma Measuring Up to 2 cm: A Meta-Analysis. Radiology 2015; 278:82-94. [PMID: 26098460 DOI: 10.1148/radiol.2015150177] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the performance of dynamic contrast material-enhanced magnetic resonance (MR) imaging in the diagnosis of small (≤2-cm) hepatocellular carcinoma (HCC) and to identify factors that influence this performance. MATERIALS AND METHODS Medline and Embase databases were searched for studies performed from January 2000 to March 2014 in which the performance of MR imaging was reported for the detection of HCC up to 2 cm on either a lesion- or patient-based level, with sufficient data to construct 2 × 2 contingency tables. Diagnostic performance was quantitatively pooled for all studies by using a bivariate random-effects model with exploration involving subgroup analysis, meta-regression, and determination of study heterogeneity. RESULTS Twenty-two studies with 1387 small HCC lesions in 1908 patients met inclusion criteria. Heterogeneity was higher for sensitivity (range, 30%-99%) than specificity (range, 61%-100%). Overall sensitivity was 78% (95% confidence interval [CI]: 68%, 85%; I(2) = 89%), and overall specificity was 92% (95% CI: 88%, 95%; I(2) = 69%). The primary potential source of bias was use of explant as the reference standard in only 13% of studies, although lower sensitivity in such studies was not significant (59% vs 80%, P = .165). Sensitivities were significantly higher for studies that originated from Asia compared with those that originated elsewhere (89% vs 71%, P = .028), those performed with hepatobiliary phase imaging compared with those without (87% vs 65%, respectively; P = .004), and those in which gadoxetate disodium was used versus an extracellular agent (92% vs 67%, P ≤ .001). Specificity was not significantly different between subgroups (P ≥ .122). At pairwise meta-regression analysis with either study origin from Asia or performance of hepatobiliary phase imaging, only gadoxetate disodium contrast agent showed significant independent association with higher sensitivity (P = .002-.007). CONCLUSION Results of this meta-analysis suggest that dynamic contrast-enhanced MR imaging has moderate sensitivity and excellent specificity in the detection of HCC up to 2 cm. Gadoxetate disodium contrast agent showed the strongest association with increased sensitivity.
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Affiliation(s)
- Andrea S Kierans
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Medical Center, 550 First Ave, New York, NY 10016
| | - Stella K Kang
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Medical Center, 550 First Ave, New York, NY 10016
| | - Andrew B Rosenkrantz
- From the Department of Radiology, Center for Biomedical Imaging, NYU Langone Medical Center, 550 First Ave, New York, NY 10016
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Cho ES, Choi JY. MRI features of hepatocellular carcinoma related to biologic behavior. Korean J Radiol 2015; 16:449-64. [PMID: 25995679 PMCID: PMC4435980 DOI: 10.3348/kjr.2015.16.3.449] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 02/23/2015] [Indexed: 12/12/2022] Open
Abstract
Imaging studies including magnetic resonance imaging (MRI) play a crucial role in the diagnosis and staging of hepatocellular carcinoma (HCC). Several recent studies reveal a large number of MRI features related to the prognosis of HCC. In this review, we discuss various MRI features of HCC and their implications for the diagnosis and prognosis as imaging biomarkers. As a whole, the favorable MRI findings of HCC are small size, encapsulation, intralesional fat, high apparent diffusion coefficient (ADC) value, and smooth margins or hyperintensity on the hepatobiliary phase of gadoxetic acid-enhanced MRI. Unfavorable findings include large size, multifocality, low ADC value, non-smooth margins or hypointensity on hepatobiliary phase images. MRI findings are potential imaging biomarkers in patients with HCC.
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Affiliation(s)
- Eun-Suk Cho
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 135-720, Korea
| | - Jin-Young Choi
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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Joo I. The role of intraoperative ultrasonography in the diagnosis and management of focal hepatic lesions. Ultrasonography 2015; 34:246-57. [PMID: 25971896 PMCID: PMC4603208 DOI: 10.14366/usg.15014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 12/12/2022] Open
Abstract
Intraoperative ultrasonography (IOUS) has been widely utilized in hepatic surgery both as a diagnostic technique and in the course of treatment. Since IOUS involves direct-contact imaging of the target organ, it can provide high spatial resolution without interference from the surrounding structures. Therefore, IOUS may improve the detection, characterization, localization, and local staging of hepatic tumors. IOUS is also a real-time imaging modality capable of providing interactive information and valuable guidance in a range of procedures. Recently, contrast-enhanced IOUS, IOUS elastography, and IOUS-guided hepatic surgery have attracted increasing interest and are expected to lead to the broader implementation of IOUS. Herein, we review the various applications of IOUS in the diagnosis and management of focal hepatic lesions.
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Affiliation(s)
- Ijin Joo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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25
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Inchingolo R, De Gaetano AM, Curione D, Ciresa M, Miele L, Pompili M, Vecchio FM, Giuliante F, Bonomo L. Role of diffusion-weighted imaging, apparent diffusion coefficient and correlation with hepatobiliary phase findings in the differentiation of hepatocellular carcinoma from dysplastic nodules in cirrhotic liver. Eur Radiol 2015; 25:1087-96. [PMID: 25430005 DOI: 10.1007/s00330-014-3500-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 11/09/2014] [Accepted: 11/12/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To investigate the utility of diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) and the correlation with hepatobiliary phase (delayed phase imaging, DPI) findings in the differentiation of cirrhotic hepatocellular nodules. METHODS Forty-three patients with 53 pathology-proven nodules (29 hepatocellular carcinomas (HCCs), 13 high-grade (HGDNs) and 11 low-grade dysplastic nodules (LGDNs); mean size 2.17 cm, range 1-4 cm), who underwent liver MRI with DWI and DPI sequences, were retrospectively reviewed. Lesions were classified as hypointense, isointense, or hyperintense relative to the adjacent liver parenchyma. ADC of each nodule, of the surrounding parenchyma, and lesion-to-liver ratio were calculated. RESULTS Hyperintensity versus iso/hypointensity on DWI, hypointensity versus iso/hyperintensity on DPI, and the mean lesion-to-liver ratio showed a statistically significant difference both between HCCs versus DNs and between "HCCs + HGDNs" versus LGDNs (p < 0.05); sensitivity, specificity, and accuracy for the diagnosis of "HCCs + HGDNs" were 96.8 %, 100 %, 97.4 % respectively when combining hyperintensity on DWI and hypointensity on DPI, and 90.9 %, 81.0 %, 83.6 % respectively when lesion-to-liver ratio was <0.95. CONCLUSIONS Hyperintensity on DWI, especially in association with hypointensity on DPI, and low lesion-to-liver ratios should raise the suspicion of HCC, or at least of HGDN, thus helping the characterization of atypically enhancing lesions. KEY POINTS • Usefulness of DWI and ADC is shown in differential diagnosis of cirrhotic nodules. • Correlation of DWI with DPI improves differential diagnosis of cirrhotic nodules. • Characterization of atypically enhancing lesions becomes more confident.
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Affiliation(s)
- Riccardo Inchingolo
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, "Agostino Gemelli" Hospital, Catholic University of the Sacred Heart, Rome, Italy,
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Watanabe A, Ramalho M, AlObaidy M, Kim HJ, Velloni FG, Semelka RC. Magnetic resonance imaging of the cirrhotic liver: An update. World J Hepatol 2015; 7:468-487. [PMID: 25848471 PMCID: PMC4381170 DOI: 10.4254/wjh.v7.i3.468] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 10/10/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023] Open
Abstract
Noninvasive imaging has become the standard for hepatocellular carcinoma (HCC) diagnosis in cirrhotic livers. In this review paper, we go over the basics of MR imaging in cirrhotic livers and describe the imaging appearance of a spectrum of hepatic nodules marking the progression from regenerative nodules to low- and high-grade dysplastic nodules, and ultimately to HCCs. We detail and illustrate the typical imaging appearances of different types of HCC including focal, multi-focal, massive, diffuse/infiltrative, and intra-hepatic metastases; with emphasis on the diagnostic value of MR in imaging these lesions. We also shed some light on liver imaging reporting and data system, and the role of different magnetic resonance imaging (MRI) contrast agents and future MRI techniques including the use of advanced MR pulse sequences and utilization of hepatocyte-specific MRI contrast agents, and how they might contribute to improving the diagnostic performance of MRI in early stage HCC diagnosis.
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Diffusion-weighted imaging of the liver in patients with chronic liver disease: comparison of monopolar and bipolar diffusion gradients for image quality and lesion detection. AJR Am J Roentgenol 2015; 204:59-68. [PMID: 25539238 DOI: 10.2214/ajr.13.11695] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of our study was to compare diffusion-weighted imaging (DWI) sequences using a bipolar versus a monopolar single-shot echo-planar imaging (EPI) gradient design for image quality and for lesion detection and characterization in patients with liver disease. MATERIALS AND METHODS In this retrospective study, 77 patients with chronic liver disease who underwent MRI including bipolar and monopolar DWI at 1.5 T were assessed. Two independent observers reviewed the DWI studies for image quality and the detection and characterization of liver lesions. The reference standard for diagnosis was established by consensus review of two different observers using imaging characteristics on conventional MRI sequences, lesion stability over time, pathologic correlation, or a combination of these findings. The estimated signal-to-noise ratio (SNR) of liver parenchyma and apparent diffusion coefficients (ADCs) of the liver and lesions were calculated for both sequences. ROC analysis was conducted to evaluate the performance of ADC for the diagnosis of hepatocellular carcinoma (HCC). RESULTS Eighty-five lesions, 50 HCCs and 35 benign lesions, were detected with the reference standard in 38 patients. There was equivalent image quality for the bipolar and monopolar sequences (p = 0.24-0.42). The HCC detection rate for observers 1 and 2 was slightly better with bipolar DWI (50.0% and 52.0%, respectively) compared with monopolar DWI (44.0% and 46.0%); however, this difference did not reach statistical significance. The estimated SNR was higher with the monopolar sequence than with the bipolar sequence (p ≤ 0.001). The AUC for the ROC curve was 0.691 for bipolar DWI and 0.649 for monopolar DWI when ADC was used for the characterization of HCC, which is not a statistically significant difference (p = 0.59). CONCLUSION The higher estimated SNR yielded by the monopolar DWI sequence did not translate into better HCC detection compared with the bipolar DWI sequence. ADC has a limited role for HCC characterization in patients with liver disease.
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Di Pietropaolo M, Briani C, Federici GF, Marignani M, Begini P, Delle Fave G, Iannicelli E. Comparison of diffusion-weighted imaging and gadoxetic acid-enhanced MR images in the evaluation of hepatocellular carcinoma and hypovascular hepatocellular nodules. Clin Imaging 2015; 39:468-75. [PMID: 25748089 DOI: 10.1016/j.clinimag.2014.12.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 11/13/2014] [Accepted: 12/20/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare diffusion-weighted imaging (DWI) and gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) magnetic resonance imaging (MRI) in the evaluation of hepatocellular carcinoma (HCC) and nodules at high risk of HCC transformation. MATERIALS AND METHODS We evaluated nodules' size, vascular pattern, and signal intensity on hepatobiliary phase images and on DWI of 105 nodules (41 cirrhotic patients). RESULTS A total of 35/66 HCCs identified on Gd-EOB-DTPA MRI showed hyperintensity on DWI. A total of 25/39 nodules (hypovascular and hypointense nodule on hepatobiliary phase images) progressed to HCC (higher risk for nodules ≥10mm in size and hyperintense on DWI, P<.05). CONCLUSION Gd-EOB-DTPA MRI demonstrated a significant role in the identification of nodule at higher risk of HCC transformation, and hyperintensity on DWI was associated with progression to HCC.
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Affiliation(s)
- Marco Di Pietropaolo
- Radiology Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy.
| | - Chiara Briani
- Radiology Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Giulia Francesca Federici
- Radiology Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Massimo Marignani
- Digestive and Liver Disease Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Paola Begini
- Digestive and Liver Disease Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Gianfranco Delle Fave
- Digestive and Liver Disease Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Elsa Iannicelli
- Radiology Unit, Department of Surgical and Medical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
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Hwang J, Kim YK, Kim JM, Lee WJ, Choi D, Hong SS. Pretransplant diagnosis of hepatocellular carcinoma by gadoxetic acid-enhanced and diffusion-weighted magnetic resonance imaging. Liver Transpl 2014; 20:1436-46. [PMID: 25103727 DOI: 10.1002/lt.23974] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/19/2014] [Accepted: 07/31/2014] [Indexed: 01/12/2023]
Abstract
We sought to evaluate the diagnostic performance of gadoxetic acid-enhanced magnetic resonance imaging (MRI) with and without additional diffusion-weighted imaging (DWI) in the detection of hepatocellular carcinoma (HCC) in pretransplant patients. We included 63 liver transplant patients (54 men and 9 women; mean age = 52 years) who had undergone gadoxetic acid-enhanced MRI with DWI at 3.0 T within 90 days before transplantation. Two image sets were reviewed for HCC in 2 separate sessions by 2 independent observers: the gadoxetic acid set and the combined set (gadoxetic acid plus DWI). The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each image set. In all, 113 HCCs (size range = 0.5-7.8 cm, mean = 2.0 ± 1.3 cm) were identified in the 52 liver explants. The per-lesion sensitivity of the combined set (78.8% for both observers) was higher than the sensitivity of the gadoxetic acid set [71.7% (P = 0.02) and 72.6% (P = 0.03) for the 2 observers], with the highest trend for Child-Pugh class A (94.4% and 97.2% for gadoxetic acid and 97.2% for combined), which was followed by class B (73.2% for gadoxetic acid and 82.9% for combined) and then class C (47.2% for gadoxetic acid and 55.6% for combined, P = 0.01). The per-patient negative predictive value of the combined set was higher than that of the gadoxetic acid set for both observers (P = 0.046). There was no difference in specificity between the 2 image sets (P > 0.05). The addition of DWI to gadoxetic acid-enhanced MRI resulted in significantly higher sensitivity to detect HCC. However, the sensitivity decreased with increasing cirrhosis severity for both imaging types.
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Affiliation(s)
- Jiyoung Hwang
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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30
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Choi SH, Byun JH, Kwon HJ, Ha HI, Lee SJ, Kim SY, Won HJ, Kim PN. The Usefulness of Gadoxetic Acid-Enhanced Dynamic Magnetic Resonance Imaging in Hepatocellular Carcinoma: Toward Improved Staging. Ann Surg Oncol 2014; 22:819-25. [DOI: 10.1245/s10434-014-4074-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Indexed: 12/30/2022]
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Lewis S, Dyvorne H, Cui Y, Taouli B. Diffusion-weighted imaging of the liver: techniques and applications. Magn Reson Imaging Clin N Am 2014; 22:373-95. [PMID: 25086935 PMCID: PMC4121599 DOI: 10.1016/j.mric.2014.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diffusion-weighted imaging (DWI) is a technique that assesses the cellularity, tortuosity of the extracellular/extravascular space, and cell membrane density based on differences in water proton mobility in tissues. The strength of the diffusion weighting is reflected by the b value. DWI using several b values enables the quantification of the apparent diffusion coefficient. DWI is increasingly used in liver imaging for multiple reasons: it can add useful qualitative and quantitative information to conventional imaging sequences; it is acquired relatively quickly; it is easily incorporated into existing clinical protocols; and it is a noncontrast technique.
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Affiliation(s)
- Sara Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1234, New York, NY 10029, USA
| | - Hadrien Dyvorne
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1234, New York, NY 10029, USA
| | - Yong Cui
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1234, New York, NY 10029, USA
| | - Bachir Taouli
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1234, New York, NY 10029, USA; Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1234, New York, NY 10029, USA.
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Abstract
In this article, functional magnetic resonance (MR) imaging techniques in the abdomen are discussed. Diffusion-weighted imaging (DWI) increases the confidence in detecting and characterizing focal hepatic lesions. The potential uses of DWI in kidneys, adrenal glands, bowel, and pancreas are outlined. Studies have shown potential use of quantitative dynamic contrast-enhanced MR imaging parameters, such as K(trans), in predicting outcomes in cancer therapy. MR elastography is considered to be a useful tool in staging liver fibrosis. A major issue with all functional MR imaging techniques is the lack of standardization of the protocol.
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Affiliation(s)
- Kumar Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, 550 N University Blvd, UH 0279, Indianapolis, IN 46202, USA.
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Di Martino M, Di Miscio R, De Filippis G, Lombardo CV, Saba L, Geiger D, Catalano C. Detection of small (≤2 cm) HCC in cirrhotic patients: added value of diffusion MR-imaging. ACTA ACUST UNITED AC 2014; 38:1254-62. [PMID: 23857505 DOI: 10.1007/s00261-013-0009-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the usefulness of the diffusion-weighted sequence in the detection of small (≤2 cm) hepatocellular carcinoma (HCC) in patients with cirrhosis. METHODS Seventy cirrhotic patients with 93 HCCs underwent MR-Imaging at 1.5 T. MR acquisitions comprised unenhanced T1- and T2-weighted images and post-contrast Gd-BOPTA-enhanced T1W GRE-3D images acquired after approximately 25, 60, 180 s (dynamic phases) and 90 min (hepatobiliary phase). DWI was performed by a SSEPI sequence (b values 0, 50, 400, 800 s/mm(2)). Quantitative analysis was performed to establish significant difference of ADC values of benign lesions compared with that of HCC. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of two different protocols with and without diffusion MRI sequence were also calculated and compared each other. RESULTS A good inverse correlation was found between reference standard and ADC values (ρ = -0.688). The mean ADC value of HCC was significantly lower than the mean value of benign focal liver lesions (p < 0.0001). No significant difference was reported in term of sensitivity, specificity, PPV, NPV and diagnostic accuracy between the two datasets. A trend to a better sensitivity was found when DWI images were considered. CONCLUSIONS The adjunction of DWI does not significantly improve the diagnostic accuracy in the detection of small HCC.
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Affiliation(s)
- Michele Di Martino
- Department of Radiological Sciences, Oncology and Anatomical Pathology "Sapienza", Università di Roma, Viale Regina Elena 324, 00161, Rome, Italy,
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Evaluation of hepatic fibrosis using intravoxel incoherent motion in diffusion-weighted liver MRI. J Comput Assist Tomogr 2014; 38:110-6. [PMID: 24378888 DOI: 10.1097/rct.0b013e3182a589be] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine whether intravoxel incoherent motion (IVIM)-diffusion-weighted image (DWI)-derived parameters showed better diagnostic performance than the apparent diffusion coefficient (ADC(total)) for the evaluation of hepatic fibrosis (HF). METHODS This retrospective study was approved by institutional review board, and informed consent was waived. Fifty-five patients with chronic liver disease who had undergone IVIM-DWI using 8 b-values at 3 T were included. True diffusion coefficient (Dt), pseudo-diffusion coefficient (Dp), perfusion fraction (f), and ADC(total) were calculated. Receiver operating characteristic analysis was performed for all parameters for the HF staging. RESULTS All parameters showed a significant correlation with the HF stages (-0.31 to -0.72, P < 0.05). All parameters were significantly higher in F0 to F1 than in F4 (P < 0.05). The Dp showed better performance than the ADC(total) in differentiating significant HF (≥F2) from F0 to F1. CONCLUSIONS The IVIM-derived parameters and ADC(total) showed significant correlation with HF. The D p showed better diagnostic performance for differentiating significant HF than did ADC(total).
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Chen ML, Zhang XY, Qi LP, Shi QL, Chen B, Sun YS. Diffusion-weighted images (DWI) without ADC values in assessment of small focal nodules in cirrhotic liver. Chin J Cancer Res 2014; 26:38-47. [PMID: 24653625 DOI: 10.3978/j.issn.1000-9604.2014.01.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/04/2013] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess if diffusion-weighted magnetic resonance (MR) imaging without apparent diffusion coefficient (ADC) values provides added diagnostic value in combination with conventional MR imaging in the detection and characterization of small nodules in cirrhotic liver. METHODS Two observers retrospectively and independently analyzed 86 nodules (≤3 cm) certified pathologically in 33 patients with liver cirrhosis, including 48 hepatocellular carcinoma (HCC) nodules, 13 high-grade dysplastic nodules (HDN), 10 low-grade dysplastic nodules (LDNs) and 15 other benign nodules. All these focal nodules were evaluated with conventional MR images (T1-weighted, T2-weighted and dynamic gadolinium-enhanced images) and breath-hold diffusion-weighted images (DWI) (b=500 s/mm(2)). The nodules were classified by using a scale of 1-3 (1, not seen; 3, well seen) on DWI for qualitative assessment. These small nodules were characterized by two radiologists. ADC values weren't measured. The diagnostic performance of the combined DWI-conventional images and the conventional images alone was evaluated using receiver operating characteristic (ROC) curves. The area under the curves (Az), sensitivity and specificity values for characterizing different small nodules were also calculated. RESULTS Among 48 HCC nodules, 33 (68.8%) were graded as 3 (well seen), 6 (12.5%) were graded as 2 (partially obscured), and 9 weren't seen on DWI. Among 13 HDNs, there were 3 (23.1%) and 4 (30.8%) graded as 3 and 2 respectively. Five (50%) of 10 benign nodules were partially obscured and slightly hyperintense. For 86 nodules, the average diagnostic accuracy of combined DWI-conventional images was 82.56%, which was increased significantly compared with conventional MR images with 76.17%. For HCC and HDN, the diagnostic accuracy of combined DWI-conventional images increased from 78.69% to 86.07%. CONCLUSIONS Diffusion-weighted MR imaging does provide added diagnostic value in the detection and characterization of HDN and HCC, and it may not be helpful for LDN and regenerative nodule (RN) in cirrhotic liver.
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Affiliation(s)
- Mai-Lin Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Li-Ping Qi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Qing-Lei Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Bin Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Zhao XT, Li WX, Chai WM, Chen KM. Detection of small hepatocellular carcinoma using gadoxetic acid-enhanced MRI: Is the addition of diffusion-weighted MRI at 3.0T beneficial? J Dig Dis 2014; 15:137-45. [PMID: 24354621 DOI: 10.1111/1751-2980.12119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether adding diffusion-weighted imaging (DWI) to gadoxetic acid-enhanced 3.0T magnetic resonance imaging (MRI) can improve the detection of hepatocellular carcinoma (HCC), particularly for small lesions (≤2 cm) in patients with liver cirrhosis. METHODS Data of patients diagnosed with focal liver lesions who had undergone gadoxetic acid-enhanced 3.0T MRI and DWI were retrospectively reviewed. Two radiologists (the observers) reviewed independently MRI images in two reading sessions, that is, gadoxetic acid-enhanced images alone and the combination of DWI (b values: 0 and 600 s/mm(2) ) and gadoxetic acid-enhanced images. They assigned to each lesion a confidence level based on a five-point scale. The area under the receiver operating characteristic curve (AUROC), sensitivity and positive predictive value (PPV) for the detection of HCC were calculated. RESULTS Both observers found the AUROC of the gadoxetic acid-enhanced images was slightly higher than that of the combined DWI and gadoxetic acid-enhanced MRI images in the detection of HCC (observer 1: 0.947 ± 0.030 vs 0.896 ± 0.042, Z = 1.478, P = 0.139; observer 2: 0.917 ± 0.038 vs 0.868 ± 0.048, Z = 1.296, P = 0.195). The sensitivity for the gadoxetic acid set alone was slightly higher than that for the combined set for observer 1 (97% vs 84%) and slightly lower for observer 2 (74% vs 82%). The PPVs were slightly higher for the gadoxetic acid set alone than for the combined set for both observers (observer 1, 89% vs 80%; observer 2, 93% vs 78%); however, none of the differences were statistically significant (P > 0.05). CONCLUSION There is no benefit in adding DWI to gadoxetic acid-enhanced MRI for the detection of HCC at 3.0T.
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Affiliation(s)
- Xiang Tian Zhao
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Xu P, Zeng M, Liu K, Shan Y, Xu C, Lin J. Microvascular invasion in small hepatocellular carcinoma: is it predictable with preoperative diffusion-weighted imaging? J Gastroenterol Hepatol 2014; 29:330-6. [PMID: 24033853 DOI: 10.1111/jgh.12358] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The presence of microvascular invasion (MVI) is an independent risk factor affecting recurrence-free survival following surgical treatment for small hepatocellular carcinoma (HCC). Our aim in this study was to investigate whether diffusion-weighted imaging (DWI) could be useful in predicting MVI for small HCC. METHODS Breath-hold DWI (b-value 0, 500 s/mm(2) ) and gadopentate dimeglumine-enhanced dynamic imaging of preoperative magnetic resonance imaging of 109 surgically proven small HCCs from 92 patients were retrospectively analyzed. The signal intensity ratio on DWI and apparent diffusion coefficients (ADCs) for lesions were quantitatively measured. Signal intensity ratio and ADC of DWI, tumor size, tumor shape, tumor capsule, peritumoral enhancement on arterial phase images, and dynamic enhancement pattern were analyzed as radiological parameters reflecting MVI and were compared with histopathological references. The chi-square test, Fisher's exact test, Mann-Whitney U test, and the independent t-test were used for univariate analysis. To identify the independent predictors of MVI among these radiological parameters and to evaluate their diagnostic performance, multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed, respectively. RESULTS A univariate analysis showed that a lower ADC value (P = 0.005) and irregular circumferential enhancement (P = 0.020) showed statistically significant associations with MVI. A multiple logistic regression analysis showed that the ADC value and irregular circumferential enhancement were independent predictors of MVI. With a cut-off of 1.227 × 10(-3) mm(2) /s, the ADC value provided a sensitivity of 66.7% and a specificity of 78.6% in the prediction of MVI with an odds ratio of 7.63 (P < 0.01). CONCLUSIONS Lower ADC values (< 1.227 × 10(-3) mm(2) /s) on DWI with b-value of 0.500 s/mm(2) can be a useful preoperative predictor of MVI for small HCCs.
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Affiliation(s)
- Pengju Xu
- Department of Radiology, Shanghai Institute of Medical Imaging, Shanghai, China
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Galea N, Cantisani V, Taouli B. Liver lesion detection and characterization: role of diffusion-weighted imaging. J Magn Reson Imaging 2014; 37:1260-76. [PMID: 23712841 DOI: 10.1002/jmri.23947] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 10/11/2012] [Indexed: 12/11/2022] Open
Abstract
Diffusion-weighted imaging (DWI) plays an emerging role for the assessment of focal and diffuse liver diseases. This growing interest is due to that fact that DWI is a noncontrast technique with inherent high contrast resolution, with promising results for detection and characterization of focal liver lesions. Recent advances in diffusion image quality have also added interest to this technique in the abdomen. The purpose of this review is to describe the current clinical roles of DWI for the detection and characterization of focal liver lesions, and to review pitfalls, limitations, and future directions of DWI for assessment of focal liver disease.
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Affiliation(s)
- Nicola Galea
- Sapienza University of Rome, Department of Radiological Sciences, Rome, Italy
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Lee NK, Kim S, Kim TU, Kim DU, Seo HI, Jeon TY. Diffusion-weighted MRI for differentiation of benign from malignant lesions in the gallbladder. Clin Radiol 2013; 69:e78-85. [PMID: 24290779 DOI: 10.1016/j.crad.2013.09.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 09/13/2013] [Accepted: 09/20/2013] [Indexed: 02/07/2023]
Abstract
AIM To investigate the value of diffusion-weighted imaging (DWI) for differentiating benign from malignant gallbladder lesions. MATERIALS AND METHODS One hundred and twenty-six patients who had undergone magnetic resonance imaging (MRI) with DWI, in whom the histopathological diagnosis of their gallbladder lesions was confirmed by biopsy or surgery were retrospectively analysed. Thirty-six malignant and 90 benign lesions were included. Two radiologists categorized gallbladder lesions into seven types on two imaging sets [T2-weighted imaging (WI) alone and combined T2WI and DWI (b = 800 s/mm(2))] according to the presence of wall thickening, layered patterns, morphology of the mass, and diffusion restriction. Disagreements were resolved in consensus. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each imaging set for diagnosing gallbladder carcinoma were calculated. The diagnostic performance of each imaging set was calculated using receiver operating characteristic (ROC) curve analysis. Additionally, ADC values of malignant and benign gallbladder lesions were compared separately for 1.5 and 3 T MRI. RESULTS The sensitivity, specificity, PPV, and NPV of diagnosis at T2WI were 97.2%, 86.7%, 74.5%, and 98.7%, respectively. The sensitivity, specificity, PPV, and NPV using combined T2WI and DWI were 97.2%, 92.2%, 83.3%, and 98.8%, respectively. Diagnostic accuracy for gallbladder carcinoma slightly improved after adding DWI, from 0.92 to 0.95 (p < 0.05). ADC values for gallbladder carcinoma were significantly lower than those for benign lesions. Mean ADC values of malignant and benign lesions were 0.97 ± 0.25 × 10(-3) and 1.72 ± 0.56 × 10(-3) mm(2)/s, respectively, at 1.5 T (p < 0.001), and 1.04 ± 0.38 × 10(-3) and 2.2 ± 0.72 × 10(-3) mm(2)/s, respectively, at 3 T (p < 0.001). CONCLUSION DWI can improve diagnostic accuracy for differentiating benign from malignant gallbladder lesions.
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Affiliation(s)
- N K Lee
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - S Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea.
| | - T U Kim
- Department of Radiology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - D U Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - H I Seo
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - T Y Jeon
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
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40
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Diffusion-weighted MRI of hepatocellular carcinoma in cirrhosis. Clin Radiol 2013; 69:1-10. [PMID: 24034549 DOI: 10.1016/j.crad.2013.07.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 07/16/2013] [Accepted: 07/18/2013] [Indexed: 12/17/2022]
Abstract
The internationally accepted diagnostic criteria for hepatocellular carcinoma (HCC) in cirrhosis are highly accurate for large tumours, but offer relatively low sensitivity for small (<2 cm) tumours. Diffusion-weighted imaging (DWI) is a functional magnetic resonance imaging (MRI) technique that has been studied extensively as an aid to visualize various abdominal malignancies, including HCC in cirrhosis. DWI maps water diffusivity, which in HCC may be restricted as a result of changes ensuing from hepatocarcinogenesis. The present review is based on up-to-date evidence and describes the strengths and weaknesses of DWI, both as a standalone technique and as an adjunct sequence to conventional protocols, in the diagnosis, staging, prognostication, and assessment of treatment response of HCC in cirrhosis.
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Yoon JH, Lee JM, Yu MH, Kiefer B, Han JK, Choi BI. Evaluation of hepatic focal lesions using diffusion-weighted MR imaging: comparison of apparent diffusion coefficient and intravoxel incoherent motion-derived parameters. J Magn Reson Imaging 2013; 39:276-85. [PMID: 23633178 DOI: 10.1002/jmri.24158] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 03/06/2013] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To determine whether parameters obtained from intravoxel incoherent motion (IVIM)-diffusion-weighted imaging (DWI) using multiple b-values can improve characterization of common focal liver lesions (FLLs), compared with the apparent diffusion coefficient (ADCtotal ). MATERIALS AND METHODS Our Institutional Review Board approved this retrospective study and informed consent was waived. In all, 142 patients with 169 FLLs underwent liver magnetic resonance imaging (MRI) including IVIM-DWI with multiple b factors at 3.0T. ADCtotal and IVIM-DWI-derived parameters including true diffusion (Dt ), pseudodiffusion (Dp ), and perfusion fraction (f) were calculated for each lesion and compared using dedicated software. RESULTS Dt and ADCtotal were significantly lower in malignancies (0.95 ± 0.21, 1.14 ± 0.24, (×10(-3) mm(2) /sec)) than in benign FLLs (1.61 ± 0.34, 1.72 ± 0.37, (×10(-3) mm(2) /sec)). In the differential diagnosis of malignancies from benign lesions, Dt (Az value: 0.971) showed better diagnostic performance than ADCtotal (Az: 0.933) (P < 0.0005). Dt (Az: 0.961) also showed better diagnostic performance than ADCtotal (Az: 0.919) in differentiating hypervascular malignancies from benign hypervascular FLLs (P < 0.0005). In addition, Dp and f were significantly higher in hypervascular FLLs (35.74 ± 20.08 (×10(-3) mm(2) /sec), 28.14 ± 11.82 (%)) than hypovascular FLLs (21.87 ± 13.8 (×10(-3) mm(2) /sec), 12.2 ± 5.92 (%)) (P < 0.0001). CONCLUSION Dt provided better diagnostic performance than ADCtotal in differentiating benign from malignant lesions. Dp and f were significant parameters for diagnosing hypervascular FLLs.
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Affiliation(s)
- Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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de Souza DAT, Parente DB, de Araújo ALE, Mortelé KJ. Modern imaging evaluation of the liver: emerging MR imaging techniques and indications. Magn Reson Imaging Clin N Am 2013; 21:337-63. [PMID: 23642557 DOI: 10.1016/j.mric.2013.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Modern MR imaging evaluation of the liver allows for a comprehensive morphologic and functional assessment of the liver parenchyma, hepatic vessels, and biliary tree, thus aiding in the diagnosis of both focal and diffuse liver diseases.
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Henninger B, Petersen J, Jaschke W. [Radiological diagnosis of primary hepatic malignancy]. Wien Med Wochenschr 2013; 163:113-22. [PMID: 23392810 DOI: 10.1007/s10354-013-0179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/10/2013] [Indexed: 11/26/2022]
Abstract
Modern radiology offers countless opportunities both in the detection but also in the characterization of primary liver malignancies. Ultrasound remains usually the first exploratory overview study whereat using ultrasound contrast agent for a further characterization of liver lesions improves this technique considerably. Advanced cross-sectional imaging methods can, in most cases, already provide an exact diagnosis. Thus, the CT is already considered a standard technique for liver imaging and magnetic resonance imaging has gained in recent years due to liver-specific contrast agents and faster sequences a central role in liver imaging. The following article provides an overview of these various radiological procedures and describes the different primary liver malignancies and their imaging characteristics.
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Affiliation(s)
- Benjamin Henninger
- Department Radiologie, Medizinische Universität Innsbruck, Anichstraße 35, 6020 Innsbruck, Österreich.
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Ooka Y, Kanai F, Okabe S, Ueda T, Shimofusa R, Ogasawara S, Chiba T, Sato Y, Yoshikawa M, Yokosuka O. Gadoxetic acid-enhanced MRI compared with CT during angiography in the diagnosis of hepatocellular carcinoma. Magn Reson Imaging 2012; 31:748-54. [PMID: 23218794 DOI: 10.1016/j.mri.2012.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 10/29/2012] [Accepted: 10/30/2012] [Indexed: 02/09/2023]
Abstract
PURPOSE To assess the value of gadoxetic acid-enhanced magnetic resonance imaging (MRI) for the pre-therapeutic detection of hepatocellular carcinoma (HCC) using receiver operating characteristic (ROC) analysis with the combination of computed tomography (CT) arterial portography and CT hepatic arteriography (CTAP/CTHA). MATERIALS AND METHODS A total of 54 consecutive patients with 87 nodular HCCs were retrospectively analyzed. All HCC nodules were confirmed pathologically. Three blinded readers independently reviewed 432 hepatic segments, including 78 segments with 87 HCCs. Each reader read two sets of images: Set 1, CTAP/CTHA; Set 2, gadoxetic acid-enhanced MRI including a gradient dual-echo sequence and diffusion-weighted imaging (DWI). The ROC method was used to analyze the results. The sensitivity, specificity, positive predictive value, negative predictive value and sensitivity according to tumor size were evaluated. RESULTS For each reader, the area under the curve was significantly higher for Set 2 than for Set 1. The mean area under the curve was also significantly greater for Set 2 than for Set 1 (area under the curve, 0.98 vs. 0.93; P=.0009). The sensitivity was significantly higher for Set 2 than for Set 1 for all three readers (P=.012, .013 and .039, respectively). The difference in the specificity, positive predictive values and negative predictive values of the two modalities for each reader was not significant (P>.05). CONCLUSION Gadoxetic acid-enhanced MRI including a gradient dual-echo sequence and DWI is recommended for the pre-therapeutic evaluation of patients with HCC.
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Affiliation(s)
- Yoshihiko Ooka
- Department of Medicine and Clinical Oncology, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
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Suh YJ, Kim MJ, Choi JY, Park MS, Kim KW. Preoperative prediction of the microvascular invasion of hepatocellular carcinoma with diffusion-weighted imaging. Liver Transpl 2012; 18:1171-8. [PMID: 22767394 DOI: 10.1002/lt.23502] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to investigate whether diffusion-weighted imaging (DWI) could be useful in predicting the microvascular invasion (MVI) of hepatocellular carcinoma (HCC). Sixty-seven surgically proven HCCs from 65 patients (54 men and 11 women with an age range of 35-75 years and a mean age of 56.0 years) were retrospectively analyzed. The signal intensities (SIs) of the lesions on preoperative diffusion-weighted (DW) images were visually categorized as isointense or hyperintense in comparison with the adjacent liver. We also quantitatively measured SIs and apparent diffusion coefficients (ADCs) by drawing regions of interest in HCCs and livers on DW images with b values of 50, 400, and 800 second/mm(2) and on ADC map images. Logistic regression analyses were performed so that we could identify independent predictors of MVI among laboratory and DWI findings. A univariate analysis showed that a histological grade of 3, a larger tumor size, a higher SI ratio on DW images, and a lower ADC value were significantly associated with MVI. A multiple logistic regression analysis showed that a histological grade of 3 and the ADC value were independent predictors of MVI. With a cutoff of 1.11 × 10(-3) mm(2)/second, the ADC value provided a sensitivity of 93.5% and a specificity of 72.2% for the prediction of MVI with an odds ratio of 24.5 (95% confidence interval = 4.14-144.8, P < 0.001). In conclusion, lower ADC values (1.11 × 10(-3) mm(2)/second or less) can be a useful predictor of MVI during the preoperative evaluation of HCC.
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Affiliation(s)
- Young Joo Suh
- Department of Radiology, Research Institute of Radiological Science, Yonsei University Severance Hospital, Seoul, Republic of Korea
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Abstract
Based on recent clinical practice guidelines, imaging is largely replacing pathology as the preferred diagnostic method for determination of hepatocellular carcinoma (HCC). A variety of imaging modalities, including ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and angiography, are currently used to examine patients with chronic liver disease and suspected HCC. Advancements in imaging techniques such as perfusion imaging, diffusion imaging, and elastography along with the development of new contrast media will further improve the ability to detect and characterize HCC. Early diagnosis of HCC is essential for prompt treatment, which may in turn improve prognosis. Considering the process of hepatocarcinogenesis, it is important to evaluate sequential changes via imaging which would help to differentiate HCC from premalignant or benign lesions. Recent innovations including multiphasic examinations, high-resolution imaging, and the increased functional capabilities available with contrast-enhanced US, multidetector row CT, and MRI have raised the standards for HCC diagnosis. Although hemodynamic features of nodules in the cirrhotic liver remain the main diagnostic criterion, newly developed cellspecific contrast agents have shown great possibilities for improved HCC diagnosis and may overcome the diagnostic dilemma associated with small or borderline hepatocellular lesions. In the 20th century paradigm of medical imaging, radiological diagnosis was based on morphological characteristics, but in the 21st century, a paradigm shift to include biomedical, physiological, functional, and genetic imaging is needed. A multidisciplinary team approach is necessary to foster an integrated approach to HCC imaging. By developing and combining new imaging modalities, all phases of HCC patient care, including screening, diagnosis, treatment, and therapy, can be dramatically improved.
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Affiliation(s)
| | - Byung Ihn Choi
- *Byung Ihn Choi, MD, Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul 110-744 (Korea), Tel. +82 2 2072 2515, E-Mail
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Park MS, Kim S, Patel J, Hajdu CH, Do RKG, Mannelli L, Babb JS, Taouli B. Hepatocellular carcinoma: detection with diffusion-weighted versus contrast-enhanced magnetic resonance imaging in pretransplant patients. Hepatology 2012; 56:140-8. [PMID: 22370974 DOI: 10.1002/hep.25681] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 02/16/2012] [Indexed: 12/13/2022]
Abstract
UNLABELLED This study evaluates the performance of diffusion-weighted magnetic resonance imaging (DWI) for the detection of hepatocellular carcinoma (HCC) in pre-liver transplantation patients, compared and combined with contrast-enhanced T1-weighted imaging (CET1WI), using liver explant as the standard of reference. We included 52 patients with cirrhosis (40 men, 12 women; mean age, 56 years) who underwent DWI and CET1WI within 90 days of liver transplantation. Magnetic resonance images were analyzed for HCC detection in three separate sessions by two independent observers: DWI images (DW-set), CET1WI (CE-set), and all images together (All-set). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), per-patient accuracy, and per-lesion PPV were calculated for each image set. A total of 72 HCCs were present in 33 patients at explant (mean size, 1.5 cm [range, 0.3-6.2 cm]). Per-patient sensitivity and NPV of CE-set were significantly higher than those of DW-set when using pooled data between observers (P = 0.02 and 0.03, respectively), whereas specificity, PPV, and accuracy were equivalent. Per-lesion sensitivity was significantly higher for CE-set versus DW-set (59.0% versus 43.8%; P = 0.008, pooled data from two observers). When stratified by lesion size, the difference was significant only for lesions with a size between 1 and 2 cm (42.0% for DW-set versus 74.0% for CE-set; P = 0.001). The addition of DWI to CET1WI improved sensitivity for the more experienced observer. CONCLUSION DWI is outperformed by CET1WI for detection of HCC, but represents a reasonable alternative to CET1WI for detection of HCC with a size above 2 cm. The addition of DWI to CET1WI slightly increases the detection rate.
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Affiliation(s)
- Mi-Suk Park
- Departments of Radiology, New York University Langone Medical Center, New York, NY, USA
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Characterization of focal liver lesions using quantitative techniques: comparison of apparent diffusion coefficient values and T2 relaxation times. Eur Radiol 2012; 22:2514-24. [PMID: 22699872 PMCID: PMC3472073 DOI: 10.1007/s00330-012-2519-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 04/18/2012] [Accepted: 05/12/2012] [Indexed: 12/21/2022]
Abstract
Objectives To compare the efficacy of two quantitative methods for discrimination between benign and malignant focal liver lesions (FLLs): apparent diffusion coefficient (ADC) values and T2 relaxation times. Methods Seventy-three patients with 215 confirmed FLLs (115 benign, 100 malignant) underwent 1.5-T MRI with respiratory-triggered single-shot SE DWI (b = 50, 400, 800) and dual-echo T2TSE (TR = 3,000 ms; TE1 = 84 ms; TE2 = 228 ms). ADC values and T2 relaxation times of FLLs were calculated. Sensitivity, specificity and accuracy of both techniques in diagnosing malignancy were assessed. Results The mean ADC value of malignant tumours (1.07 × 10−3 mm2/s) was significantly lower (P < 0.05) than that of benign lesions (1.86 × 10−3 mm2/s ); however, with the use of the optimal cut-off value of 1.25 × 10−3 mm2/s, 20 false positive (FP) and 20 false negative (FN) diagnoses of malignancy were noted, generating 79 % sensitivity, 82.6 % specificity and 80.9 % accuracy. The mean T2 relaxation time of malignant tumours (64.4 ms) was significantly lower (P < 0.05) than that of benign lesions (476.1 ms). At the threshold of 107 ms 22 FP and 1 FN diagnoses were noted; the sensitivity was 99 %, specificity 80.9 % and accuracy 89.3 %. Conclusions Quantitative analysis of T2 relaxation times yielded significantly higher sensitivity and accuracy in diagnosing malignant liver tumour than ADC values. Key Points • Diffusion-weighted magnetic resonance imaging is increasingly used for liver lesions. • But ADC values demonstrated only moderate accuracy for differentiation of liver lesions. • T2 relaxation times yielded higher accuracy in diagnosing malignant liver tumours. • Both ADC and T2 values overlapped between focal nodular hyperplasia and malignant lesions. • Nevertheless T2 liver mapping could be valuable for evaluating focal liver lesions.
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Lee JM, Yoon JH, Joo I, Woo HS. Recent Advances in CT and MR Imaging for Evaluation of Hepatocellular Carcinoma. Liver Cancer 2012; 1:22-40. [PMID: 24159569 PMCID: PMC3747553 DOI: 10.1159/000339018] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Accurate diagnosis and assessment of disease extent are crucial for proper management of patients with HCC. Imaging plays a crucial role in early detection, accurate staging, and the planning of management strategies. A variety of imaging modalities are currently used in evaluating patients with suspected HCC; these include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and angiography. Among these modalities, dynamic MRI and CT are regarded as the best imaging techniques available for the noninvasive diagnosis of HCC. Recent improvements in CT and MRI technology have made noninvasive and reliable diagnostic assessment of hepatocellular nodules possible in the cirrhotic liver, and biopsy is frequently not required prior to treatment. Until now, the major challenge for radiologists in imaging cirrhosis has been the characterization of small cirrhotic nodules smaller than 2 cm in diameter. Further technological advancement will undoubtedly have a major impact on liver tumor imaging. The increased speed of data acquisition in CT and MRI has allowed improvements in both spatial and temporal resolution, which have made possible a more precise evaluation of the hemodynamics of liver nodules. Furthermore, the development of new, tissue-specific contrast agents such as gadoxetic acid has improved HCC detection on MRI. In this review, we discuss the role of CT and MRI in the diagnosis and staging of HCC, recent technological advances, and the strengths and limitations of these imaging modalities.
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Affiliation(s)
| | - Jeong-Hee Yoon
- *Jeong Min Lee, MD, Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul 110-744 (South Korea), Tel. +82 2 2072 3154, E-Mail
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