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Nguyen T, Vennatt J, Downs L, Surabhi V, Stanietzky N. Advanced Imaging of Hepatocellular Carcinoma: A Review of Current and Novel Techniques. J Gastrointest Cancer 2024:10.1007/s12029-024-01094-8. [PMID: 39158837 DOI: 10.1007/s12029-024-01094-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/20/2024]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary carcinoma arising from the liver. Although HCC can arise de novo, the vast majority of cases develop in the setting of chronic liver disease. Hepatocarcinogenesis follows a well-studied process during which chronic inflammation and cellular damage precipitate cellular and genetic aberrations, with subsequent propagation of precancerous and cancerous lesions. Surveillance of individuals at high risk of HCC, early diagnosis, and individualized treatment are keys to reducing the mortality associated with this disease. Radiological imaging plays a critical role in the diagnosis and management of these patients. HCC is a unique cancer in that it can be diagnosed with confidence by imaging that meets all radiologic criteria, obviating the risks associated with tissue sampling. This article discusses conventional and emerging imaging techniques for the evaluation of HCC.
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Affiliation(s)
- Trinh Nguyen
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Jaijo Vennatt
- Department of Diagnostic Radiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Lincoln Downs
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Venkateswar Surabhi
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Nir Stanietzky
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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An Overview of Hepatocellular Carcinoma Surveillance Focusing on Non-Cirrhotic NAFLD Patients: A Challenge for Physicians. Biomedicines 2023; 11:biomedicines11020586. [PMID: 36831120 PMCID: PMC9953185 DOI: 10.3390/biomedicines11020586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide and it ranges from simple steatosis to hepatocellular carcinoma (HCC). HCC represents the first liver tumor and the third source of cancer death. In the next few years, the prevalence of NAFLD and consequently of HCC is estimated to increase, becoming a major public health problem. The NAFLD-HCC shows several differences compared to other causes of chronic liver disease (CLD), including the higher percentage of patients that develop HCC in the absence of liver cirrhosis. In HCC surveillance, the international guidelines suggest a six months abdominal ultrasound (US), with or without alpha-fetoprotein (AFP) evaluation, in patients with cirrhosis and in a subgroup of patients with chronic hepatitis B infection. However, this screening program reveals several limitations, especially in NAFLD patients. Thus, new biomarkers and scores have been proposed to overcome the limits of HCC surveillance. In this narrative review we aimed to explore the differences in the HCC features between NAFLD and non-NAFLD patients, and those between NAFLD-HCC developed in the cirrhotic and non-cirrhotic liver. Finally, we focused on the limits of tumor surveillance in NAFLD patients, and we explored the new biomarkers for the early diagnosis of HCC.
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MRI features of histologic subtypes of hepatocellular carcinoma: correlation with histologic, genetic, and molecular biologic classification. Eur Radiol 2022; 32:5119-5133. [PMID: 35258675 DOI: 10.1007/s00330-022-08643-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/31/2022] [Accepted: 02/11/2022] [Indexed: 02/07/2023]
Abstract
HCC is a heterogeneous group of tumors in terms of histology, genetic aberration, and protein expression. Advancements in imaging techniques have allowed imaging diagnosis to become a critical part of managing HCC in the clinical setting, even without pathologic diagnosis. With the identification of many HCC subtypes, there is increasing correlative evidence between imaging phenotypes and histologic, molecular, and genetic characteristics of various HCC subtypes. In this review, current knowledge of histologic heterogeneity of HCC correlated to features on gadolinium-enhanced dynamic liver MRI will be discussed. In addition, HCC subtype classification according to transcriptomic profiles will be outlined with descriptions of histologic, genetic, and molecular characteristics of some relatively well-established morphologic subtypes, namely the low proliferation class (steatohepatitic HCC and CTNNB1-mutated HCC) and the high proliferation class (macrotrabecular-massive HCC (MTM-HCC), scirrhous HCC, and CK19-positive HCC). Characteristics of sarcomatoid HCC and fibrolamellar HCC will also be discussed. Further research on radiological characteristics of HCC subtypes may ultimately enable non-invasive diagnosis and serve as a biomarker in predicting prognosis, molecular characteristics, and therapeutic response. In the era of precision medicine, a multidisciplinary effort to develop an integrated radiologic and clinical diagnostic system of various HCC subtypes is necessary. KEY POINTS: • HCC is a heterogeneous group of tumors in terms of histology, genetic aberration, and protein expression, which can be divided into many subtypes according to transcriptome profiles. • There is increasing evidence of a correlation between imaging phenotypes and histologic, genetic, and molecular biologic characteristics of various HCC subtypes. • Imaging characteristics may ultimately enable non-invasive diagnosis and subtype characterization, serving as a biomarker for predicting prognosis, molecular characteristics, and therapeutic response.
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Nguyen SA, Merrill CD, Burrowes DP, Medellin GA, Wilson SR. Hepatocellular Carcinoma in Evolution: Correlation with CEUS LI-RADS. Radiographics 2022; 42:1028-1042. [PMID: 35486579 DOI: 10.1148/rg.210149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver with a high incidence worldwide and a high associated mortality. Well-recognized risk factors that cause a predisposition to the development of HCC include chronic infection with the hepatitis B or C virus, alcohol-related and non-alcohol-related fatty liver disease, and cirrhosis. In these chronically diseased livers, benign regenerative nodules can increase in size and develop cellular atypia that progress into dysplastic nodules and ultimately HCC. This sequence of hepatocarcinogenesis is coupled with changes in nodule vascularity, including progressive decreased density of portal triads and induced neoangiogenesis, resulting in increased hepatic arterial recruitment. Changes in vascularity result in an array of patterns of nodule enhancement and washout, which can be sensitively depicted with dynamic real-time contrast-enhanced US. Regenerative nodules are isoenhancing relative to the liver with all phases, while HCC classically shows avid arterial phase hyperenhancement with late mild washout. In between, there is great variation as nodules evolve through progressive grades of dysplasia toward HCC. Observed patterns of enhancement and washout can be used to diagnose or stratify the risk of malignancy in liver nodules by using the diagnostic algorithm described by the American College of Radiology Liver Imaging Reporting and Data System (LI-RADS). This facilitates the detection and close monitoring of potential early-stage disease. LI-RADS categorizes nodules according to a probabilistic likelihood for HCC with criteria for LR-5 nodules that are highly specific for the diagnosis of HCC, allowing treatment without exposing the patient to invasive biopsy. An invited commentary by Fetzer is available online. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2022.
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Affiliation(s)
- Stephanie A Nguyen
- From the Department of Radiology, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9
| | - Christina D Merrill
- From the Department of Radiology, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9
| | - David P Burrowes
- From the Department of Radiology, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9
| | - G Alexandra Medellin
- From the Department of Radiology, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9
| | - Stephanie R Wilson
- From the Department of Radiology, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9
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Kang JH, Choi SH, Lee JS, Kim DW, Jang JK. Inter-reader reliability of contrast-enhanced ultrasound Liver Imaging Reporting and Data System: a meta-analysis. Abdom Radiol (NY) 2021; 46:4671-4681. [PMID: 34156509 DOI: 10.1007/s00261-021-03169-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To systematically determine the inter-reader reliability of the contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS), with emphasis on its major features for hepatocellular carcinoma (HCC) and LR-M (LI-RADS category M) features for non-HCC malignancy. METHODS MEDLINE, EMBASE, and Cochrane databases were searched from January 2016 to March 2021 to identify original articles reporting the inter-reader reliability of CEUS LI-RADS. Meta-analytic pooled kappa values (κ) were calculated for major features [nonrim arterial-phase hyperenhancement (APHE), mild and late washout], LR-M features (rim APHE, early washout), and LI-RADS categorization using the DerSimonian-Laird random-effects model. Meta-regression analysis was performed to explore any causes of study heterogeneity. RESULTS Twelve studies with a total of 2862 lesions were included. The meta-analytic pooled κ of nonrim APHE, mild and late washout, rim APHE, early washout, and LI-RADS categorization were 0.73 [95% confidence interval (CI), 0.67 - 0.79], 0.69 (95% CI, 0.54-0.84), 0.54 (95% CI, 0.37-0.71), 0.62 (95% CI, 0.45-0.79), and 0.75 (95% CI, 0.64-0.87), respectively. Compared with the major features, LR-M features had a lower meta-analytic pooled κ. Substantial study heterogeneity was noted in the LI-RADS categorization, and lesion size (p = 0.03) and the homogeneity in reader experience (p = 0.03) were significantly associated with study heterogeneity. CONCLUSIONS CEUS LI-RADS showed substantial inter-reader reliability for major features and LI-RADS categorization, but relatively lower reliability was found for LR-M features. In our opinion, the definitions of imaging features require further refinement to improve the inter-reader reliability of CEUS LI-RADS.
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Affiliation(s)
- Ji Hun Kang
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Republic of Korea
| | - Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Clinical Research Center, Asan Medical Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wook Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Fung A, Shanbhogue KP, Taffel MT, Brinkerhoff BT, Theise ND. Hepatocarcinogenesis: Radiology-Pathology Correlation. Magn Reson Imaging Clin N Am 2021; 29:359-374. [PMID: 34243923 DOI: 10.1016/j.mric.2021.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In the background of chronic liver disease, hepatocellular carcinoma develops via a complex, multistep process called hepatocarcinogenesis. This article reviews the causes contributing to the process. Emphasis is made on the imaging manifestations of the pathologic changes seen at many stages of hepatocarcinogenesis, from regenerative nodules to dysplastic nodules and then to hepatocellular carcinoma.
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Affiliation(s)
- Alice Fung
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L-340, Portland, OR 97239, USA.
| | - Krishna P Shanbhogue
- Department of Radiology, New York University Grossman School of Medicine, 660 First Avenue, 3rd Floor, New York, NY 10016, USA
| | - Myles T Taffel
- Department of Radiology, New York University Grossman School of Medicine, 660 First Avenue, 3rd Floor, New York, NY 10016, USA
| | - Brian T Brinkerhoff
- Department of Pathology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L-113, Portland, OR 97239, USA
| | - Neil D Theise
- Department of Pathology, MSB 504A, New York University Grossman School of Medicine, 560 First Avenue, New York, NY 10016, USA
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Kovac JD, Ivanovic A, Milovanovic T, Micev M, Alessandrino F, Gore RM. An overview of hepatocellular carcinoma with atypical enhancement pattern: spectrum of magnetic resonance imaging findings with pathologic correlation. Radiol Oncol 2021; 55:130-143. [PMID: 33544992 PMCID: PMC8042819 DOI: 10.2478/raon-2021-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the setting of cirrhotic liver, the diagnosis of hepatocellular carcinoma (HCC) is straightforward when typical imaging findings consisting of arterial hypervascularity followed by portal-venous washout are present in nodules larger than 1 cm. However, due to the complexity of hepatocarcinogenesis, not all HCCs present with typical vascular behaviour. Atypical forms such as hypervascular HCC without washout, isovascular or even hypovascular HCC can pose diagnostic dilemmas. In such cases, it is important to consider also the appearance of the nodules on diffusion-weighted imaging and hepatobiliary phase. In this regard, diffusion restriction and hypointensity on hepatobiliary phase are suggestive of malignancy. If both findings are present in hypervascular lesion without washout, or even in iso- or hypovascular lesion in cirrhotic liver, HCC should be considered. Moreover, other ancillary imaging findings such as the presence of the capsule, fat content, signal intensity on T2-weighted image favour the diagnosis of HCC. Another form of atypical HCCs are lesions which show hyperintensity on hepatobiliary phase. Therefore, the aim of the present study was to provide an overview of HCCs with atypical enhancement pattern, and focus on their magnetic resonance imaging (MRI) features. CONCLUSIONS In order to correctly characterize atypical HCC lesions in cirrhotic liver it is important to consider not only vascular behaviour of the nodule, but also ancillary MRI features, such as diffusion restriction, hepatobiliary phase hypointensity, and T2-weighted hyperintensity. Fat content, corona enhancement, mosaic architecture are other MRI feautures which favour the diagnosis of HCC even in the absence of typical vascular profile.
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Affiliation(s)
- Jelena Djokic Kovac
- Center for Radiology and MRI, Clinical Center Serbia, School of Medicine, University of Belgrade; Belgrade, Serbia
| | - Aleksandar Ivanovic
- Center for Radiology and MRI, Clinical Center Serbia, School of Medicine, University of Belgrade; Belgrade, Serbia
| | - Tamara Milovanovic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia School of Medicine, University of Belgrade; Belgrade, Serbia
| | - Marjan Micev
- Departament of Digestive Pathology, Clinical Center of Serbia, Belgrade, Serbia
| | - Francesco Alessandrino
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Richard M. Gore
- Department of Gastrointestinal Radiology, NorthShore University, Evanston, Pritzker School of Medicine at the University of Chicago, ChicagoUSA
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8
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Dietrich CF, Dong Y, Kono Y, Caraiani C, Sirlin CB, Cui XW, Tang A. LI-RADS ancillary features on contrast-enhanced ultrasonography. Ultrasonography 2020; 39:221-228. [PMID: 32475089 PMCID: PMC7315297 DOI: 10.14366/usg.19052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 05/09/2020] [Indexed: 12/11/2022] Open
Abstract
The Liver Imaging Reporting and Data System (LI-RADS) was created to standardize liver imaging in patients at high risk for hepatocellular carcinoma (HCC), and it uses a diagnostic algorithm to assign categories that reflect the relative probability of HCC, non-HCC malignancies, or benign focal liver lesions. In addition to major imaging features, ancillary features (AFs) are used by radiologists to refine the categorization of liver nodules. In the present document, we discuss and explain the application of AFs currently defined within the LI-RADS guidelines. We also explore possible additional AFs visible on contrast-enhanced ultrasonography (CEUS). Finally, we summarize the management of CEUS LI-RADS features, including the role of current and potential future AFs.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Beau Site, Salem und Permanence, Hirslanden, Bern, Switzerland.,Ultrasound Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuko Kono
- Department of Medicine and Radiology, University of California, San Diego, CA, USA
| | - Cosmin Caraiani
- Department of Medical Imaging, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Claude B Sirlin
- Department of Radiology, University of California San Diego, San Diego, CA, USA
| | - Xin-Wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - An Tang
- Department of Radiology, Université de Montréal, Montreal, Canada
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9
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Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management. AJR Am J Roentgenol 2019; 213:8-16. [PMID: 30973778 DOI: 10.2214/ajr.19.21240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can present with hemorrhage, including their characteristic imaging features, and to propose a diagnostic approach. CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.
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Navin PJ, Venkatesh SK. Hepatocellular Carcinoma: State of the Art Imaging and Recent Advances. J Clin Transl Hepatol 2019; 7:72-85. [PMID: 30944823 PMCID: PMC6441649 DOI: 10.14218/jcth.2018.00032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 12/31/2018] [Accepted: 01/04/2019] [Indexed: 02/07/2023] Open
Abstract
The incidence of hepatocellular carcinoma (HCC) is increasing, with this trend expected to continue to the year 2030. Hepatocarcinogenesis follows a predictable course, which makes adequate identification and surveillance of at-risk individuals central to a successful outcome. Moreover, imaging is central to this surveillance, and ultimately to diagnosis and management. Many liver study groups throughout Asia, North America and Europe advocate a surveillance program for at-risk individuals to allow early identification of HCC. Ultrasound is the most commonly utilized imaging modality. Many societies offer guidelines on how to diagnose HCC. The Liver Image Reporting and Data System (LIRADS) was introduced to standardize the acquisition, interpretation, reporting and data collection of HCC cases. The LIRADS advocates diagnosis using multiphase computed tomography or magnetic resonance imaging (MRI) imaging. The 2017 version also introduces contrast-enhanced ultrasound as a novel approach to diagnosis. Indeed, imaging techniques have evolved to improve diagnostic accuracy and characterization of HCC lesions. Newer techniques, such as T1 mapping, intravoxel incoherent motion analysis and textural analysis, assess specific characteristics that may help grade the tumor and guide management, allowing for a more personalized approach to patient care. This review aims to analyze the utility of imaging in the surveillance and diagnosis of HCC and to assess novel techniques which may increase the accuracy of imaging and determine optimal treatment strategies.
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Affiliation(s)
| | - Sudhakar K. Venkatesh
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- *Correspondence to: Sudhakar K. Venkatesh, Mayo Clinic, Rochester, 200 1 Street, Rochester MN 55905, USA. Tel: +1-507-284-1728, Fax: +1-507-284-2405, E-mail:
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Krishan S, Dhiman RK, Kalra N, Sharma R, Baijal SS, Arora A, Gulati A, Eapan A, Verma A, Keshava S, Mukund A, Deva S, Chaudhary R, Ganesan K, Taneja S, Gorsi U, Gamanagatti S, Madhusudan KS, Puri P, Shalimar, Govil S, Wadhavan M, Saigal S, Kumar A, Thapar S, Duseja A, Saraf N, Khandelwal A, Mukhopadyay S, Gulati A, Shetty N, Verma N. Joint Consensus Statement of the Indian National Association for Study of the Liver and Indian Radiological and Imaging Association for the Diagnosis and Imaging of Hepatocellular Carcinoma Incorporating Liver Imaging Reporting and Data System. J Clin Exp Hepatol 2019; 9:625-651. [PMID: 31695253 PMCID: PMC6823668 DOI: 10.1016/j.jceh.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind.
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Affiliation(s)
- Sonal Krishan
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Radha Krishan Dhiman, MD, DM, FACG, FRCP, FAASLD, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Navin Kalra
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay S. Baijal
- Department of Diagnostic and Intervention Radiology, Medanta Hospital, Gurgaon, India
| | - Anil Arora
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Ajay Gulati
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anu Eapan
- Department of Radiology, Christian Medical College, Vellore, India
| | - Ashish Verma
- Department of Radiology, Banaras Hindu University, Varanasi, India
| | - Shyam Keshava
- Department of Radiology, Christian Medical College, Vellore, India
| | - Amar Mukund
- Department of Intervention Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - S. Deva
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Chaudhary
- Department of Radiology, Medanta Hospital, Gurgaon, India
| | | | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | | | - Kumble S. Madhusudan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Puri
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shalimar
- Department of GastroEnterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manav Wadhavan
- Institute of Digestive and Liver Diseases, BLK Hospital, Delhi, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | - Ashish Kumar
- Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Gangaram Hospital, New Delhi, India
| | - Shallini Thapar
- Department of Radiology, Institute of liver and biliary Sciences, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurgaon, India
| | | | | | - Ajay Gulati
- Department of Radiology, Postgraduate Institute Of Medical Education and Research, Chandigarh, India
| | - Nitin Shetty
- Department of Radiology, Tata Memorial Hospital, Kolkata, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Cerny M, Chernyak V, Olivié D, Billiard JS, Murphy-Lavallée J, Kielar AZ, Elsayes KM, Bourque L, Hooker JC, Sirlin CB, Tang A. LI-RADS Version 2018 Ancillary Features at MRI. Radiographics 2018; 38:1973-2001. [DOI: 10.1148/rg.2018180052] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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13
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Affiliation(s)
- Roberto Cannella
- Department of Radiology, University of Palermo, Palermo, Italy
- Abdominal Imaging Division, Department of Radiology, University of Pittsburgh, 200 Lothrop street, Pittsburgh, PA, 15213, USA
| | - Alessandro Furlan
- Abdominal Imaging Division, Department of Radiology, University of Pittsburgh, 200 Lothrop street, Pittsburgh, PA, 15213, USA.
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14
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Patella F, Pesapane F, Fumarola EM, Emili I, Spairani R, Angileri SA, Tresoldi S, Franceschelli G, Carrafiello G. CT-MRI LI-RADS v2017: A Comprehensive Guide for Beginners. J Clin Transl Hepatol 2018; 6:222-236. [PMID: 29951368 PMCID: PMC6018316 DOI: 10.14218/jcth.2017.00062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 12/02/2017] [Accepted: 12/05/2017] [Indexed: 12/16/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second leading cause of cancer-related deceases worldwide. Early diagnosis is essential for correct management and improvement of prognosis. Proposed for the first time in 2011 and updated for the last time in 2017, the Liver Imaging-Reporting and Data System (LI-RADS) is a comprehensive system for standardized interpretation and reporting of computed tomography (CT) and magnetic resonance imaging (MRI) liver examinations, endorsed by the American College of Radiology to achieve congruence with HCC diagnostic criteria in at-risk populations. Understanding its algorithm is fundamental to correctly apply LI-RADS in clinical practice. In this pictorial review, we provide a guide for beginners, explaining LI-RADS indications, describing major and ancillary features and eventually elucidating the diagnostic algorithm with the use of some clinical examples.
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Affiliation(s)
- Francesca Patella
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Filippo Pesapane
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
- *Correspondence to: Filippo Pesapane, Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Via Festa del Perdono 7, Milan 20122, Italy. Tel: +39-13012751123; Fax: +39-2-50323393; E-mail:
| | - Enrico Maria Fumarola
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Ilaria Emili
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Riccardo Spairani
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Salvatore Alessio Angileri
- Department of Health Sciences, Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Silvia Tresoldi
- Department of Health Sciences, Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Giuseppe Franceschelli
- Department of Health Sciences, Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Gianpaolo Carrafiello
- Department of Health Sciences, Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
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15
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Abstract
Hepatocarcinogenesis is a multi-step process characterized by progressive cellular and molecular dedifferentiation of hepatocytes and culminating in the emergence of hepatocellular carcinoma (HCC). Knowledge of hepatocarcinogenesis is important because familiarity with the associated imaging features can lead to improved diagnosis of HCC at its early stages. The article reviews the alterations that accumulate leading to HCC result in abnormal imaging features, many of which are included in LI-RADS v2017 as major and ancillary features.
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16
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Chernyak V, Tang A, Flusberg M, Papadatos D, Bijan B, Kono Y, Santillan C. LI-RADS ® ancillary features on CT and MRI. Abdom Radiol (NY) 2018. [PMID: 28647768 DOI: 10.1007/s00261-017-1220-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Liver Imaging Reporting and Data System (LI-RADS) uses an algorithm to assign categories that reflect the probability of hepatocellular carcinoma (HCC), non-HCC malignancy, or benignity. Unlike other imaging algorithms, LI-RADS utilizes ancillary features (AFs) to refine the final category. AFs in LI-RADS v2017 are divided into those favoring malignancy in general, those favoring HCC specifically, and those favoring benignity. Additionally, LI-RADS v2017 provides new rules regarding application of AFs. The purpose of this review is to discuss ancillary features included in LI-RADS v2017, the rationale for their use, potential pitfalls encountered in their interpretation, and tips on their application.
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Affiliation(s)
| | - An Tang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, Université de Montréal, Montreal, QC, Canada
| | | | - Demetri Papadatos
- Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bijan Bijan
- Sutter Imaging (SMG)/University of California Davis (UCD), Sacramento, CA, USA
| | - Yuko Kono
- Department of Medicine, Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Cynthia Santillan
- Liver Imaging Group, Department of Radiology, University of California, San Diego, CA, USA
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17
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Li R, Cai P, Ma KS, Ding SY, Guo DY, Yan XC. Dynamic enhancement patterns of intrahepatic cholangiocarcinoma in cirrhosis on contrast-enhanced computed tomography: risk of misdiagnosis as hepatocellular carcinoma. Sci Rep 2016; 6:26772. [PMID: 27226026 PMCID: PMC4880940 DOI: 10.1038/srep26772] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/06/2016] [Indexed: 12/16/2022] Open
Abstract
This study aimed to assess the features of intrahepatic cholangiocarcinoma (ICC) at
computerized tomography (CT) and verify the risk of misdiagnosis of ICC as
hepatocellular carcinoma (HCC) in cirrhosis. CT appearances of 98 histologically
confirmed ICC nodules from 84 cirrhotic patients were retrospectively reviewed,
taking into consideration the pattern and dynamic contrast uptake during the
arterial, portal venous and delayed phases. During the arterial phase, 53 nodules
(54.1%) showed peripheral rim-like enhancement, 35 (35.7%) hyperenhancement, 9
(9.2%) hypoenhancement and 1 (1.0%) isoenhancement. The ICC nodules showed
heterogeneous dynamic contrast patterns, being progressive enhancement in 35 nodules
(35.7%), stable enhancement in 28 nodules (28.6%), wash-in and wash-out pattern in
15 nodules (15.3%) and all other enhancement patterns in 20 nodules (20.4%). There
were no significant differences in the dynamic vascular patterns of ICC according to
nodule size (p > 0.05). ICC in cirrhosis has
varied enhancement patterns at contrast-enhanced multiphase multidetector CT. Though
the majority of ICC did not display typical radiological hallmarks of HCC, if
dynamic CT scan was used as the sole modality for the non-invasive diagnosis of
nodules in cirrhosis, the risk of misdiagnosis of ICC for HCC is not negligible.
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Affiliation(s)
- Rui Li
- Dept. Hepato-biliary-Pancreatic Surgery, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
| | - Ping Cai
- Dept. Radiology, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
| | - Kuan-Sheng Ma
- Dept. Hepato-biliary-Pancreatic Surgery, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
| | - Shi-Yi Ding
- Dept. Radiology, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
| | - De-Yu Guo
- Dept. Pathology, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
| | - Xiao-Chu Yan
- Dept. Pathology, Southwest Hospital Affiliated to Third Military Medical University, P. R. China
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18
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Cruite I, Santillan C, Mamidipalli A, Shah A, Tang A, Sirlin CB. Liver Imaging Reporting and Data System: Review of Ancillary Imaging Features. Semin Roentgenol 2016; 51:301-307. [PMID: 27743566 DOI: 10.1053/j.ro.2016.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Cynthia Santillan
- Department of Radiology, Liver Imaging Group, University of California, San Diego, CA
| | - Adrija Mamidipalli
- Department of Radiology, Liver Imaging Group, University of California, San Diego, CA
| | - Amol Shah
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - An Tang
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Claude B Sirlin
- Department of Radiology, Liver Imaging Group, University of California, San Diego, CA
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19
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Hennedige T, Venkatesh SK. Advances in computed tomography and magnetic resonance imaging of hepatocellular carcinoma. World J Gastroenterol 2016; 22:205-220. [PMID: 26755871 PMCID: PMC4698486 DOI: 10.3748/wjg.v22.i1.205] [Citation(s) in RCA: 22] [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: 05/29/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Imaging is important for establishing a diagnosis of HCC and early diagnosis is imperative as several potentially curative treatments are available when HCC is small. Hepatocarcinogenesis occurs in a stepwise manner on a background of chronic liver disease or cirrhosis wherein multiple genes are altered resulting in a range of cirrhosis-associated nodules. This progression is related to increased cellularity, neovascularity and size of the nodule. An understanding of the stepwise progression may aid in early diagnosis. Dynamic and multiphase contrast-enhanced computed tomography and magnetic resonance imaging still form the cornerstone in the diagnosis of HCC. An overview of the current diagnostic standards of HCC in accordance to the more common practicing guidelines and their differences will be reviewed. Ancillary features contribute to diagnostic confidence and has been incorporated into the more recent Liver Imaging Reporting and Data System. The use of hepatocyte-specific contrast agents is increasing and gradually changing the standard of diagnosis of HCC; the most significant benefit being the lack of uptake in the hepatocyte phase in the earlier stages of HCC progression. An outline of supplementary techniques in the imaging of HCC will also be reviewed.
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20
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Multiphase Multi–Detector Row Computed Tomography Imaging Characteristics of Large (>5 cm) Focal Hepatocellular Carcinoma. J Comput Assist Tomogr 2016; 40:493-7. [DOI: 10.1097/rct.0000000000000379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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21
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Kwon S, Kim YK, Park HJ, Jeong WK, Lee WJ, Choi D. Is gadoxetic acid-enhanced MRI limited in tumor characterization for patients with chronic liver disease? Magn Reson Imaging 2014; 32:1214-22. [DOI: 10.1016/j.mri.2014.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/09/2014] [Accepted: 08/10/2014] [Indexed: 12/25/2022]
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22
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Choi JY, Lee JM, Sirlin CB. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part I. Development, growth, and spread: key pathologic and imaging aspects. Radiology 2014; 272:635-54. [PMID: 25153274 PMCID: PMC4263631 DOI: 10.1148/radiol.14132361] [Citation(s) in RCA: 323] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Computed tomography (CT) and magnetic resonance (MR) imaging play critical roles in the diagnosis and staging of hepatocellular carcinoma (HCC). The first article of this two-part review discusses key concepts of HCC development, growth, and spread, emphasizing those features with imaging correlates and hence most relevant to radiologists; state-of-the-art CT and MR imaging technique with extracellular and hepatobiliary contrast agents; and the imaging appearance of precursor nodules that eventually may transform into overt HCC.
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Affiliation(s)
- Jin-Young Choi
- From the Department of Radiology, Research Institute of Radiological Science, Yonsei University Health System, Seoul, Korea (J.Y.C.); Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, Seoul, Korea (J.M.L.); and Liver Imaging Group, Department of Radiology, University of California, San Diego Medical Center, 408 Dickinson St, San Diego, CA 92103-8226 (C.B.S.)
| | - Jeong-Min Lee
- From the Department of Radiology, Research Institute of Radiological Science, Yonsei University Health System, Seoul, Korea (J.Y.C.); Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, Seoul, Korea (J.M.L.); and Liver Imaging Group, Department of Radiology, University of California, San Diego Medical Center, 408 Dickinson St, San Diego, CA 92103-8226 (C.B.S.)
| | - Claude B. Sirlin
- From the Department of Radiology, Research Institute of Radiological Science, Yonsei University Health System, Seoul, Korea (J.Y.C.); Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, Seoul, Korea (J.M.L.); and Liver Imaging Group, Department of Radiology, University of California, San Diego Medical Center, 408 Dickinson St, San Diego, CA 92103-8226 (C.B.S.)
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23
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Chen W, DelProposto Z, Liu W, Kassir M, Wang Z, Zhao J, Xie B, Wen Y, Wang J, Hu J. Susceptibility-weighted imaging for the noncontrast evaluation of hepatocellular carcinoma: a prospective study with histopathologic correlation. PLoS One 2014; 9:e98303. [PMID: 24879409 PMCID: PMC4039503 DOI: 10.1371/journal.pone.0098303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/01/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Specific morphologic features of hepatocellular carcinoma (HCC) on imaging have identifiable pathologic correlates as well as implications for altering surgical management and defining prognosis. In this study, we compared susceptibility-weighted imaging (SWI) to conventional techniques and correlated our findings with histopathology to determine the role of SWI in assessing morphologic features of HCC without using a contrast agent. METHODS 86 consecutive patients with suspected HCC were imaged with MRI (including T1, T2, T2*, and SWI) and subsequently CT. 59 histologically-proven HCC lesions were identified in 53 patients. Each lesion on each imaging sequence was evaluated by two radiologists, and classified with respect to lesion morphology, signal intensity relative to surrounding hepatic parenchyma, presence of a pseudocapsule, presence of venous invasion, and internal homogeneity. RESULTS Histopathology confirmed pseudocapsules in 41/59 lesions. SWI was able to detect a pseudocapsule in 34/41 lesions; compared to conventional T1/T2 imaging (12/41) and T2* (27/41). Mosaic pattern was identified in 25/59 lesions by histopathology; SWI confirmed this in all 25 lesions, compared to T1/T2 imaging (13/25) or T2* (18/25). Hemorrhage was confirmed by histopathology in 43/59 lesions, and visible on SWI in 41/43 lesions, compared to T1/T2 (7/43) and T2* (38/43). Venous invasion was confirmed by histopathology in 31/59 patients; SWI demonstrated invasion in 28/31 patients, compared to T1/T2 (7/31) and T2* (24/31). CONCLUSIONS SWI is better at identifying certain morphologic features such as pseudocapsule and hemorrhage than conventional MRI without using a contrast agent in HCC patients.
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Affiliation(s)
- Wei Chen
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zachary DelProposto
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, United States of America
| | - Wei Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Mohammad Kassir
- Department of Radiology, Wayne State University, Detroit, Michigan, United States of America
| | - Zhiyuan Wang
- Cancer Biotherapy Center, Hunan Provincial Tumor Hospital, Xiangya Medical School, Central South University, Hunan, China
| | - Jun Zhao
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Bing Xie
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yaming Wen
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jian Wang
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
- * E-mail: (JH); (JW)
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, Michigan, United States of America
- * E-mail: (JH); (JW)
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24
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Qian LJ, Zhu J, Zhuang ZG, Xia Q, Liu Q, Xu JR. Spectrum of multilocular cystic hepatic lesions: CT and MR imaging findings with pathologic correlation. Radiographics 2014; 33:1419-33. [PMID: 24025933 DOI: 10.1148/rg.335125063] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A multilocular cystic hepatic lesion detected at computed tomography (CT) and magnetic resonance (MR) imaging is a common but nonspecific radiologic finding that can cause potential challenges for differential diagnosis. This imaging pattern may be observed in a wide spectrum of common and uncommon neoplastic or nonneoplastic entities. Neoplastic lesions include cystadenoma, cystadenocarcinoma, hepatocellular carcinoma (HCC), metastases, mesenchymal hamartoma, and inflammatory myofibroblastic tumor. Nonneoplastic lesions include hepatic abscess, echinococcal cyst, intrahepatic hematoma, and biloma. The multiple coalescent cysts seen in polycystic liver disease may exhibit an imaging pattern similar to that of a multilocular cystic lesion. Mural nodularity, irregular thickness of the septa, ragged inner surface, and typical enhancement pattern in the solid portion of the lesion are often indicative of malignancy, although multilocular primary or secondary malignant tumors are uncommon. Recognition of the more common necrosis or cystic change of HCC and metastases induced by locoregional or systemic treatment also is important. The nonenhanced cystic component may be composed of different types of fluids (eg, serous, mucinous, proteinaceous, hemorrhagic, bilious, or mixed) or spontaneous or treatment-related necrosis, whereas the septa may be formed by a wide range of tissues depending on the lesion type. An understanding of the CT and MR imaging findings of these lesions and their respective pathologic correlation aids in accurate diagnosis.
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Affiliation(s)
- Li Jun Qian
- Departments of Radiology, Hepatic Surgery, and Pathology, Renji Hospital, Shanghai Jiaotong University School of Medicine, No. 1630 Dongfang Rd, Pudong, Shanghai 200127, P.R. China
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25
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Abstract
Cirrhosis is the main risk factor for the development of hepatocellular carcinoma (HCC). The major causative factors of cirrhosis in the United States and Europe are chronic hepatitis C infection and excessive alcohol consumption with nonalcoholic steatohepatitis emerging as another important risk factor. Magnetic resonance imaging is the most sensitive imaging technique for the diagnosis of HCC, and the sensitivity can be further improved with the use of diffusion-weighted imaging and hepatocyte-specific contrast agents. The combination of arterial phase hyperenhancement, venous or delayed phase hypointensity "washout feature," and capsular enhancement are features highly specific for HCC with reported specificities of 96% and higher. When these features are present in a mass in the cirrhotic liver, confirmatory biopsy to establish the diagnosis of HCC is not necessary. Other tumors, such as cholangiocarcinoma, sometimes occur in the cirrhotic at a much lower rate than HCC and can mimic HCC, as do other benign lesions such as perfusion abnormalities. In this article, we discuss the imaging features of cirrhosis and HCC, the role of magnetic resonance imaging in the diagnosis of HCC and other benign and malignant lesions that occur in the cirrhotic liver, and the issue of nonspecific arterially hyperenhancing nodules often seen in cirrhosis.
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Affiliation(s)
- Daniel C Barr
- From the Department of Radiology/MRI, University of Michigan Health System, Ann Arbor, MI
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26
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Lim S, Kim YK, Park HJ, Lee WJ, Choi D, Park MJ. Infiltrative hepatocellular carcinoma on gadoxetic acid-enhanced and diffusion-weighted MRI at 3.0T. J Magn Reson Imaging 2013; 39:1238-45. [PMID: 24136725 DOI: 10.1002/jmri.24265] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 05/16/2013] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To determine imaging features of infiltrative hepatocellular carcinoma (HCC) on 3T magnetic resonance imaging (MRI) including gadoxetic acid-enhanced and diffusion-weighted imaging (DWI). MATERIALS AND METHODS Eighteen patients with infiltrative HCC underwent liver MRI that consisted of T1- and T2-weighted image (T2WI), gadoxetic acid-enhanced arterial, portal, 3-min late and 20-min hepatobiliary phase (HBP), and DWI. Two reviewers evaluated in consensus tumor characteristics and lesion conspicuity using a 4-point scale. The tumor-to-liver contrast ratio was also measured. RESULTS Most of the tumors (n = 16, 88.9%) were seen as irregular permeative masses (4.0-23.0 cm, mean 10.5 cm in diameter) and the remaining two as poorly defined amorphous infiltration among thrombosed portal veins. Internal reticulation within the tumor was characteristic and was most frequently observed on 3-min late phase (n = 18), followed by HBP (n = 15). Tumor conspicuity and tumor-to-liver contrast ratio was highest with b-800 DWI, which was significantly higher than those of other images (P < 0.05). CONCLUSION DWI provides the highest conspicuity for infiltrative HCC compared to unenhanced T1- and T2WI and gadoxetic acid-enhanced MRI. The gadoxetic acid-enhanced 3-min late image is useful in characterizing infiltrative HCC, as it clearly depicts internal reticulation in all tumors.
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Affiliation(s)
- SangHyeok Lim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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27
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28
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Abstract
Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy, and usually develops in the setting of liver cirrhosis. The early diagnosis of HCC is essential as curative treatment (including surgical resection and liver transplantation) improves survival. While screening and surveillance are traditionally performed with ultrasound, reported accuracies of ultrasound vary greatly, and poor sensitivity for small nodules is a uniformly recognized concern. Advances in computed tomography (CT) and magnetic resonance imaging (MRI), including multidetector technology and fast breath hold sequences now allow dynamic multiphasic enhanced imaging of the liver with excellent spatial and temporal resolution, holding much promise for improved HCC detection.
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29
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Tao R, Zhang J, Dai Y, You Z, Fan Y, Cui J, Wang J. Characterizing hepatocellular carcinoma using multi-breath-hold two-dimensional susceptibility-weighted imaging: comparison to conventional liver MRI. Clin Radiol 2012; 67:e91-7. [PMID: 22981726 DOI: 10.1016/j.crad.2012.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Revised: 07/22/2012] [Accepted: 08/06/2012] [Indexed: 11/25/2022]
Abstract
AIM To characterize the imaging manifestations of hepatocellular carcinoma (HCC) using multi-breath-hold two-dimensional susceptibility-weighted imaging (SWI) and compare to conventional liver magnetic resonance imaging (MRI). MATERIALS AND METHODS Forty-three patients with histopathologically confirmed HCC underwent conventional liver MRI, multi-breath-hold two-dimensional SWI, and contrast-enhanced CT preoperatively. The T1-weighted imaging (WI), T2WI, and SWI images were evaluated in consensus by two experienced radiologists. The tumour boundaries, blood products in the tumour, venous vessels, and non-tumour liver parenchyma were compared. RESULTS SWI demonstrated significantly better tumour boundary detection than T1WI and T2WI imaging (67.4 and 25.6%, respectively). The detection rate for intra-tumoural blood products using SWI was higher than that of T1WI and T2WI (76.7 and 16.3%, respectively). The detection rate for tumour venous vessels using SWI was 72.1%, while none was detected with conventional T1WI and T2WI. The detection rate for siderotic nodules in non-tumour liver parenchyma using SWI was higher than that of conventional T1WI and T2WI (65.1 and 20.9%, respectively). CONCLUSIONS SWI can provide more detailed information than conventional liver MRI in evaluation of tumour boundaries, blood products, venous vasculature, and non-tumour liver parenchyma. SWI is a valuable complement to conventional liver MRI.
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Affiliation(s)
- R Tao
- Department of Radiology, Southwest Hospital, Third Military Medical University, Chongqing, China
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30
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Khatri G, Merrick L, Miller FH. MR imaging of hepatocellular carcinoma. Magn Reson Imaging Clin N Am 2011; 18:421-50, x. [PMID: 21094448 DOI: 10.1016/j.mric.2010.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) is a common malignancy typically associated with chronic liver disease and is a leading cause of mortality among these patients. Prognosis is improved when detected early. MRI is the best imaging examination for accurate diagnosis. Although arterial enhancement with delayed washout, increased T2-weighted signal intensity, delayed capsular enhancement, restricted diffusion, and tumor thrombus are typical features, not all lesions demonstrate these findings. The radiologist must be familiar with these typical imaging characteristics, and less common appearances and associated findings of HCC, and must be able to differentiate them from those of lesions that mimic HCC. Knowledge of therapeutic options and how those are related to imaging findings is imperative to assist clinicians in managing these patients.
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Affiliation(s)
- Gaurav Khatri
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North St Clair Street, Suite 800, Chicago, IL 60611, USA
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31
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Golfieri R, Renzulli M, Lucidi V, Corcioni B, Trevisani F, Bolondi L. Contribution of the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI to Dynamic MRI in the detection of hypovascular small (≤2 cm) HCC in cirrhosis. Eur Radiol 2011; 21:1233-42. [DOI: 10.1007/s00330-010-2030-1] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 09/15/2010] [Accepted: 10/20/2010] [Indexed: 12/20/2022]
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32
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Ayyappan AP, Jhaveri KS. CT and MRI of hepatocellular carcinoma: an update. Expert Rev Anticancer Ther 2010; 10:507-19. [PMID: 20397916 DOI: 10.1586/era.10.24] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and one of the few malignancies with an increasing incidence in the USA. Imaging plays a crucial role in early detection, accurate staging and planning management strategies. Contrast material-enhanced MRI or computed tomography (CT) are the best imaging techniques currently available for the noninvasive diagnosis of HCC. The diagnosis of HCC is strongly dependent on hemodynamic features (arterial hypervascularity and washout in the venous phase) on dynamic imaging, and biopsy is no longer recommended for tumors with classical imaging features prior to treatment. The major challenge for radiologists in imaging cirrhosis is the characterization of hypervascular nodules smaller than 2 cm, which often have nonspecific imaging characteristics. In this review, we discuss the role of CT and MRI in the diagnosis and staging of HCC. The strengths and current limitations of these imaging modalities are highlighted.
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Affiliation(s)
- Anoop P Ayyappan
- Texas Tech University Health Sciences Center, Paul L Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA.
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33
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Lee J, Lee WJ, Lim HK, Lim JH, Choi N, Park MH, Kim SW, Park CK. Early hepatocellular carcinoma: three-phase helical CT features of 16 patients. Korean J Radiol 2008; 9:325-32. [PMID: 18682670 PMCID: PMC2627272 DOI: 10.3348/kjr.2008.9.4.325] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Accepted: 12/11/2007] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate the three-phase helical CT features of early hepatocellular carcinomas, based on the new Japanese classification. MATERIALS AND METHODS Over the course of an eight-year period, we collected 16 pathologically proven early hepatocellular carcinomas from 16 patients having undergone a three-phase helical CT prior to surgery. The three-phase CT images were acquired at 20-35 sec (arterial phase), 70 sec (portal phase), and 180 sec (equilibrium phase) from the beginning of intravenous injection of contrast material. All the CT images were retrospectively analyzed by two radiologists in consensus, based on their description of morphologic (size, margin, fibrous capsule and mosaic pattern) and enhancement patterns of tumors. RESULTS Only seven (44%) of the 16 early hepatocellular carcinomas having undergone a CT were described (mean diameter, 1.2 cm; range, 0.4-2.5 cm). All the tumors had an ill-defined margin with no fibrous capsule. The mosaic pattern was found in only one tumor. Only three (43%) of the seven tumors detected on CT were hyperattenuating during the arterial phase. The four remaining tumors (25%) were hypoattenuating throughout the three phases. CONCLUSION Despite the higher resolution provided by the three phase scans, the contrast-enhanced CT provides only limited detection of the variable morphologic and enhancement features of early hepatocellular carcinomas.
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Affiliation(s)
- Jongmee Lee
- Department of Radiology and Center of Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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34
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Willatt JM, Hussain HK, Adusumilli S, Marrero JA. MR Imaging of hepatocellular carcinoma in the cirrhotic liver: challenges and controversies. Radiology 2008; 247:311-30. [PMID: 18430871 DOI: 10.1148/radiol.2472061331] [Citation(s) in RCA: 307] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The incidence of hepatocellular carcinoma (HCC) is expected to increase in the next 2 decades, largely due to hepatitis C infection and secondary cirrhosis. HCC is being detected at an earlier stage owing to the implementation of screening programs. Biopsy is no longer required prior to treatment, and diagnosis of HCC is heavily dependent on imaging characteristics. The most recent recommendations by the American Association for the Study of Liver Diseases (AASLD) state that a diagnosis of HCC can be made if a mass larger than 2 cm shows typical features of HCC (hypervascularity in the arterial phase and washout in the venous phase) at contrast material-enhanced computed tomography or magnetic resonance (MR) imaging or if a mass measuring 1-2 cm shows these features at both modalities. There is an ever-increasing demand on radiologists to detect smaller tumors, when curative therapies are most effective. However, the major difficulty in imaging cirrhosis is the characterization of hypervascular nodules smaller than 2 cm, which often have nonspecific imaging characteristics. The authors present a review of the MR imaging and pathologic features of regenerative nodules and dysplastic nodules and focus on HCC in the cirrhotic liver, with particular reference to small tumors and lesions that may mimic HCC. The authors also review the sensitivity of MR imaging for the detection of these tumors and discuss the staging of HCC and the treatment options in the context of the guidelines of the AASLD and the imaging criteria required by the United Network for Organ Sharing for transplantation. MR findings following ablation and chemoembolization are also reviewed.
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Affiliation(s)
- Jonathon M Willatt
- Department of Radiology/MRI, University of Michigan Health System, UH-B2A209K, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0030, USA
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Miller G, Schwartz LH, D'Angelica M. The use of imaging in the diagnosis and staging of hepatobiliary malignancies. Surg Oncol Clin N Am 2007; 16:343-68. [PMID: 17560517 DOI: 10.1016/j.soc.2007.04.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review addresses the optimal use of imaging in the diagnosis, staging, and treatment planning of patients with hepatobiliary neoplasms. We focus on primary liver cancers, including hepatocellular carcinoma and intrahepatic cholangiocarcinoma as well as extrahepatic biliary tract malignancies, including hilar cholangiocarcinoma and gallbladder cancer. In each section, we provide an overview of the staging requirements for each disease followed by a discussion of various imaging modalities that can be used to optimally stage the disease and plan therapy.
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Affiliation(s)
- George Miller
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Small hepatocellular carcinoma with peripheral enhancement: pathological correlation with dual phase images by helical CT. Chin Med J (Engl) 2007. [DOI: 10.1097/00029330-200709020-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Doyle DJ, O'Malley ME, Jang HJ, Jhaveri K. Value of the unenhanced phase for detection of hepatocellular carcinomas 3 cm or less when performing multiphase computed tomography in patients with cirrhosis. J Comput Assist Tomogr 2007; 31:86-92. [PMID: 17259838 DOI: 10.1097/01.rct.0000233126.21303.f0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether unenhanced images are of added benefit to dual-phase computed tomography (CT) for detection of hepatocellular carcinomas (HCCs) 3 cm or less. METHODS Thirty-six patients with cirrhosis underwent unenhanced, arterial and portal venous phase CT, 17 with pathologically proven HCCs 3 cm or less and 19 without HCC. Two radiologists reviewed dual-phase images with and without unenhanced images. Presence or absence of HCC in each segment (n = 324) and subjective added benefit of unenhanced images were recorded. RESULTS For readers 1 and 2, unenhanced CT was subjectively helpful in 16 (5%) of 324 and 23 (7%) of 324 segments. Sensitivity and area under the receiver operating characteristic curve were identical for dual-phase versus triple-phase images for reader 1 (82.4% and 0.882) and reader 2 (100% and 0.997). CONCLUSIONS Addition of unenhanced to dual-phase CT does not statistically significantly increase the diagnostic accuracy or sensitivity for HCCs 3 cm or less.
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Affiliation(s)
- Deirdre J Doyle
- Department of Medical Imaging, Mount Sinai Hospital-University Health Network, University of Toronto, Ontario, Canada
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Abstract
Hepatocellular carcinoma (HCC) is responsible for a large proportion of cancer deaths worldwide. HCC is frequently diagnosed after the development of clinical deterioration at which time survival is measured in months. Long-term survival requires detection of small tumors, often present in asymptomatic individuals, which may be more amenable to invasive therapeutic options. Surveillance of high-risk individuals for HCC is commonly performed using the serum marker alpha-fetoprotein (AFP) often in combination with ultrasonography. Various other serologic markers are currently being tested to help improve surveillance accuracy. Diagnosis of HCC often requires more sophisticated imaging modalities such as CT scan and MRI, which have multiphasic contrast enhancement capabilities. Serum AFP used alone can be helpful if levels are markedly elevated, which occurs in fewer than half of cases at time of diagnosis. Confirmation by liver biopsy can be performed under circumstances when the diagnosis of HCC remains unclear.
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Affiliation(s)
- Eldad S Bialecki
- Division of Gastroenterology and Hepatology, St Louis University Liver Center, St Louis University School of Medicine, USA
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Abstract
The ability of x-ray computed tomography (CT) to detect and characterize liver lesions has been one of the most studied issues in radiology during the past 20 years. Technological advances, combined with increased knowledge about the pathophysiological characteristics of these tumors, have dramatically increased the ability to detect and characterize large hepatocellular carcinomas (HCCs). Nonetheless, detection and characterization of early and small HCC lesions remains a difficult task. We review the imaging appearances of HCC on CT and discuss the sensitivity and specificity of computed tomographic imaging in screening patients with cirrhosis for HCC.
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Affiliation(s)
- Richard L Baron
- Department of Radiology, University of Chicago, 5841 South Maryland Avenue, MC 2026, Chicago, Illinois 60637, USA.
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Kim KA, Lee WJ, Lim HK, Park CM, Park CK, Cha IH, Seol HY. Small hepatocellular carcinoma: ultrasonographic findings and histopathologic correlation. Clin Imaging 2003; 27:340-5. [PMID: 12932687 DOI: 10.1016/s0899-7071(02)00574-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
It is known that small hepatocellular carcinoma (HCCs) were usually hypoechoic at ultrasonography (US). In this study, we analyzed US findings of 42 small HCCs less than 2 cm in diameter and correlated them with histopathologic findings. US parameters were tumor size, tumor echogenecity, and morphologic features (peripheral halo, lateral shadow, posterior enhancement, and mosaic pattern), while histopathologic parameters were Edmonson grade and microscopic features (coagulation necrosis, interstitial fibrosis, fatty metamorphosis, sinusoidal dilatation, hemorrhage, encapsulation, and internal septation). One-third of HCCs was not hypoechoic. Tumor echogenecity and morphologic features were variable, regardless of tumor differentiation and microscopic features. In our study, it seemed that US detected histopathologic changes in small HCCs more frequently than previously known, but none of these US findings could suggest a specific histopathologic finding in small HCCs less than 2 cm in diameter.
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Affiliation(s)
- Kyeong Ah Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, South Korea.
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Lim JH, Choi D, Kim SH, Lee SJ, Lee WJ, Lim HK, Kim S. Detection of hepatocellular carcinoma: value of adding delayed phase imaging to dual-phase helical CT. AJR Am J Roentgenol 2002; 179:67-73. [PMID: 12076907 DOI: 10.2214/ajr.179.1.1790067] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The purpose of our study was to determine the value of adding delayed phase imaging to dual-phase helical CT for the detection of hepatocellular carcinoma. SUBJECTS AND METHODS One hundred thirteen patients with 131 hepatocellular carcinomas underwent triple-phase helical CT. The diagnosis was established by pathologic examination after surgical resection in all patients. For triple-phase helical CT, hepatic arterial, portal venous, and delayed phase scanning began 30, 60, and 180 sec, respectively, after the injection of 120 mL of iodinated contrast material. Dual-phase helical CT excluding delayed phase and triple-phase helical CT images were reviewed independently by three radiologists on a segment-by-segment basis. Diagnostic accuracy was assessed using receiver operating characteristic analysis in 330 resected segments. Sensitivities and specificities were calculated. The value of the delayed phase images in the characterization of hepatocellular carcinoma was also assessed. RESULTS The diagnostic accuracy of triple-phase helical CT including delayed phase (area under the curve [A(z)], 0.973) was significantly higher than that of dual-phase helical CT (A(z), 0.954). The mean sensitivity of triple-phase CT (89%) was also significantly higher than that of dual-phase CT (86%). The mean specificities of triple-phase CT (99%) and dual-phase CT (99%) were equal. Delayed phase images were helpful in the characterization of hepatocellular carcinoma in 14% of patients. CONCLUSION The addition of delayed phase imaging to dual-phase helical CT is valuable for the detection and characterization of hepatocellular carcinoma.
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Affiliation(s)
- Jae Hoon Lim
- Department of Radiology, Samsung Medical Center, 50 Ilwon-dong, Kangnam-ku, Seoul, Korea 135-710
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Koyama T, Fletcher JG, Johnson CD, Kuo MS, Notohara K, Burgart LJ. Primary hepatic angiosarcoma: findings at CT and MR imaging. Radiology 2002; 222:667-73. [PMID: 11867783 DOI: 10.1148/radiol.2223010877] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate and describe cross-sectional imaging findings in patients with pathologically confirmed primary hepatic angiosarcoma. MATERIALS AND METHODS Findings from imaging examinations in 13 patients with pathologically confirmed primary hepatic angiosarcoma were retrospectively reviewed (computed tomographic [CT] images obtained in 10 patients and magnetic resonance [MR] images obtained in five patients were available for review). Two gastrointestinal radiologists evaluated lesion number, size, attenuation and signal intensity characteristics, and the pattern and degree of contrast material enhancement. Medical records were reviewed for clinical features associated with angiosarcoma. RESULTS Angiosarcoma appeared as multiple nodules (n = 6), as dominant masses (n = 6), or as a diffusely infiltrating lesion (n = 1). Multiple nodules were hypoattenuating at unenhanced and contrast material--enhanced CT (six of six patients). When dominant masses were encountered at MR imaging, T2-weighted MR imaging demonstrated heterogeneous internal architecture (four of four patients) similar to that of hepatocellular carcinoma. Multiphase contrast-enhanced CT and MR images showed dominant masses to have heterogeneous and progressive enhancement (three of three patients). Clinical features associated with angiosarcoma included splenic metastases (six of 13 patients), thrombocytopenia (seven of 13 patients), disseminated intravascular coagulation (four of 13 patients), and hemolytic anemia (three of 13 patients). CONCLUSION Primary hepatic angiosarcoma exhibits a spectrum of appearances that reflect its varied pathologic features.
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Affiliation(s)
- Takashi Koyama
- Department of Diagnostic Imaging and Nuclear Medicine, School of Medicine, Kyoto University, Japan
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Baron RL, Peterson MS. From the RSNA refresher courses: screening the cirrhotic liver for hepatocellular carcinoma with CT and MR imaging: opportunities and pitfalls. Radiographics 2001; 21 Spec No:S117-32. [PMID: 11598252 DOI: 10.1148/radiographics.21.suppl_1.g01oc14s117] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The inherent distortion of the appearance of liver parenchyma by the underlying pathologic changes of cirrhosis can obscure and simulate malignancy at imaging. That hepatocellular carcinoma is the most common abdominal malignancy worldwide and occurs most often in patients with chronic liver disease and cirrhosis compounds this problem. Magnetic resonance (MR) imaging and, to a lesser extent, computed tomography (CT) can depict the underlying nodular and fibrotic changes in patients with cirrhosis, particularly when siderotic nodular regeneration is present. Application of state-of-the-art helical CT and MR imaging techniques has improved the ability to detect hepatocellular carcinoma in this population, but, even with these advances, fewer than 50% of small tumors are detected with either of these techniques in a screening population. Dynamic hepatic arterial-phase contrast material-enhanced imaging is essential with both CT and MR imaging to achieve even these levels of success. Benign lesions that simulate tumor tissue are encountered in many patients with cirrhosis and include focal fibrosis, infarcted regenerative nodules, arteriovenous shunts, hemangiomas, pseudoaneurysms, and focal transient hepatic enhancement. An awareness of the imaging characteristics of these lesions can help one avoid a mistaken diagnosis of hepatocellular carcinoma in many cases.
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Affiliation(s)
- R L Baron
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop St, Pittsburgh, PA 15213, USA.
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Abstract
Substantial recent technologic improvements in CT scanning, US scanning, and MR imaging, together with advances in the understanding of the optimal application of contrast administration techniques, have facilitated advances in radiologic imaging detection for HCC diagnosis. Despite a large number of earlier publications reporting a high sensitivity for imaging detection of HCC, more recent screening studies of large cirrhotic populations confirm that only 37% to 45% of HCC tumor nodules are detected by CT scanning, US scanning, or MR imaging. Future investigation will include efforts to improve the detection of small tumors and to characterize with greater specificity the spectrum of nodular changes that occur with cirrhosis. Although several small series have attempted to characterize cirrhotic nodules by evaluating the relative arterial or portal blood supply, these preliminary results require substantiation with larger series. Continued technologic advances such as multidetector helical CT scanning and new US and MR contrast agents under investigation may improve the imaging characterization of cirrhotic nodules.
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Affiliation(s)
- M S Peterson
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Nino-Murcia M, Olcott EW, Jeffrey RB, Lamm RL, Beaulieu CF, Jain KA. Focal liver lesions: pattern-based classification scheme for enhancement at arterial phase CT. Radiology 2000; 215:746-51. [PMID: 10831693 DOI: 10.1148/radiology.215.3.r00jn03746] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE To present our early experience with a classification scheme for categorizing focal liver lesions on the basis of the enhancement patterns that they exhibit in the arterial phase of computed tomography (CT) and to determine whether particular enhancement patterns suggest particular diagnoses. MATERIALS AND METHODS The authors reviewed arterial phase CT images in 100 consecutive patients with focal liver lesions, excluding simple cysts. The enhancement pattern of the dominant or representative lesion in each patient was classified into one of five categories-homogeneous, abnormal internal vessels or variegated, peripheral puddles, complete ring, or incomplete ring-by three radiologists blinded to the proved diagnosis. Lesions without enhancement were recorded separately. Agreement was reached by consensus in all cases. Standards of reference included findings at histologic examination, correlative imaging, or clinical and imaging follow-up. RESULTS Ninety-two percent of the 100 lesions demonstrated arterial phase enhancement. Patterns associated with positive predictive values of 82% or greater and specificity of 80% or greater included abnormal internal vessels or variegated (hepatocellular carcinoma), peripheral puddles (hemangioma), and complete ring (metastasis). CONCLUSION The appearance of hepatic lesions in the arterial phase of enhancement has potential use in the determination of specific diagnoses. The classification scheme used in this study may be a useful tool for the interpretation of arterial phase CT studies.
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Affiliation(s)
- M Nino-Murcia
- Department of Radiology, Stanford University Medical Center, CA, USA.
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Lee KH, Choi BI, Han JK, Jang HJ, Kim TK, Han MC. Nodular hepatocellular carcinoma: variation of tumor conspicuity on single-level dynamic scan and optimization of fixed delay times for two-phase helical CT. J Comput Assist Tomogr 2000; 24:212-8. [PMID: 10752880 DOI: 10.1097/00004728-200003000-00005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this work was to determine the optimal delay times in two-phase helical CT for nodular hepatocellular carcinoma (HCC). METHOD Twenty-four patients with nodular HCC (size 2.1-6.7 cm, mean 4.2 cm) were divided into three groups to undergo single-level dynamic CT with 150 ml of contrast material (iodine load of 45 g) at a rate of 3 ml/s. CT acquisition started 10, 30, or 60 s after the injection for each group, respectively, and lasted for 110 or 120 s. The optimal 20 s windows that allowed a tumor-to-liver contrast of >10 HU were determined in the pooled tumor-to-liver contrast curve. RESULTS The determined temporal windows were 36-56 and 130-150 s, respectively. However, each window was not appropriate in seven (33%) and five (36%) patients because of the individual variations of the contrast curve. CONCLUSION There is no optimal fixed delay time that is appropriate in all individual patients. The best delay times are 36 and at least 130 s with our injection protocol.
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Affiliation(s)
- K H Lee
- Department of Radiology, Institute of Radiation Medicine, Seoul National University College of Medicine, Korea
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