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Xing F, Ma Q, Lu J, Zhu W, Du S, Jiang J, Zhang T, Xing W. Nodule-in-nodule architecture of hepatocellular carcinomas: enhancement patterns in the hepatobiliary phase and pathological features. Abdom Radiol (NY) 2024:10.1007/s00261-024-04259-y. [PMID: 38913136 DOI: 10.1007/s00261-024-04259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE This study aimed to evaluate the enhancement patterns in the hepatobiliary phase (HBP) and pathological features of nodule-in-nodule-type hepatocellular carcinoma (NIN-HCC) patients. METHODS In this single-institution retrospective study, 27 consecutive cirrhosis patients with 29 histologically confirmed NIN-HCCs who underwent preoperative examination via Gd-EOB-DTPA-enhanced MRI were enrolled from January 2016 to September 2023. Two blinded radiologists assessed the imaging features of both the inner and outer nodules in NIN-HCCs to reach a consensus on the Liver Imaging Reporting & Data System (LI-RADS) categories of the lesions. Based on the different enhancement patterns of the inner and outer nodules in the HBP, NIN-HCCs were classified into different groups and further divided into different types. Imaging features and LI-RADS categories were subsequently compared among the groups. Pathological findings for NIN-HCCs were also evaluated. RESULTS Among 29 NIN-HCCs, all inner nodules showed hypervascularity, with a maximum diameter of 13.2 ± 5.5 mm; 51.7% (15/29) showed "wash-in with washout" enhancement; and 48.3% (14/29) showed "wash-in without washout" enhancement. All outer nodules showed hypovascularity, with a maximum diameter of 25.6 ± 7.3 mm, and 51.9% (14/29) showed a washout appearance on PVP. Among all the lesions, the maximum diameter was 27.5 ± 6.8 mm; 12 (41.4%) lesions were LR-4, and 17 (58.6%) lesions were LR-5. NIN-HCCs were classified into hypointense (62.1%, 18/29) and isointense (37.9%, 11/29) groups based on the signal intensity of the outer nodules in the HBP. In the hypointense group, 2 (6.9%) of the inner nodules were hypointense (type A), 11 (37.9%) were isointense (type B), and 5 (17.2%) were hyperintense (type C) compared to the background hypointense outer nodules. In the isointense group, 9 (31.0%) of the inner nodules were hypointense (type D), 2 (6.9%) were isointense (type E), and no (0%) was hyperintense (type F) compared to the background isointense outer nodules. There were no significant differences in the diameter, dynamic enhancement patterns of the inner or outer nodules, or LI-RADS scores of the lesions between the hypointense group and the isointense group (all P > 0.05). Histologically, the inner nodules of NIN-HCCs were mainly composed of moderately differentiated HCC (75.9% 22/29), whereas the outer nodules consisted of either well-differentiated HCC or high-grade dysplastic nodules (HGDNs). CONCLUSIONS NIN-HCCs exhibit specific MRI findings closely associated with their pathological features. The spectrum of HBP enhancement patterns provides valuable insights into the underlying cell biological mechanisms of these lesions. NIN-HCC subtypes may be used as a morphologic marker in the early stage of multistep hepatocarcinogenesis.
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Affiliation(s)
- Fei Xing
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Qinrong Ma
- Department of Pathology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Jiang Lu
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Wenjing Zhu
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Sheng Du
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Jifeng Jiang
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China
| | - Tao Zhang
- Department of Radiology, Third Affiliated Hospital of Nantong University and Nantong Third People's Hospital, #99 Youth Middle Road, Chongchuan District, Nantong, 226000, Jiangsu, China.
| | - Wei Xing
- Department of Radiology, Third Affiliated Hospital of Soochow University, No. 185 Juqian Street, Tianning District, Changzhou, 213000, Jiangsu, China.
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Brandi N, Renzulli M. Liver Lesions at Risk of Transformation into Hepatocellular Carcinoma in Cirrhotic Patients: Hepatobiliary Phase Hypointense Nodules without Arterial Phase Hyperenhancement. J Clin Transl Hepatol 2024; 12:100-112. [PMID: 38250460 PMCID: PMC10794268 DOI: 10.14218/jcth.2023.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 01/23/2024] Open
Abstract
Recent technical advances in liver imaging and surveillance for patients at high risk for developing hepatocellular carcinoma (HCC) have led to an increase in the detection of borderline hepatic nodules in the gray area of multistep carcinogenesis, particularly in those that are hypointense at the hepatobiliary phase (HBP) and do not show arterial phase hyperenhancement. Given their potential to transform and advance into hypervascular HCC, these nodules have progressively attracted the interest of the scientific community. To date, however, no shared guidelines have been established for the decision management of these borderline hepatic nodules. It is therefore extremely important to identify features that indicate the malignant potential of these nodules and the likelihood of vascularization. In fact, a more complete knowledge of their history and evolution would allow outlining shared guidelines for their clinical-surgical management, to implement early treatment programs and decide between a preventive curative treatment or a watchful follow-up. This review aims to summarize the current knowledge on hepatic borderline nodules, particularly focusing on those imaging features which are hypothetically correlated with their malignant evolution, and to discuss current guidelines and ongoing management in clinical practice.
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Affiliation(s)
- Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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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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Cannella R, Calandra A, Cabibbo G, Midiri M, Tang A, Brancatelli G. Hyperintense nodule-in-nodule on hepatobiliary phase arising within hypovascular hypointense nodule: Outcome and rate of hypervascular transformation. Eur J Radiol 2019; 120:108689. [DOI: 10.1016/j.ejrad.2019.108689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/04/2019] [Accepted: 09/18/2019] [Indexed: 02/06/2023]
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Kobayashi S, Matsui O, Gabata T, Koda W, Minami T, Ryu Y, Kozaka K, Kitao A. Intranodular signal intensity analysis of hypovascular high-risk borderline lesions of HCC that illustrate multi-step hepatocarcinogenesis within the nodule on Gd-EOB-DTPA-enhanced MRI. Eur J Radiol 2012; 81:3839-45. [PMID: 22884705 DOI: 10.1016/j.ejrad.2012.06.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 06/12/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To analyze intranodular signal intensity pattern of hypovascular high-risk borderline lesions of HCC that illustrate multi-step hepatocarcinogenesis within the nodule on Gd-EOB-DTPA-enhanced MRI. METHODS A total of 73 nodules showing hypervascular foci in hypovascular high-risk borderline lesions identified by angiography-assisted CT were included in this study. The intranodular signal intensities of both the hypervascular foci and the hypovascular high-risk borderline lesions were evaluated on hepatobiliary-phase EOB-enhanced MRI obtained 20 min after intravenous injection of contrast media. RESULTS Among 59 hypervascular foci within hypointense hypovascular high-risk borderline lesions, 6 showed more hypointensity, 32 isointensity, and 21 hyperintensity compared to the surrounding hypointense, hypovascular portion of the nodules. Among 14 hypervascular foci within isointense hypovascular high-risk borderline lesions, 5 showed isointensity, and 9 hypointensity compared to the surrounding isointense hypovascular high-risk borderline lesions. No hypervascular foci showed hyperintensity compared to the surrounding isointense hypovascular high-risk borderline lesions. CONCLUSIONS In most of the hypovascular high-risk borderline lesions containing hypervascular foci within the nodule, the signal intensity was decreased in hypervascular foci as compared with hypovascular high-risk borderline lesions and the surrounding background liver parenchyma. This supports the concept of signal intensity decrease during the dedifferentiation process in multistep hepatocarcinogenesis. However, around 30% of the nodules did not follow this rule, and hypervascular foci showed hyperintensity relative to the hypovascular high-risk borderline lesions.
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Affiliation(s)
- Satoshi Kobayashi
- Dept of Radiology, Kanazawa University School of Medicine, 13-1, Takara Machi, Kanazawa 920-8641, Japan.
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Motosugi U, Ichikawa T, Sano K, Sou H, Onohara K, Muhi A, Amemiya F, Enomoto N, Matsuda M, Fujii H, Araki T. Outcome of hypovascular hepatic nodules revealing no gadoxetic acid uptake in patients with chronic liver disease. J Magn Reson Imaging 2011; 34:88-94. [PMID: 21608068 DOI: 10.1002/jmri.22630] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 04/05/2011] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To elucidate the natural history of hypovascular nodules that appear hypointense on hepatocyte-phase gadoxetic acid-enhanced MR images by focusing on hypervascularization over time. MATERIALS AND METHODS In this study, 135 hypovascular nodules revealing no gadoxetic acid uptake in 53 patients were examined. All nodules were retrospectively examined using serial follow-up computed tomography (CT) and MRI examinations until hypervascularity was observed on arterial-phase dynamic CT or gadoxetic acid-enhanced MR images, or on CT during hepatic arteriography. Logistic regression analysis was used to investigate the association between hypervascularization and MR findings including a presence of fat assessed by a signal drop on opposed-phase T1-weighted images. RESULTS Of the 135 nodules, 16 underwent hypervascularization. The size of the nodules and the presence of fat in the nodules were independent indicators of hypervascularization. The 1-year cumulative risk of hypervascularization was 15.6%. This risk was significantly increased in the case of nodules >10 mm (37.6%, P < 0.01) and fat-containing nodules (26.5%, P < 0.01). CONCLUSION Hypovascular nodules that appear hypointense on hepatocyte-phase gadoxetic acid-enhanced MR images may progress to conventional hypervascular hepatocellular carcinoma. Nodules more than 10 mm in diameter and containing fat are at high risk for developing hypervascularization.
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Affiliation(s)
- Utaroh Motosugi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
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Gadolinium ethoxybenzyl diethylenetriamine pentaacetic Acid-enhanced magnetic resonance imaging findings of borderline lesions at high risk for progression to hypervascular classic hepatocellular carcinoma. J Comput Assist Tomogr 2011; 35:181-6. [PMID: 21412087 DOI: 10.1097/rct.0b013e3182026f3b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The objectives of the study were to assess the imaging features of hypovascular borderline lesions containing hypervascular foci on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and to evaluate the ability of Gd-EOB-DTPA-enhanced MRI to diagnose high-risk borderline lesions possibly consistent with early hepatocellular carcinoma (HCC). METHODS Institutional review board approval was obtained for this retrospective analysis of imaging findings, and informed consent was obtained from 217 consecutive patients undergoing Gd-EOB-DTPA-enhanced MRI and angiography-assisted computed tomography (CT) for examination of hepatocellular nodular lesions in cirrhotic livers. There were 73 nodules showing hypervascular foci in borderline lesions identified by angiography-assisted CT. Signal intensity patterns of the nodules were evaluated on hepatobiliary-phase Gd-EOB-DTPA-enhanced T1-weighted MRI obtained 20 minutes after intravenous injection of contrast media. RESULTS Among 73 high-risk borderline lesions, 59 were hypointense (81%), and 14 were isointense (19%), compared with background liver parenchyma. There were 27 untreated lesions followed by CT and/or MRI. Almost half of these nodules transformed into hypervascular HCC, regardless of signal intensities seen on hepatobiliary-phase Gd-EOB-DTPA-enhanced MRI. CONCLUSIONS Although many high-risk borderline HCC lesions are hypointense on hepatobiliary-phase Gd-EOB-DTPA-enhanced MRI, some high-risk borderline lesions are isointense and transform at the same rate into hypervascular HCC.
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