The Liver Imaging Reporting and Data System tumor-in-vein category: a systematic review and meta-analysis

The Diagnosis and Staging of Hepatocellular Carcinoma: A Review of Current Practices

Promoting the early detection and diagnosis of hepatocellular carcinoma (HCC) is a critical strategy to improve patient outcomes as this can lead to greater access to curative treatments. This review highlights the diagnostic tests for HCC, including the use of the Liver Imaging Reporting and Data System systems and histopathology. Staging is essential for informing prognosis and guiding treatment decisions; this review also covers a widely used and well-validated staging system called the Barcelona-Clinic Liver Cancer (BCLC) algorithm. The BCLC incorporates tumor status, liver function, and patient performance to stage patients with newly diagnosed HCC.

Transplant Oncology: An Emerging Discipline of Cancer Treatment

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.

Inter-observer agreement and accuracy of LI-RADS v2018 for differentiating tumor in vein from bland thrombus using gadoxetic acid-enhanced magnetic resonance imaging

PURPOSE

To assess inter-observer agreement and accuracy of LI-RADS v2018 for differentiating tumor in vein (TIV) from bland thrombus on gadoxetic acid-enhanced magnetic resonance imaging (Gx-MRI). Secondarily, to determine whether a multi-feature model improves accuracy compared to LI-RADS.

METHODS

We retrospectively identified consecutive patients at risk for hepatocellular carcinoma with venous occlusion(s) reported on Gx-MRI. Five radiologists independently classified each occlusion as TIV or bland thrombus using the LI-RADS TIV criterion (enhancing soft tissue in vein). They also evaluated imaging features suggestive of TIV or bland thrombus. Intra-class correlation coefficient (ICC) was calculated for individual features. A multi-feature model was developed based on consensus scores of features with > 5% consensus prevalence and > 0.40 ICC. Sensitivity and specificity of the LI-RADS criterion and of the cross-validated multi-feature model were compared.

RESULTS

Ninety-eight patients with 103 venous occlusions (58 TIV, 45 bland thrombus) were included. The LI-RADS criterion provided 0.63 ICC and, depending on the reader, 0.62-0.93 sensitivity and 0.87-1.00 specificity. Five other features had > 5% consensus prevalence and > 0.40 ICC, including three LI-RADS suggestive features and two non-LI-RADS features. The optimal multi-feature model incorporated the LI-RADS criterion and one LI-RADS suggestive feature (occluded or obscured vein contiguous with malignant parenchymal mass). After cross-validation, the multi-feature model did not improve sensitivity or specificity compared to the LI-RADS criterion (P = 0.23 and 0.25, respectively).

CONCLUSION

Using Gx-MRI, the LI-RADS criterion for TIV provides substantial inter-observer agreement, variable sensitivity, and high specificity for differentiating TIV from bland thrombus. A cross-validated multi-feature model did not improve diagnostic performance.

Standardizing liver imaging reporting and interpretation: LI-RADS and beyond

Imaging plays a crucial role in diagnosis and post-treatment monitoring of primary liver cancers. Clear, consistent, and actionable communication of imaging results is crucial to avoid miscommunication and potential detrimental impact on patient care. In this review, we discuss the importance, advantages, and potential impact of universal adoption of standardized terminology and interpretive criteria for liver imaging, from the point of view of radiologists and clinicians.

Identification of the origin of tumor in vein: comparison between CEUS LI-RADS v2017 and v2016 for patients at high risk

Objectives

To compare the diagnostic performance of the Contrast-Enhanced Ultrasound (CEUS) Liver Imaging Report and Data System (LI-RADS) v2016 and v2017 in identifying the origin of tumor in vein (TIV).

Methods

From April 2014 to December 2018, focal liver lesions (FLLs) accompanied by TIV formation in patients at high risk for hepatocellular carcinoma (HCC) were enrolled. Histologic evaluation or composite imaging reference standard were served as the reference standard. Each case was categorized according to the CEUS LI-RADS v2016 and v2017, respectively. Diagnostic performance of CEUS LI-RADS v2016 and v2017 in identifying the originated tumor of TIV was validated via sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value.

Results

A total of 273 FLLs with TIV were analyzed finally, including 266 HCCs and 7 non-HCCs. In v2016, when adopting all TIV as LR-5V, the accuracy and PPV in identifying the originated tumor were both 97.4%. In v2017, when assigning TIV according to contiguous FLLs CEUS LI-RADS category, the accuracy and PPV were 61.9% and 99.4% in subclass of LR-5 as the diagnostic criteria of HCC, and 64.1% and 99.4% in subclass of LR-4/5 as the criteria of HCC diagnosis. There were significant differences in diagnostic accuracy between CEUS LI-RADS v2016 and v2017 in identifying the originated tumor of TIV (p < 0.001).

Conclusions

CEUS LI-RADS v2016 could be better than v2017 in identifying the originated tumor of TIV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00912-4.

Imaging mimickers of cholangiocarcinoma: a pictorial review

Cholangiocarcinoma (CCA) is the second most common primary hepatobiliary malignancy and presents as three separate morphological subtypes; namely mass-forming, periductal-infiltrating, and intraductal-growing patterns. Each of these subtypes have distinct imaging characteristics, as well as a variety of benign and malignant mimics, making accurate diagnosis of CCA on imaging challenging. Whilst histopathological examination is required to arrive at a definitive diagnosis, it is still important for radiologists to be cognizant of these entities and provide reasonable differential diagnoses, as these potentially have a large impact on patient management. This pictorial essay illustrates the three morphological subtypes of CCA, as well as some important mimics for each subtype, that are encountered in clinical practice.

Tumor in vein (LR-TIV) and liver imaging reporting and data system (LI-RADS) v2018: diagnostic features, pitfalls, prognostic and management implications

Vascular invasion by hepatocellular carcinoma (HCC), also known as tumor in vein (TIV), indicates highly invasive tumor behavior and is also associated with poor outcome. Because a diagnosis of TIV precludes liver transplantation, knowledge of the imaging findings to differentiate between TIV and bland thrombus is key for proper patient management. Prior versions of liver imaging reporting and data system (LI-RADS) included presence of TIV as part of LR-5 criteria. However, even if HCC is the most common liver malignancy associated with TIV, other tumors can have vascular invasion and may occur in cirrhotic patients. For these reasons, in LI-RADS v2017 LR-TIV has been introduced as a new different diagnostic category. The aim of this article is to discuss the diagnostic criteria of LR-TIV according to LI-RADS v2018 and analyze potential pitfalls encountered on daily clinical practice. Indeterminate cases and how to manage them will also be discussed.

Transplant Oncology: An Evolving Field in Cancer Care

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The application of oncology, transplant medicine, and surgery to improve patients' survival and quality of life is the core of transplant oncology. Hepatobiliary malignancies have been treated by liver transplantation (LT) with significant improved outcome. In addition, as the liver is the most common site of metastasis for colorectal cancer (CRC), patients with CRC who have stable unresectable liver metastases are good candidates for LT, and initial studies have shown improved survival compared to palliative systemic therapy. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years in a stepwise manner; however, they have only been shown to improve patient survival in the setting of limited systemic therapy options. This review illustrates the concept and history of transplant oncology as an evolving field for the management of hepatocellular carcinoma, intrahepatic biliary cancer, and liver-only metastasis of non-hepatobiliary carcinoma. The utility of immunotherapy in the transplant setting is discussed as well as the feasibility of using circulating tumor DNA for surveillance post-transplantation.

LI-RADS Tumor in Vein at CT and Hepatobiliary MRI

Background Diagnostic performance of the Liver Imaging Reporting and Data System tumor in vein (LR-TIV) category at CT and/or MRI has not yet been evaluated, to the knowledge of the authors. Purpose To assess the diagnostic performance of the LR-TIV category in detecting macroscopic tumors in veins (TIVs) at CT and hepatobiliary contrast agent-enhanced (HBA) MRI, with pathologic results used as the reference standard. Materials and Methods Between January 2010 and December 2019, consecutive patients with or without macroscopic TIV who underwent both CT and HBA MRI before hepatic resection or liver transplant were retrospectively included. Three radiologists independently assessed the LR-TIV features of enhancing soft tissue in vein and features suggestive of TIV (FSTIV) and reached a consensus. Macroscopic TIV at pathologic examination was the reference standard. Sensitivities and specificities of the LR-TIV category without and with FSTIV were calculated, and the added value of FSTIV was evaluated by using the McNemar test. Results In the 1322 patients with (n = 101) or without (n = 1221) macroscopic TIV (median age, 64 years [interquartile range, 58-70 years]; 1053 men), without consideration of FSTIV, the sensitivity and specificity of enhancing soft tissue in vein for detecting macroscopic TIV at pathologic examination were 64.4% (65 of 101) and 99.8% (1218 of 1221) with CT and 62.4% (63 of 101) and 99.8% (1218 of 1221) with HBA MRI, respectively. With consideration of FSTIV, the sensitivity and specificity of the LR-TIV category became 67.3% (68 of 101 patients) and 99.7% (1217 of 1221 patients) at both CT and HBA MRI. No difference was found between measurements without and with FSTIV (sensitivity, 62% vs 67% for CT [P = .45] and 64% vs 67% for HBA MRI [P = .18]; specificity, 99% for both CT and HBA MRI [P > .99 for both]). Conclusion The Liver Imaging Reporting and Data System tumor in vein category showed moderate sensitivity and high specificity in the detection of macroscopic tumors in veins at both CT and hepatobiliary contrast agent-enhanced MRI, with pathologic examination used as the reference standard. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Morrell in this issue.

MR Imaging Contrast Agents: Role in Imaging of Chronic Liver Diseases

Contrast-enhanced MR imaging plays an important role in the evaluation of patients with chronic liver disease, particularly for detection and characterization of liver lesions. The two most commonly used contrast agents for liver MR imaging are extracellular agents (ECAs) and hepatobiliary agents (HBAs). In patients with liver disease, the main advantage of ECA-enhanced MR imaging is its high specificity for the diagnosis of progressed HCCs. Conversely, HBAs have an additional contrast mechanism, which results in high liver-to-lesion contrast and highest sensitivity for lesion detection in the hepatobiliary phase. Emerging data suggest that features depicted on contrast-enhanced MR imaging scans are related to tumor biology and are predictive of patients' prognosis, likely to further expand the role of contrast-enhanced MR imaging in the clinical care of patients with chronic liver disease.

Up-to-Date Role of CT/MRI LI-RADS in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide and a major healthcare burden in most societies. Computed tomography (CT) and magnetic resonance imaging (MRI) play a pivotal role in the medical care of patients with or at risk for hepatocellular carcinoma (HCC). When stringent imaging criteria are fulfilled, CT and MRI allow for diagnosis, staging, and assessment of response to treatment, without the need for invasive workup, and can inform clinical decision making. Owing to the central role of these imaging modalities in HCC management, standardization is essential to facilitate proper imaging technique, accurate interpretation, and clear communication among all stakeholders in both the clinical practice and research settings. The Liver Imaging Reporting and Data System (LI-RADS) is a comprehensive system that provides standardization across the continuum of HCC imaging, including ordinal probabilistic approach for reporting that directs individualized management. This review discusses the up-to-date role of CT and MRI in HCC imaging from the LI-RADS perspective. It also provides a glimpse into the future by discussing how advances in knowledge and technology are likely to enrich the LI-RADS approach.