Intrahepatic mass-forming cholangiocarcinoma: enhancement pattern on Gd-BOPTA-MRI with emphasis of hepatobiliary phase

Imaging Findings in Cirrhotic Liver: Pearls and Pitfalls for Diagnosis of Focal Benign and Malignant Lesions

Cirrhosis is the end stage of chronic liver disease and causes architectural distortion and perfusional anomalies. It is a major risk factor for developing hepatocellular carcinoma (HCC). Common disease entities in noncirrhotic livers, such as hemangiomas, can be rare in cirrhotic livers, and benign entities such as confluent hepatic fibrosis and focal nodular hyperplasia-like lesions may mimic the appearance of malignancies,. HCC usually has typical imaging characteristics, such as the major features established by the Liver Imaging Reporting and Data System. However, HCC can also have a spectrum of atypical or uncommon appearances, such as cystic HCC, hypovascular HCC, or macroscopic fat-containing HCC. HCCs with certain genetic mutations such as CTNNB-1-mutated HCC can harbor unique imaging features not seen in other types of HCC. In addition, malignancies that are less common than HCC, such as cholangiocarcinoma and metastases, which can be difficult to differentiate, can still occur in cirrhotic livers. Atypical imaging features of benign and malignant lesions can be challenging to accurately diagnose. Therefore, familiarity with these features and an understanding of the prevalence of disease entities in cirrhotic livers are key in the daily practice of radiologists for evaluation of cirrhotic livers. The authors illustrate the typical and atypical features of benign and malignant lesions in cirrhosis and discuss the technical pitfalls and unique advantages associated with various imaging modalities in assessing cirrhotic livers, including noncontrast and contrast-enhanced US, CT, and MRI. Work of the U.S. Government published under an exclusive license with the RSNA. Quiz questions for this article are available in the supplemental material.

Contrast-Enhanced Imaging in the Management of Intrahepatic Cholangiocarcinoma: State of Art and Future Perspectives

Intrahepatic cholangiocarcinoma (iCCA) represents the second most common liver cancer after hepatocellular carcinoma, accounting for 15% of primary liver neoplasms. Its incidence and mortality rate have been rising during the last years, and total new cases are expected to increase up to 10-fold during the next two or three decades. Considering iCCA's poor prognosis and rapid spread, early diagnosis is still a crucial issue and can be very challenging due to the heterogeneity of tumor presentation at imaging exams and the need to assess a correct differential diagnosis with other liver lesions. Abdominal contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) plays an irreplaceable role in the evaluation of liver masses. iCCA's most typical imaging patterns are well-described, but atypical features are not uncommon at both CT and MRI; on the other hand, contrast-enhanced ultrasound (CEUS) has shown a great diagnostic value, with the interesting advantage of lower costs and no renal toxicity, but there is still no agreement regarding the most accurate contrastographic patterns for iCCA detection. Besides diagnostic accuracy, all these imaging techniques play a pivotal role in the choice of the therapeutic approach and eligibility for surgery, and there is an increasing interest in the specific imaging features which can predict tumor behavior or histologic subtypes. Further prognostic information may also be provided by the extraction of quantitative data through radiomic analysis, creating prognostic multi-parametric models, including clinical and serological parameters. In this review, we aim to summarize the role of contrast-enhanced imaging in the diagnosis and management of iCCA, from the actual issues in the differential diagnosis of liver masses to the newest prognostic implications.

Nomogram based on MRI for preoperative prediction of Ki-67 expression in patients with intrahepatic mass cholangiocarcinoma

OBJECTIVES

To validate a new nomogram based on magnetic resonance imaging (MRI) for pre-operative prediction of Ki-67 expression in patients with intrahepatic mass cholangiocarcinoma (IMCC).

METHODS

A total of 78 patients with clinicopathologically confirmed IMCC who underwent pre-operative gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid enhanced MRI between 2016 and 2022 were enrolled in the training and validation group (53 patients and 25 patients, respectively). Images including qualitative, quantitative MRI features and clinical data were evaluated. Univariate analysis and multivariate logistic regression were used to select the independent predictors and establish different predictive models. The predictive performance was validated by operating characteristic curve (ROC) analysis, calibration curve, and decision curve analysis (DCA). The validation cohort was used to test the predictive performance of the optimal model. The nomogram was constructed with the optimal model.

RESULTS

In the training cohort, independent predictors obtained from the combined model were DWI (OR 1822.741; 95% CI 6.189, 536,781.805; P = 0.01) and HBP enhancement pattern (OR 14.270; 95% CI 1.044, 195.039; P = 0.046). The combined model showed the good performance (AUC 0.981; 95% CI 0.952, 1.000) for predicting Ki-67 expression. In the validation cohort, The combined model (AUC 0.909; 95% CI 0.787, 1.000)showed the best performance compared to the clinical model (AUC 0.448; 95% CI 0.196, 0.700) and MRI model (AUC 0.770; 95% CI 0.570, 0.970).

CONCLUSION

This new nomogram has a good performance in predicting Ki-67 expression in patients with IMCC, which could help the decision-making of the patients' therapy strategies.

Preoperative differentiation of hepatocellular carcinoma with peripheral rim-like enhancement from intrahepatic mass-forming cholangiocarcinoma on contrast-enhanced MRI

Purpose

The present study aimed to determine the reliable imaging features to distinguish atypical hepatocellular carcinoma (HCC) with peripheral rim-like enhancement from intrahepatic mass-forming cholangiocarcinoma (IMCC) on contrast-enhanced magnetic resonance imaging (MRI).

Methods

A total of 168 patients (130 male, 57.10 ± 10.53 years) pathological confirmed HCC or IMCC who underwent contrast-enhanced MRI between July 2019 and February 2022 were retrospectively included. Univariate and multivariate logistic regression analyses were used to determine independent differential factors for distinguishing HCC from IMCC, and the model was established. Bootstrap resampling 1000 times was used to verify the model, which was visualized by nomograms. The predictive performance of the model was evaluated based on discrimination, calibration, and clinical utility.

Results

Radiological capsule (OR 0.024, 95% CI: 0.006, 0.095, P<0.001), heterogeneous signal intensity (SI) on T1WI (OR 0.009, 95%CI: 0.001,0.056, P<0.001) were independent differential factors for predicting HCC over IMCC. A lobulated contour (OR 11.732, 95%CI: 2.928,47.007, P = 0.001), target sign on DP (OR 14.269, 95%CI: 2.849,82.106, P = 0.007), bile duct dilatation (OR 12.856, 95%CI: 2.013, P = 0.001) were independent differential factors for predicting IMCCs over HCCs. The independent differential factors constituted a model to distinguish atypical HCCs and IMCCs. The area under receiver operating characteristic (ROC) curve, sensitivity, and specificity values of the model were 0.964(0.940,0.987), 0.88, and 0.906, indicating that the model had an excellent differential diagnostic performance. The decision curve analysis (DCA) curve showed that the model obtained a better net clinical benefit.

Conclusion

The present study identified reliable imaging features for distinguishing atypical HCCs with peripheral rim-like enhancement from IMCCs on contrast-enhanced MRI. Our findings may help radiologists provide clinicians with more accurate preoperative imaging diagnoses to select appropriate treatment options.

Values of MRI Imaging Presentations in the Hepatobiliary Phase, DWI and T2WI Sequences in Predicting Pathological Grades of Intrahepatic Mass-Forming Cholangiocarcinoma

Objective

To retrospectively investigate the value of various MRI image menifestations in the hepatobiliary phase (HBP), DWI and T2WI sequences in predicting the pathological grades of intrahepatic mass-forming cholangiocarcinoma (IMCC).

Materials and Methods

Forty-three patients of IMCCs confirmed by pathology were enrolled including 25 cases in well- or moderately-differentiated group and 18 cases in poorly-differentiated group. All patients underwent DWI, T2WI and HBP scan. The Chi square test was used to compare the differences in the general information. Logistic regression analysis was used to analyze the risk factors in predicting the pathological grade of IMCCs.

Results

The maximal diameter of the IMCC lesion was < 3 cm in 11 patients, between 3 cm and 6 cm in 15, and > 6 cm in 17. Sixteen cases had intrahepatic metastasis, including 5 in the well- or moderately-differentiated group and 11 in the poorly-differentiated group. Seventeen (39.5%) patients presented with target signs in the DWI sequence, including 9 in the well- or moderately-differentiated group and 8 in the poorly-differentiated group. Twenty (46.5%) patients presented with target signs in the T2WI sequence, including 8 in the well- or moderately-differentiated group and 12 in the poorly-differentiated group. Nineteen cases (54.3%) had a complete hypointense signal ring, including 13 in the well- or moderately-differentiated group and 6 in the poorly-differentiated group. Sixteen (45.7%) cases had an incomplete hypointense signal ring, including 5 in the well- or moderately-differentiated group and 11 in the poorly-differentiated group. The lesion size, intrahepatic metastasis, T2WI signal, and integrity of a hypointense signal ring in HBP were statistically significantly different between two gourps. T2WI signal, presence or non-presence of intrahepatic metastasis, and integrity of hypointense signal ring were the independent influencing factors for pathological grade of IMCC.

Conclusion

Target sign in T2WI sequence, presence of intrahepatic metastasis and an incomplete hypointense-signal ring in HBP are more likely to be present in poorly-differentiated IMCCs.

DWI Combined With Hepatobiliary-Phase Enhanced Imaging Can Better Differentiate Cholangiocarcinoma From Atypical Liver Abscesses

Objective

To investigate the value of diffusion-weighted imaging (DWI) combined with the hepatobiliary phase (HBP) Gd-BOPTA enhancement in differentiating intrahepatic mass-forming cholangiocarcinoma (IMCC) from atypical liver abscess.

Materials and Methods

A retrospective analysis was performed on 43 patients with IMCCs (IMCC group) and 25 patients with atypical liver abscesses (liver abscess group). The DWI signal, the absolute value of the contrast noise ratio (│CNR│) at the HBP, and visibility were analyzed.

Results

A relatively high DWI signal and a relatively high peripheral signal were presented in 29 patients (67.5%) in the IMCC group, and a relatively high DWI signal was displayed in 15 patients (60.0%) in the atypical abscess group with a relatively high peripheral signal in only one (6.7%) patient and a relatively high central signal in 14 (93.3%, 14/15). A significant (P<0.001) difference existed in the pattern of signal between the two groups of patients. On T2WI, IMCC was mainly manifested by homogeneous signal (53.5%), whereas atypical liver abscesses were mainly manifested by heterogeneous signal and relatively high central signal (32%, and 64%), with a significant difference (P<0.001) in T2WI imaging presentation between the two groups. On the HBP imaging, there was a statistically significant difference in peripheral │CNR│ (P< 0.001) and visibility between two groups. The sensitivity of the HBP imaging was significantly (P=0.002) higher than that of DWI. The sensitivity and accuracy of DWI combined with enhanced HBP imaging were significantly (P=0.002 and P<0.001) higher than those of either HBP imaging or DWI alone.

Conclusion

Intrahepatic mass-forming cholangiocarcinoma and atypical liver abscesses exhibit different imaging signals, and combination of DWI and hepatobiliary-phase enhanced imaging has higher sensitivity and accuracy than either technique in differentiating intrahepatic mass-forming cholangiocarcinoma from atypical liver abscesses.

Added-value of ancillary imaging features for differentiating hepatocellular carcinoma from intrahepatic mass-forming cholangiocarcinoma on Gd-BOPTA-enhanced MRI in LI-RADS M

OBJECTIVE

To identify the reliable imaging features and added-value of ancillary imaging features for differentiating hepatocellular carcinoma (HCC) and intrahepatic mass-forming cholangiocarcinoma (IMCC) assigned to LI-RADS M on Gd-BOPTA-enhanced MRI.

METHODS

This retrospective study included 116 liver observations assigned to LI-RADS M, including 82 HCC and 34 IMCC histologically confirmed. Before and after adding ancillary imaging features, all variables with a p-value of < 0.05 in univariable analysis were entered into a multivariable logistic regression analysis to build diagnostic model 1 and model 2 to find reliable predictors of HCC diagnosis. Receiver operating characteristic (ROC) analysis and the DeLong test were used to compare the two models.

RESULTS

Forty-nine of 82(59.8%) HCCs had a considerably higher frequency of enhancing "capsule" compared with IMCCs (p < 0.001). Based on LI-RADS major and LR-M features and clinical-pathologic factors, an elevated AFP level (OR = 10.676, 95%CI = 2.125-4.470, p = 0.004) and enhancing "capsule" (OR = 20.558, 95%CI = 4.470-94.550, p < 0.001) were extracted as independent risk factors in Model 1. After adding ancillary imaging features, Male (OR = 23.452, 95%CI = 1.465-375.404, p = 0.026), enhancing "capsule" (OR = 13.161, 95%CI = 1.725-100.400, p = 0.013), septum (OR = 17.983, 95%CI = 1.049-308.181, p = 0.046), small-scale central HBP hyperintensity (OR = 44.386, 95%CI = 1.610-1223.484, p = 0.025) were confirmed as independent significant variables associated with HCC. Model 2 demonstrated significantly superior AUC (0.918 vs 0.845, p = 0.021) compared with Model 1. When any two or more predictors in model 2 were satisfied, sensitivity was 91.46%, and accuracy was at the top (87.93%).

CONCLUSION

Enhancing "capsule" was a reliable imaging feature to help identify HCC. Adding ancillary imaging features improved sensitivity and accuracy for HCC diagnosis with differentiation from IMCC in LR-M.

Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations

Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.

Magnetic Resonance Imaging of Nonhepatocellular Malignancies in Chronic Liver Disease

Hepatocellular carcinoma (HCC) is the most common liver malignancy associated with chronic liver disease. Nonhepatocellular malignancies may also arise in the setting of chronic liver disease. The imaging diagnosis of non-HCC malignancies may be challenging. Non-HCC malignancies in patients with chronic liver disease most commonly include intrahepatic cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma, and less commonly hepatic lymphomas and metastases. On MR imaging, non-HCC malignancies often demonstrate a targetoid appearance, manifesting as rim arterial phase hyperenhancement, peripheral washout, central delayed enhancement, and peripheral restricted diffusion. When applying the Liver Imaging Reporting and Data System algorithm, observations with targetoid appearance are categorized as LR-M.

Imaging of calcified hepatic lesions: spectrum of diseases

Hepatic calcifications have been increasingly identified over the past decade due to the widespread use of high-resolution Computed Tomography (CT) imaging. Calcifications can be seen in a vast spectrum of common and uncommon diseases, from benign to malignant, including cystic lesions, solid neoplastic masses, and inflammatory focal lesions. The purpose of this paper is to present an updated review of CT imaging findings of a wide range of calcified hepatic focal lesions, which can help radiologists to narrow the differential diagnosis.

Targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement: diagnostic value for differentiating HCC from other primary liver carcinomas

OBJECTIVES

To evaluate targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement as potential new LI-RADS features for differentiating hepatocellular carcinoma (HCC) from other non-HCC primary liver carcinomas (PLCs).

METHODS

This IRB-approved, retrospective study was performed at two liver transplant centers. The final population included 375 patients with pathologically proven lesions imaged between 2007 and 2017 with contrast-enhanced CT or MRI. The cohort consisted of 165 intrahepatic cholangiocarcinomas and 74 combined hepatocellular-cholangiocarcinomas, with the addition of 136 HCCs for control. Two abdominal radiologists (R1; R2) independently reviewed the imaging studies (112 CT; 263 MRI) and recorded the presence of targetoid appearance on T2-weighted images and features of tumor vascular involvement including encasement, narrowing, tethering, occlusion, and obliteration. The sensitivity and specificity of each feature were calculated for the diagnosis of non-HCC PLCs. Cohen's kappa (k) test was used to assess inter-reader agreement.

RESULTS

The sensitivity of targetoid appearance on T2-weighted images for the diagnosis of non-HCC PLCs was 27.5% and 32.6% (R1 and R2) and the specificity was 98.2% and 97.3% (R1 and R2). Among the features of tumor vascular involvement, those providing the highest sensitivity for non-HCC PLCs were vascular encasement (R1: 34.3%; R2: 37.2%) and obliteration (R1: 25.5%; R2: 29.7%). The highest specificity for non-HCC PLCs was provided by tethering (R1: 100%; R2: 97.1%) and occlusion (R1: 99.3%; R2: 99.3%). The inter-reader agreement was moderate to substantial (k = 0.48-0.77).

CONCLUSIONS

Targetoid appearance on T2-weighted images and features of tumor vascular involvement demonstrated high specificity for non-HCC malignancy.

KEY POINTS

• Targetoid appearance on T2-weighted imaging and signs of tumor vascular involvement have high specificity (92-100%) for the diagnosis of non-HCC PLCs, regardless of the presence of liver risk factors. • In the subset of patients with risk factors for HCC, the sensitivity of signs of tumor vascular involvement decreases for both readers (1.7-20.3%), while the specificity increases reaching values higher than 94.2%. • The inter-reader agreement is substantial for targetoid appearance on T2-weighted images (k = 0.74) and moderate to substantial for signs of tumor vascular involvement (k = 0.48-0.77).

Hepatospecific MR contrast agent uptake on hepatobiliary phase can be used as a biomarker of marked β-catenin activation in hepatocellular adenoma

OBJECTIVES

To assess the value of hepatospecific MR contrast agent uptake on hepatobiliary phase (HBP) images to detect marked activation of the β-catenin pathway in hepatocellular adenomas (HCAs).

METHODS

This multicentric retrospective IRB-approved study included all patients with a pathologically proven HCA who underwent gadobenate dimeglumine-enhanced liver MRI with HBP. Tumor signal intensity on HBP was first assessed visually, and lesions were classified into three distinct groups-hypointense, isointense, or hyperintense-according to the relative signal intensity to liver. Uptake was then quantified using the lesion-to-liver contrast enhancement ratio (LLCER). Finally, the accuracy of HBP analysis in depicting marked β-catenin activation in HCA was evaluated.

RESULTS

A total of 124 HCAs were analyzed including 12 with marked β-catenin activation (HCA B+). Visual analysis classified 94/124 (76%), 12/124 (10%), and 18/124 (14%) HCAs as being hypointense, isointense, and hyperintense on HBP, respectively. Of these, 1/94 (1%), 3/12 (25%), and 8/18 (44%) were HCA B+, respectively (p < 0.001). The LLCER of HCA B+ was higher than that of HCA without marked β-catenin activation in the entire cohort (means 4.9 ± 11.8% vs. - 19.8 ± 11.4%, respectively, p < 0.001). A positive LLCER, i.e., LLCER ≥ 0%, had 75% (95% CI 43-95%) sensitivity and 97% (95% CI 92-99%) specificity, with a LR+ of 28 (95% CI 8.8-89.6) for the diagnosis of HCA B+.

CONCLUSIONS

Hepatospecific contrast uptake on hepatobiliary phase is strongly associated with marked activation of the β-catenin pathway in hepatocellular adenoma, and its use might improve hepatocellular adenoma subtyping on MRI.

KEY POINTS

• Tumor uptake on hepatobiliary phase in both the visual and quantitative analyses had a specificity higher than 90% for the detection of marked β-catenin activation in hepatocellular adenoma. • However, the sensitivity of visual analysis alone is inferior to that of LLCER quantification on HBP due to the high number of HCAs with signal hyperintensity on HBP, especially those developed on underlying liver steatosis.

Atypical Enhancement of Gd-BOPTA on the Hepatobiliary Phase in Hepatic Metastasis from Carcinoid Tumor - Case Report

Patient: Female, 65-year-old

Final Diagnosis: Carcinoid tumor

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Radiology

Comparison of the clinical and MRI features of patients with hepatic hemangioma, epithelioid hemangioendothelioma, or angiosarcoma

Background

Comparisons of hepatic epithelioid hemangioendothelioma (HEHE), hepatic hemangioma, and hepatic angiosarcoma (HAS) have rarely been reported. The purpose of our study was to analyze the clinical and magnetic resonance imaging (MRI) findings of these conditions.

Methods

A total of 57 patients (25 with hemangioma, 13 with HEHE, and 19 with HAS) provided hepatic vascular endothelial cell data between June 2006 and May 2017.

Results

The proportions of cases with circumscribed margins were 88% (22/25), 84.6% (11/13), and 31.6% (6/19) for hemangioma, HEHE, and HAS, respectively (P < 0.001). HAS lesions were less likely to have circumscribed margins. The proportions of lesions with hemorrhaging were 4% (1/25), 30.8% (4/13), and 36.8% (7/19) for hemangioma, HEHE, and HAS, respectively (P = 0.014). HEHE and HAS cases were more likely to show heterogeneous signals on T1-weighted (T1WI) MRI. HEHE and HAS cases were more likely to show heterogeneous signals on T2-weighted (T2WI) MRI. Centripetal enhancement was the most common pattern in vascular tumors, with proportions of 100, 46.2% (6/13), and 68.4% (13/19) for hemangioma, HEHE, and HAS, respectively. The difference in enhancement pattern between HEHE and HAS was not significant, but rim enhancement was more common for HEHE (46.2%, 6/13).

Conclusions

Our study revealed clinical and imaging differences between HEHE and HAS. The platelet count (PLT) and coagulation function of the HAS group decreased, whereas the alpha-fetoprotein (AFP) level increased. The 5-year survival rate for HAS was significantly lower than that of HEHE. A higher malignancy degree indicated a more blurred lesion margin, easier occurrence of hemorrhaging, and more heterogeneous T1WI and T2WI signals.

Hepatic hemangioendothelioma: CT, MR, and FDG-PET-CT in 67 patients-a bi-institutional comprehensive cancer center review

OBJECTIVE

To evaluate the imaging features of hepatic epithelioid hemangioendothelioma (HEH) on multiphasic CT, MR, and FDG-PET-CT.

METHODS

Bi-institutional review identified 67 adults (mean age, 47 years; 23 M/44 F) with pathologically proven HEH and pretreatment multiphasic CT (n = 67) and/or MR (n = 30) and/or FDG-PET-CT (n = 13).

RESULTS

HEHs were multifocal in 88% (59/67). Mean size of the dominant mass was 4.1 cm (range, 1.4-19 cm). The tumors were located in the peripheral, subcapsular regions of the liver in 96% (64/67). Capsular retraction was present in 81% (54/67 cases) and tumors were coalescent in 61% (41/67). HEH demonstrated peripheral ring enhancement on arterial phase imaging in 33% (21/64) and target appearance on the portal venous phase in 69% (46/67). Persistent peripheral enhancement on the delayed phase was seen in 49% (31/63). On MR, multilayered target appearance was seen on the T2-weighted sequences in 67% (20/30) and on the diffusion-weighted sequences in 61% (11/18). Target appearance on hepatobiliary phase of MRI was seen in 57% (4/7). On pre-therapy FDG-PET-CT, increased FDG uptake above the background liver parenchyma was seen in 62% (8/13).

CONCLUSION

HEHs typically manifest as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. Peripheral arterial ring enhancement and target appearance on portal venous phase are commonly seen on CT. Similarly, multilayered target appearance correlating with its histopathological composition is typically seen on multiple sequences of MR including T2-weighted, diffusion-weighted, and dynamic contrast-enhanced multiphasic MR.

KEY POINTS

• Hepatic epithelioid hemangioendotheliomas manifest on CT and MR as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. • Enhancement pattern on contrast-enhanced CT and MR can vary but peripheral ring enhancement on arterial phase and target appearance on portal venous phase are commonly seen. • Retrospective two-center study showed that cross-sectional imaging may help in the diagnosis.

Spectrum of Pitfalls, Pseudolesions, and Potential Misdiagnoses in Cirrhosis

OBJECTIVE

The purposes of this article are to review a variety of pitfalls in liver imaging that can lead to the inaccurate diagnosis of focal hepatic lesions in cirrhosis, to describe the pathophysiologic processes of these pitfalls, and to provide specific clues for achieving the correct diagnoses.

CONCLUSION

Cirrhosis complicates liver imaging. The distortion and replacement of normal liver parenchyma by fibrous and regenerative tissue can change the typical appearance of many benign lesions, causing them to be misinterpreted as malignancy. In addition, the high incidence and prevalence of hepatocellular carcinoma among patients with cirrhosis put radiologists on high alert for any suspicious findings, especially because not all hepatocellular carcinomas have a typical imaging appearance.

Staging of liver fibrosis using Gd-EOB-DTPA and Gd-BOPTA enhanced magnetic resonance imaging

The severity of cirrhosis is closely related to its clinical treatment. Therefore, it is important to stage liver fibrosis accurately. Although liver biopsy can accurately stage the degree of cirrhosis, it has certain limitations in clinical application because of its invasive nature. Magnetic resonance imaging (MRI) has been used in the diagnosis of liver diseases. In recent years, two new contrast agents, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) and gadobenate dimeglumine (Gd-BOPTA), have been successfully used for noninvasive liver imaging. They can be used for liver fibrosis staging and assessment of liver function. Cirrhotic patients with different liver function levels have a statistical difference in the liver parenchyma enhancement after giving contrast agents. This article briefly summarizes the progress of Gd-EOB-DTPA and Gd-BOPTA enhanced MRI in staging liver fibrosis stage.

Intrahepatic cholangiocarcinoma: current perspectives

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy arising from the liver. ICC makes up about 10% of all cholangiocarcinomas. It arises from the peripheral bile ducts within the liver parenchyma, proximal to the secondary biliary radicals. Histologically, the majority of ICCs are adenocarcinomas. Only a minority of patients (15%) present with resectable disease, with a median survival of less than 3 years. Multidisciplinary management of ICC is complicated by large differences in disease course for individual patients both across and within tumor stages. Risk models and nomograms have been developed to more accurately predict survival of individual patients based on clinical parameters. Predictive risk factors are necessary to improve patient selection for systemic treatments. Molecular differences between tumors, such as in the epidermal growth factor receptor status, are promising, but their clinical applicability should be validated. For patients with locally advanced disease, several treatment strategies are being evaluated. Both hepatic arterial infusion chemotherapy with floxuridine and yttrium-90 embolization aim to downstage locally advanced ICC. Selected patients have resectable disease after downstaging, and other patients might benefit because of postponing widespread dissemination and biliary obstruction.