MR imaging features and long-term evolution of benign focal liver lesions in Budd-Chiari syndrome and Fontan-associated liver disease

MRI Using Gadoxetic Acid in the Work-Up of Liver Nodules Not Conclusively Benign in Budd-Chiari Syndrome: A Prospective Long-Term Follow-Up

Introduction

The incidence of hepatocellular carcinoma (HCC) in Budd-Chiari syndrome (BCS) is unknown and there is no validated diagnostic work-up to define the liver nodules with arterial phase hyperenhancement (APHE), suggesting malignancy. This prospective study evaluates HCC incidence in a Western cohort of patients with BCS and assesses the performance of MRI with hepatobiliary contrast (HB-MRI) for nodule characterization.

Methods

Patients with BCS followed in our hospital were prospectively evaluated by MRI with extracellular contrast (EC-MRI). Nodules with APHE categorized as non-conclusively benign by 2 radiologists were studied by HB-MRI and reviewed by 2 radiologists blinded to the EC-MRI results. A new EC-MRI 1 year later and clinical, analytical, and sonographic follow-up every 6 months for a median of 10 years was performed.

Results

A total of 55 non-conclusively benign nodules with APHE were detected at EC-MRI in 41 patients. While 32 of them were suggestive of HCC by EC-MRI, all the 55 nodules showed increased uptake of hepatobiliary contrast. An unequivocal central scar was seen in 12/55 nodules at HB-MRI regardless of it was not detected on the EC-MRI. None of the nodules was hypointense in the hepatobiliary phase (HBP). HCC was not detected during a median of 10 years of follow-up.

Conclusions

Detection of nodules with APHE is frequent in patients with BCS, but HCC is rare in Western patients with BCS. While EC-MRI may detect nodules suggesting malignancy, the identification of contrast uptake in the HBP at HB-MRI may help categorize them as benign.

EASL-ERN position paper on liver involvement in patients with Fontan-type circulation

Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.

Focal Liver Lesions in Budd-Chiari Syndrome: Spectrum of Imaging Findings

Budd-Chiari syndrome (BCS) is a rare clinical entity characterized by hepatic venous outflow obstruction, resulting in liver congestion and subsequent chronic parenchymal damage. This condition often leads to the development of focal liver lesions, including benign focal nodular hyperplasia-like regenerative nodules, hepatocellular carcinoma, and perfusion-related pseudo-lesions. Computed tomography, ultrasound, and magnetic resonance are the commonly employed imaging modalities for the follow-up of BCS patients and for the detection and characterization of new-onset lesions. The accurate differentiation between benign and malignant nodules is crucial for optimal patient management and treatment planning. However, it can be challenging due to the variable and overlapping characteristics observed. This review aims to provide a comprehensive overview of the imaging features and differential diagnosis of focal liver lesions in BCS, emphasizing the key findings and discussing the challenges associated with their interpretation, with the purpose of facilitating the subsequent clinical decision-making.

Budd-Chiari Syndrome Imaging Diagnosis: State of the Art and Future Perspectives

Budd-Chiari syndrome (BCS) is a rare hepatic vascular disorder defined by the presence of partial or complete impairment of hepatic venous drainage in the absence of right heart failure or constrictive pericarditis. Several conditions can lead to BCS, from hypercoagulable states to malignancies. Primary BCS is the most common subtype, and usually bartends hypercoagulability states, while secondary BCS involves tumor invasion or extrinsic compression. A combination of clinical and imaging features leads to the diagnosis of BCS, including (1) direct signs: occlusion or compression of the hepatic veins and/or inferior vena cava, and the presence of venous collaterals; (2) indirect signs: morphological hepatic changes with caudate lobe enlargement; inhomogeneous enhancement, and hypervascular nodules. From a clinicopathological point of view, two forms of BCS can be distinguished: acute and subacute/chronic BCS, although asymptomatic and fulminant forms are also possible. Acute presentations are rare, and symptoms include hepatomegaly, ascites, and hepatic insufficiency. Subacute/chronic forms are the most common presentation, with dysmorphic liver and variable degrees of fibrosis deposition. Patients with chronic BCS can develop benign regenerative nodules (large regenerative nodules or FNH [Focal Nodular Hyperplasia]-like lesions), but are also at a higher risk of hepatocellular carcinoma (HCC). The radiologist role is therefore fundamental in both diagnosis and surveillance of BCS. The aim of this review is to present all clinical and imaging signs that can help to reach the diagnosis of BCS, with their clinical significance, providing tips and tricks for the cross-sectional diagnosis of this condition.

Impact of liver fibrosis and nodules formation on hemodynamics in young adults after total cavopulmonary connection. A magnetic resonance study

Background

The aim of this study was to analyze the relation between the hepatic fibrosis markers, liver morphology and hemodynamics assessed by magnetic resonance imaging (MRI) after total cavopulmonary connection (TCPC).

Materials and methods

Adult patients after TCPC performed in childhood between 1993 and 2003 are the subjects of this observational study. The follow-up protocol consisted of clinical and echocardiographic examination, liver elastography, cardiopulmonary exercise test, MRI hemodynamics and liver morphology assessment and direct enhanced liver fibrosis (ELF) test.

Results

The cohort consisted of 39 patients (46% female) with a median age at study 26 (IQR 23–28) years and interval from TCPC 21 (IQR 20–23) years. There was no correlation between ELF test and any MRI variables, but procollagen III amino-terminal peptide (PIIINP), a single component of ELF test, correlated significantly with ventricular end-diastolic volume (r = 0.33; p = 0.042) and inferior vena cava flow (r = 0.47; p = 0.003). Fifteen (38%) patients with liver nodules had compared to other 24 patients higher end-diastolic volume (ml/m²) 102.8 ± 20.0 vs. 88.2 ± 17.7; p = 0.023, respectively. PIIINP correlated significantly with inferior vena cava flow (r = 0.56; p = 0.030) and with end-diastolic volume (r = 0.53; p = 0.043), but only in patients with liver nodules.

Conclusion

Gradual progression of liver fibrosis, particularly hepatic arterialization caused by liver nodules formation, increases inferior vena cava flow and subsequent ventricular volume overload may further compromise single ventricle functional reserve in adult patients after TCPC.

Fast T2-weighted liver MRI: Image quality and solid focal lesions conspicuity using a deep learning accelerated single breath-hold HASTE fat-suppressed sequence

PURPOSE

Acceleration of MRI acquisitions and especially of T2-weighted sequences is essential to reduce the duration of MRI examinations but also kinetic artifacts in liver imaging. The purpose of this study was to compare the acquisition time and the image quality of a single-shot fat-suppressed turbo spin-echo (TSE) T2-weighted sequence with deep learning reconstruction (HASTE_DL) with that of a fat-suppressed T2-weighted BLADE TSE sequence in patients with focal liver lesions.

MATERIALS AND METHODS

Ninety-five patients (52 men, 43 women; mean age: 61 ± 14 [SD]; age range: 28-87 years) with 42 focal liver lesions (17 hepatocellular carcinomas, 10 sarcoidosis lesions, 9 myeloma lesions, 3 liver metastases and 3 focal nodular hyperplasias) who underwent liver MRI at 1.5 T including HASTE_DL and BLADE sequences were retrospectively included. Overall image quality, noise level in the liver, lesion conspicuity and sharpness of liver lesion contours were assessed by two independent readers. Liver signal-to-noise ratio (SNR) and lesion contrast-to-noise ratio (CNR) were measured and compared between the two sequences, as well as the mean duration of the sequences (Student t-test or Wilcoxon test for paired data).

RESULTS

Median overall quality on HASTE_DL images (3; IQR: 3, 3) was significantly greater than that on BLADE images (2; IQR: 1, 3) (P < 0.001). Median noise level in the liver on HASTE_DL images (0; IQR: 0, 0.5) was significantly lower than that on BLADE images (1; IQR: 1, 2) (P < 0.001). On HASTE_DL images, mean liver SNR (107.3 ± 39.7 [SD]) and mean focal liver lesion CNR (87.0 ± 76.6 [SD]) were significantly greater than those on BLADE images (67.1 ± 23.8 [SD], P < 0.001 and 48.6 ± 43.9 [SD], P = 0.027, respectively). Acquisition time was significantly shorter with the HASTE_DL sequence (18 ± [0] s; range: 18-18 s) compared to BLADE sequence (152 ± 47 [SD] s; range: 87-263 s) (P < 0.001).

CONCLUSION

By comparison with the BLADE sequence, HASTE_DL sequence significantly reduces acquisition time while improving image quality, liver SNR and focal liver lesions CNR.