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Șirli R, Popescu A, Jenssen C, Möller K, Lim A, Dong Y, Sporea I, Nürnberg D, Petry M, Dietrich CF. WFUMB Review Paper. Incidental Findings in Otherwise Healthy Subjects, How to Manage: Liver. Cancers (Basel) 2024; 16:2908. [PMID: 39199678 PMCID: PMC11352778 DOI: 10.3390/cancers16162908] [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: 07/04/2024] [Revised: 08/07/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
An incidental focal liver lesion (IFLL) is defined as a hepatic lesion identified in a patient imaged for an unrelated reason. They are frequently encountered in daily practice, sometimes leading to unnecessary, invasive and potentially harmful follow-up investigations. The clinical presentation and the imaging aspects play an important role in deciding if, and what further evaluation, is needed. In low-risk patients (i.e., without a history of malignant or chronic liver disease or related symptoms), especially in those younger than 40 years old, more than 95% of IFLLs are likely benign. Shear Wave liver Elastography (SWE) of the surrounding liver parenchyma should be considered to exclude liver cirrhosis and for further risk stratification. If an IFLL in a low-risk patient has a typical appearance on B-mode ultrasound of a benign lesion (e.g., simple cyst, calcification, focal fatty change, typical hemangioma), no further imaging is needed. Contrast-Enhanced Ultrasound (CEUS) should be considered as the first-line contrast imaging modality to differentiate benign from malignant IFLLs, since it has a similar accuracy to contrast-enhanced (CE)-MRI. On CEUS, hypoenhancement of a lesion in the late vascular phase is characteristic for malignancy. CE-CT should be avoided for characterizing probable benign FLL and reserved for staging once a lesion is proven malignant. In high-risk patients (i.e., with chronic liver disease or an oncological history), each IFLL should initially be considered as potentially malignant, and every effort should be made to confirm or exclude malignancy. US-guided biopsy should be considered in those with unresectable malignant lesions, particularly if the diagnosis remains unclear, or when a specific tissue diagnosis is needed.
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Affiliation(s)
- Roxana Șirli
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (R.Ș.); (A.P.); (I.S.)
- Center for Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (R.Ș.); (A.P.); (I.S.)
- Center for Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland GmbH, 15344 Strausberg, Germany;
- Brandenburg Institute for Clinical Ultrasound (BICUS) at Medical University Brandenburg “Theodor Fontane”, 16816 Neuruppin, Germany
| | - Kathleen Möller
- Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, 10365 Berlin, Germany;
| | - Adrian Lim
- Department of Imaging, Imperial College London and Healthcare NHS Trust, London W6 8RF, UK;
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China;
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (R.Ș.); (A.P.); (I.S.)
- Center for Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Dieter Nürnberg
- Brandenburg Institute for Clinical Ultrasound (BICUS) at Medical University Brandenburg “Theodor Fontane”, 16816 Neuruppin, Germany
- Faculty of Medicine and Philosophy and Faculty of Health Sciences Brandenburg, 16816 Neuruppin, Germany;
| | - Marieke Petry
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, 3013 Bern, Switzerland;
| | - Christoph F. Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, 3013 Bern, Switzerland;
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Focal Liver Lesions other than Hepatocellular Carcinoma in Cirrhosis: Diagnostic Challenges. J Transl Int Med 2023; 10:308-327. [PMID: 36860624 PMCID: PMC9969567 DOI: 10.2478/jtim-2022-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Liver cirrhosis is associated with regenerative nodules and an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may also occur. Differentiating the other lesions from HCC is important for further therapeutic decisions. This review discusses the characteristics of non-HCC liver lesions in cirrhosis and their consequent appearance on contrast-enhanced ultrasonography (CEUS) with consideration of other imaging. Knowledge of this data would be helpful in avoiding misdiagnoses.
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De Muzio F, Grassi F, Dell’Aversana F, Fusco R, Danti G, Flammia F, Chiti G, Valeri T, Agostini A, Palumbo P, Bruno F, Cutolo C, Grassi R, Simonetti I, Giovagnoni A, Miele V, Barile A, Granata V. A Narrative Review on LI-RADS Algorithm in Liver Tumors: Prospects and Pitfalls. Diagnostics (Basel) 2022; 12:diagnostics12071655. [PMID: 35885561 PMCID: PMC9319674 DOI: 10.3390/diagnostics12071655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022] Open
Abstract
Liver cancer is the sixth most detected tumor and the third leading cause of tumor death worldwide. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with specific risk factors and a targeted population. Imaging plays a major role in the management of HCC from screening to post-therapy follow-up. In order to optimize the diagnostic-therapeutic management and using a universal report, which allows more effective communication among the multidisciplinary team, several classification systems have been proposed over time, and LI-RADS is the most utilized. Currently, LI-RADS comprises four algorithms addressing screening and surveillance, diagnosis on computed tomography (CT)/magnetic resonance imaging (MRI), diagnosis on contrast-enhanced ultrasound (CEUS) and treatment response on CT/MRI. The algorithm allows guiding the radiologist through a stepwise process of assigning a category to a liver observation, recognizing both major and ancillary features. This process allows for characterizing liver lesions and assessing treatment. In this review, we highlighted both major and ancillary features that could define HCC. The distinctive dynamic vascular pattern of arterial hyperenhancement followed by washout in the portal-venous phase is the key hallmark of HCC, with a specificity value close to 100%. However, the sensitivity value of these combined criteria is inadequate. Recent evidence has proven that liver-specific contrast could be an important tool not only in increasing sensitivity but also in diagnosis as a major criterion. Although LI-RADS emerges as an essential instrument to support the management of liver tumors, still many improvements are needed to overcome the current limitations. In particular, features that may clearly distinguish HCC from cholangiocarcinoma (CCA) and combined HCC-CCA lesions and the assessment after locoregional radiation-based therapy are still fields of research.
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Affiliation(s)
- Federica De Muzio
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy;
| | - Francesca Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Federica Dell’Aversana
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Naples, Italy
- Correspondence:
| | - Ginevra Danti
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Federica Flammia
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Giuditta Chiti
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Tommaso Valeri
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Andrea Agostini
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Pierpaolo Palumbo
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
- Area of Cardiovascular and Interventional Imaging, Department of Diagnostic Imaging, Abruzzo Health Unit 1, 67100 L’Aquila, Italy
| | - Federico Bruno
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
- Emergency Radiology, San Salvatore Hospital, Via Lorenzo Natali 1, 67100 L’Aquila, Italy;
| | - Carmen Cutolo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Fisciano, Italy;
| | - Roberta Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Igino Simonetti
- Radiology Division, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Via Mariano Semmola, 80131 Naples, Italy; (I.S.); (V.G.)
| | - Andrea Giovagnoni
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Vittorio Miele
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Antonio Barile
- Emergency Radiology, San Salvatore Hospital, Via Lorenzo Natali 1, 67100 L’Aquila, Italy;
| | - Vincenza Granata
- Radiology Division, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Via Mariano Semmola, 80131 Naples, Italy; (I.S.); (V.G.)
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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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Contrast-Enhanced Ultrasound for Focal Hepatic Lesions: When to Use and How to Differentiate Lesions? Ultrasound Q 2020; 36:224-234. [PMID: 32890325 DOI: 10.1097/ruq.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Contrast-enhanced ultrasound can be used effectively to evaluate focal hepatic lesions and offers unique advantages over computed tomography and magnetic resonance imaging. Serial vascular filling patterns of focal hepatic lesions during arterial, portal, and late phases can provide unique information on lesion characterization and differentiation. Sensitive depiction of arterial hypervascularity and analysis of washout pattern are clues for differentiation of several indeterminate hepatic nodules on conventional ultrasound and computed tomography/magnetic resonance. In this report, we present cases demonstrating clinical applications of contrast-enhanced ultrasound in the diagnosis and management of focal hepatic lesions.
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Characterization of Indeterminate Liver Lesions on CT and MRI With Contrast-Enhanced Ultrasound: What Is the Evidence? AJR Am J Roentgenol 2020; 214:1295-1304. [DOI: 10.2214/ajr.19.21498] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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New Arterial Phase Enhancing Nodules on MRI of Cirrhotic Liver: Risk of Progression to Hepatocellular Carcinoma and Implications for LI-RADS Classification. AJR Am J Roentgenol 2020; 215:382-389. [PMID: 32432909 DOI: 10.2214/ajr.19.22033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE. The purposes of this study were to evaluate the outcome of new arterial phase enhancing nodules at MRI of cirrhotic livers, including clinical and imaging factors that affect progression to hepatocellular carcinoma (HCC), and to assess the diagnostic performance of Liver Imaging Reporting and Data System version 2018 (LI-RADSv2018) versus version 2017 (LI-RADSv2017) in categorizing these nodules. MATERIALS AND METHODS. A database search identified 129 new arterial phase enhancing, round, solid, space-occupying nodules in 79 patients with cirrhosis who underwent surveillance MRI. Three readers assessed the nodules for LI-RADS findings and made assessments based on the 2017 and 2018 criteria. Clinical information and laboratory values were collected. Outcome data were assessed on the basis of follow-up imaging and pathology results. Interreader agreement was assessed. Logistic regression and ROC curve analyses were used to assess the utility of the features for prediction of progression to HCC. RESULTS. Of the 129 nodules, 71 (55%) progressed to HCC. LI-RADSv2017 score, LIRADSv2018 score, and mild-to-moderate T2 hyperintensity were significant independent predictors of progression to HCC in univariate analyses. Serum α-fetoprotein level, hepatitis B or C virus infection as the cause of liver disease, and presence of other HCCs were significant predictors of progression to HCC in multivariate analyses. The rates of progression of LI-RADS category 3 and 4 observations were 38.1% and 57.6%, respectively, for LI-RADSv2017 and 44.4% and 69.9%, respectively, for LI-RADSv2018. CONCLUSION. New arterial phase enhancing nodules in patients with cirrhosis frequently progress to HCC. Factors such as serum α-fetoprotein level and presence of other HCCs are strong predictors of progression to HCC.
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Makoyeva A, Kim TK, Jang HJ, Medellin A, Wilson SR. Use of CEUS LI-RADS for the Accurate Diagnosis of Nodules in Patients at Risk for Hepatocellular Carcinoma: A Validation Study. Radiol Imaging Cancer 2020; 2:e190014. [PMID: 33778701 PMCID: PMC7983739 DOI: 10.1148/rycan.2020190014] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/27/2019] [Accepted: 01/20/2020] [Indexed: 02/06/2023]
Abstract
Purpose To validate the contrast agent-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) algorithm for accurate diagnosis of hepatocellular carcinoma (HCC) and categorization of all nodules encountered in patients at risk for HCC. Materials and Methods A single-center retrospective review of 196 nodules in 184 patients at risk for HCC (consisting of 139 HCCs, 18 non-HCC malignancies, and 39 benign nodules) was performed in a three-reader blinded read format, with the use of the CEUS LI-RADS algorithm. Pathologic confirmation was available for 143 nodules (122 HCCs, 18 non-HCC malignancies, and three benign nodules). Nodule sizes ranged between 1.0 and 16.2 cm. Nodules assessed with contrast-enhanced US were assigned various CEUS LI-RADS categories by three blinded readers. CEUS LI-RADS categorization was then compared against histopathologic findings, concurrent CT, and/or MR images or follow-up imaging to assess diagnostic accuracy of CEUS LI-RADS. In addition, the proportion of HCC in all LI-RADS (LR) categories, univariable and multivariable feature analysis, and interrater agreement using Light κ were determined. Results The LR-5 category, determined through radiologist categorization of nodules using the CEUS LI-RADS criteria, showed sensitivity, specificity, positive predictive value, and negative predictive value of 86% (119 of 139), 96% (55 of 57), 98% (119 of 121), and 73% (55 of 75), respectively, for the diagnosis of HCC. Two false-positive cases of LR-5 included a cholangiocarcinoma and a combined hepatocellular and cholangiocarcinoma. The remainder of the cholangiocarcinomas in the sample (n = 8) were appropriately categorized as LR-M. Multivariable logistic regression analysis showed that washout of greater than 60 seconds was the contrast-enhanced US feature most predictive of HCC diagnosis, whereas washout of less than 60 seconds was the feature most predictive of nonhepatocellular malignancy. The proportion of HCC nodules categorized in the LR-M and LR-4 categories was 35% and 20%, respectively. Light κ agreement between readers for LI-RADS categorization was 90%. Conclusion This study showed excellent specificity for the CEUS LI-RADS LR-5 category, allowing for confident imaging diagnosis of HCC, without necessity for pathologic confirmation. In addition, there was accurate differentiation of HCC from non-HCC malignancies and benign nodules. Only a single cholangiocarcinoma was misdiagnosed as category LR-5, with the remainder of the cholangiocarcinomas in the sample appropriately characterized as category LR-M.Keywords: Abdomen/GI, Evidence Based Medicine, Liver, Neoplasms-Primary, Ultrasound-Contrast© RSNA, 2020.
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Affiliation(s)
- Alina Makoyeva
- From the Departments of Radiology (A. Makoyeva, A. Medellin, S.R.W.) and Medicine (S.R.W.), University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, AB, Canada T2N 2T9; and Department of Medical Imaging, University of Toronto, Toronto, Canada (T.K.K., H.J.J.)
| | - Tae Kyoung Kim
- From the Departments of Radiology (A. Makoyeva, A. Medellin, S.R.W.) and Medicine (S.R.W.), University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, AB, Canada T2N 2T9; and Department of Medical Imaging, University of Toronto, Toronto, Canada (T.K.K., H.J.J.)
| | - Hyun-Jung Jang
- From the Departments of Radiology (A. Makoyeva, A. Medellin, S.R.W.) and Medicine (S.R.W.), University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, AB, Canada T2N 2T9; and Department of Medical Imaging, University of Toronto, Toronto, Canada (T.K.K., H.J.J.)
| | - Alejandra Medellin
- From the Departments of Radiology (A. Makoyeva, A. Medellin, S.R.W.) and Medicine (S.R.W.), University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, AB, Canada T2N 2T9; and Department of Medical Imaging, University of Toronto, Toronto, Canada (T.K.K., H.J.J.)
| | - Stephanie R. Wilson
- From the Departments of Radiology (A. Makoyeva, A. Medellin, S.R.W.) and Medicine (S.R.W.), University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, AB, Canada T2N 2T9; and Department of Medical Imaging, University of Toronto, Toronto, Canada (T.K.K., H.J.J.)
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Hu J, Bhayana D, Burak KW, Wilson SR. Resolution of indeterminate MRI with CEUS in patients at high risk for hepatocellular carcinoma. Abdom Radiol (NY) 2020; 45:123-133. [PMID: 31440801 DOI: 10.1007/s00261-019-02181-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To show the contribution of CEUS to characterization of indeterminate MRI observations in high-risk patients for hepatocellular carcinoma (HCC). METHODS From July to December 2015, 42 consecutive patients referred to CEUS with indeterminate MRI scans comprise our study cohort. There are 50 indeterminate nodule-like observations and 10 arterial phase hyperenhancing foci, suggesting pseudolesions/arterio-portal shunts. MRI and CEUS lesions are classified according to their enhancement features in all phases and Liver Imaging and Reporting Data System (LI-RADS) in a blind read format. Clinical pathologic correlation and 24 months follow-up are performed. RESULTS A majority, 37/50 (74%), of indeterminate nodule-like observations have arterial phase enhancement without washout on MRI. CEUS further characterizes enhancement and shows washout in 14/37 (38%). In total, CEUS diagnoses 16 malignant lesions in 14 patients including 14 HCC and 2 ICC. 12/16 (75%) malignant lesions are confirmed by biopsy or follow-up. Ultrasound identification of a nodule differentiates real nodules from pseudolesions. Of the ten suspected arterial-portal shunts on MRI, two show a real nodule on ultrasound, confirmed as an HCC and a regenerative nodule. 15/42 (36%) patients have LI-RADS escalated from LR-3 or 4 on MRI to LR-4 or 5 on CEUS. Overall, the sensitivity of CEUS is (13/16) 81.3% and specificity is (37/37) 100% for malignant diagnosis. CONCLUSION Grayscale ultrasound detects true nodules. Dynamic CEUS detects and characterizes washout, correctly predicting HCC. CEUS is complimentary to MRI and can serve as a problem-solving tool when MRI is indeterminate.
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Mehana SM. Assessment of the follow-up interval changes of the less than 2 cm arterial phase enhancing hepatic nodules in correlation with Liver Imaging Reporting and Data System (LI-RADS) classification version 18 using contrast-enhanced multidetector computed tomography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0068-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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11
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Vernuccio F, Cannella R, Meyer M, Choudhoury KR, Gonzáles F, Schwartz FR, Gupta RT, Bashir MR, Furlan A, Marin D. LI-RADS: Diagnostic Performance of Hepatobiliary Phase Hypointensity and Major Imaging Features of LR-3 and LR-4 Lesions Measuring 10-19 mm With Arterial Phase Hyperenhancement. AJR Am J Roentgenol 2019; 213:W57-W65. [PMID: 31039012 DOI: 10.2214/ajr.18.20979] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE. The purpose of this study was to determine the diagnostic performance of hepatobiliary phase hypointensity and Liver Imaging Reporting and Data System (LI-RADS) major imaging features in the diagnosis of hepatocellular carcinoma (HCC) in hepatic lesions with arterial phase hyperenhancement (APHE) measuring 10-19 mm in patients at high risk of HCC. MATERIALS AND METHODS. A composite reference standard of pathologic analysis and imaging follow-up was used. The diagnostic performance (sensitivity and specificity) of hepatobiliary phase hypointensity and LI-RADS major imaging features other than APHE for the diagnosis of HCC was assessed and compared by means of a logistic regression model. RESULTS. This retrospective dual-institution study included 189 LI-RADS LR-3 and LR-4 lesions measuring 10-19 mm and having APHE in 144 consecutively registered patients (96 men, 48 women; mean age, 58 years). Hepatobiliary phase hypointensity had significantly higher sensitivity (84% [92/109], p < 0.00001) than major imaging features in the diagnosis of HCC but lower specificity (84% [67/80]; p = 0.01). However, hepatobiliary phase hypointensity in LR-3 observations measuring 10-19 mm and having APHE had moderately elevated sensitivity (73% [44/60]) and specificity (85%, 64/75). All three major imaging features had high specificity for the diagnosis of HCC, including 95% (76/80) for washout, 100% (80/80) for enhancing capsule, and 99% (79/80) for threshold growth. CONCLUSION. Major imaging features have high specificity for the diagnosis of HCC in lesions measuring 10-19 mm that have APHE. The finding of hepatobiliary phase hypointensity significantly improves sensitivity while moderately high specificity is maintained for the diagnosis of HCC in LR-3 lesions measuring 10-19 mm that exhibit APHE.
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Affiliation(s)
- Federica Vernuccio
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
- 2 Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Roberto Cannella
- 3 Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
- 4 Department of Biopathology and Medical Biotechnologies, University of Palermo, Palermo, Italy
| | - Mathias Meyer
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
| | - Kingshuk Roy Choudhoury
- 5 Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Fernando Gonzáles
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
- 6 Department of Radiology, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Fides R Schwartz
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
| | - Rajan T Gupta
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
| | - Mustafa R Bashir
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
- 7 Center for Advanced Magnetic Resonance Development and Department of Medicine, Duke University, Durham, NC
| | - Alessandro Furlan
- 3 Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniele Marin
- 1 Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710
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12
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Bartolotta TV, Taibbi A, Midiri M, Lagalla R. Contrast-enhanced ultrasound of hepatocellular carcinoma: where do we stand? Ultrasonography 2019; 38:200-214. [PMID: 31006227 PMCID: PMC6595127 DOI: 10.14366/usg.18060] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/25/2019] [Indexed: 12/12/2022] Open
Abstract
Contrast-enhanced ultrasound (CEUS) represents a significant breakthrough in ultrasonography (US), and it is being increasingly used for the evaluation of focal liver lesions (FLLs). CEUS is unique in that it allows non-invasive assessment of liver perfusion in real time throughout the vascular phase, which has led to dramatic improvements in the diagnostic accuracy of US in the detection and characterization of FLLs, the choice of therapeutic procedures, and the evaluation of response. Currently, CEUS is included as a part of the suggested diagnostic work-up of FLLs, including in cirrhotic patients with hepatocellular carcinoma, resulting in better patient management and cost-effective delivery of therapy.
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Affiliation(s)
| | - Adele Taibbi
- Department of Radiology, University of Palermo, Palermo, Italy
| | - Massimo Midiri
- Department of Radiology, University of Palermo, Palermo, Italy
| | - Roberto Lagalla
- Department of Radiology, University of Palermo, Palermo, Italy
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13
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Semelka RC, Prybylski JP, Ramalho M. Influence of excess ligand on Nephrogenic Systemic Fibrosis associated with nonionic, linear gadolinium-based contrast agents. Magn Reson Imaging 2018; 58:174-178. [PMID: 30471330 DOI: 10.1016/j.mri.2018.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 09/25/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The molecular structure, charge, thermodynamic and kinetic stability are approximately the same for gadodiamide and gadoversetamide, the main substantive difference is that gadodiamide is manufactured with 5% free ligand to form Omniscan® and gadoversetamide with 10% free ligand to form OptiMARK®. PURPOSE To determine the relative risk of Nephrogenic Systemic Fibrosis (NSF) between gadodiamide (Omniscan®) and gadoversetamide (OptiMARK®) and to explore the potential contribution of the amount of excess ligand added to their commercial formulations. MATERIALS AND METHODS In this retrospective observational study, the number of doses and NSF cases associated with these agents were calculated based on two different approaches: the number of doses was determined based on pharmaceutical companies' information, and the number of unconfounded NSF cases was obtained from the previously published literature based on a legal database. A second analysis estimates the number of doses and NSF cases from the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). RESULTS Approximately 87 million and 12 million doses of Omniscan® and OptiMARK®, respectively, have been administered worldwide since their original approval for use in the various countries throughout the world. A total of 197 and 8 unconfounded cases of NSF have been reported with Omniscan® and OptiMARK®, rendering an incidence of 2.3/million and 0.7/million for these agents, respectively. The FAERS analysis suggested reported incidences of 13.1/million and 5.0/million. CONCLUSION There is an approximately 3-fold greater incidence of NSF from Omniscan® than OptiMARK®. The difference in incidence might reflect the lesser quantity of added free ligand to the formulation of Omniscan®.
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Affiliation(s)
- Richard C Semelka
- Department of Radiology, University of North Carolina at Chapel Hill, NC, USA.
| | - John P Prybylski
- Division of Molecular Pharmaceutics, University of North Carolina at Chapel Hill, NC, USA
| | - Miguel Ramalho
- Department of Radiology, Hospital Garcia de Orta, EPE, Almada, Portugal
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14
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Contrast-Enhanced Ultrasound to Monitor Early Recurrence of Primary Hepatocellular Carcinoma after Curative Treatment. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8910562. [PMID: 30533441 PMCID: PMC6247733 DOI: 10.1155/2018/8910562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/18/2018] [Indexed: 01/27/2023]
Abstract
Objective To evaluate contrast-enhanced ultrasound (CEUS) for monitoring early intrahepatic recurrence of primary hepatocellular carcinoma (HCC) after curative treatment. Methods We prospectively analyzed 97 patients (124 nodules) with primary HCC who underwent hepatic resection or radiofrequency ablation and subsequently experienced intrahepatic recurrence. Patients were assessed with conventional ultrasound and CEUS. They were also assessed with contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI). The image characteristics of CEUS of recurrent hepatocellular carcinoma and high-grade dysplastic nodules (HGDNs) were analyzed. In addition, the ability of CEUS and CECT/MRI to assess internal artery vascularization in recurrent disease was compared. Results CEUS of recurrent hepatocellular carcinoma showed hyperenhancement in the arterial phase in 96 of 99 nodules, and it showed hypo- or isoenhancement for portal venous and delayed phases. The most common enhancement patterns were “fast-in and slow-out” and “fast-in and fast-out”. Based on the arterial hyperenhancement of lesions and with clinical data such as patient history of HCC and increased level of serum alpha-fetoprotein, the diagnostic accuracy of CEUS for recurrent HCC was significantly higher than that based on the enhancement pattern of “fast-in and fast-out”. CEUS of HGDNs showed local or global hyperenhancement during the arterial phase, isoenhancement during the portal venous phase, and isoenhancement or slight hypoenhancement during the delayed phase. The enhancement pattern was “fast-in and slow-out”. In some cases, it was difficult to differentiate HGDNs from recurrent disease using CEUS. Vascularization in recurrent disease was significantly higher when assessed by CEUS than when assessed with CECT/MRI (P < 0.05). For detecting recurrent disease, CEUS showed sensitivity of 97.0%, specificity of 68.0%, positive predictive value of 92.3%, and negative predictive value of 85.0%. The corresponding parameters for CECT/MRI were 71.7%, 72.0%, 88.8%, and 39.1%. Conclusion Intrahepatic recurrent HCC and HGDNs with diameter ≤ 3.0 cm have a characteristic appearance on CEUS. This imaging modality may be effective for monitoring early intrahepatic recurrence after curative treatment of primary HCC.
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15
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Liu X, Jang HJ, Khalili K, Kim TK, Atri M. Successful Integration of Contrast-enhanced US into Routine Abdominal Imaging. Radiographics 2018; 38:1454-1477. [DOI: 10.1148/rg.2018170152] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Xiaoyang Liu
- From the Department of Medical Imaging, University of Toronto, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2
| | - Hyun-Jung Jang
- From the Department of Medical Imaging, University of Toronto, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2
| | - Korosh Khalili
- From the Department of Medical Imaging, University of Toronto, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2
| | - Tae Kyoung Kim
- From the Department of Medical Imaging, University of Toronto, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2
| | - Mostafa Atri
- From the Department of Medical Imaging, University of Toronto, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2
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16
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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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17
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Furlan A, Borhani AA. Problematic lesions in cirrhosis. Clin Liver Dis (Hoboken) 2018; 11:43-47. [PMID: 30992786 PMCID: PMC6314281 DOI: 10.1002/cld.689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/05/2017] [Accepted: 12/13/2017] [Indexed: 02/04/2023] Open
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18
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Heimbach JK, Kulik LM, Finn RS, Sirlin CB, Abecassis MM, Roberts LR, Zhu AX, Murad MH, Marrero JA. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 2018; 67:358-380. [PMID: 28130846 DOI: 10.1002/hep.29086] [Citation(s) in RCA: 2746] [Impact Index Per Article: 457.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Julie K Heimbach
- Division of Transplant Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Laura M Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Richard S Finn
- Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine at the University of California, Los Angeles, Santa Monica Geffen School of Medicine at UCLA, Los Angeles, California
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California, San Diego
| | | | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - M Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN
| | - Jorge A Marrero
- Digestive and Liver Diseases Division, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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19
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Abstract
Chronic liver disease, irrespective of cause, can eventually lead to cirrhosis, which is the primary risk factor for developing hepatocellular carcinoma (HCC). In patients with cirrhosis or appropriate risk factors, HCC can be diagnosed by imaging with high specificity using liver imaging reporting and data system v2017, obviating the need for histologic confirmation. Confident recognition of cirrhosis by conventional imaging alone can be challenging, as radiologists are not always provided with the requisite information to determine if the patient has cirrhosis or other risk factors for HCC. Moreover, cirrhosis-associated abnormalities may impair the diagnostic accuracy of imaging for HCC. This article addresses the diagnosis of cirrhosis by non-invasive imaging and the implications of cirrhosis for imaging interpretation and accuracy.
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20
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Mitchell DG, Bashir MR, Sirlin CB. Management implications and outcomes of LI-RADS-2, -3, -4, and -M category observations. Abdom Radiol (NY) 2018; 43:143-148. [PMID: 28779335 DOI: 10.1007/s00261-017-1251-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A radiologist issuing a LI-RADS category is, implicitly or explicitly, a member of a multidisciplinary team. If the definite diagnosis of a benign or malignant entity is not possible, categorizing the uncertainty as LR-2, -3, -4, or -M has important management implications. In this article, we discuss the range of options for management or further diagnostic testing and how a LR category may affect the choice between them. We then review recent published data regarding eventual diagnoses following assignment of a LR category.
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21
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Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV. Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:1429-1437. [DOI: 10.1016/j.jacr.2017.07.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023]
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22
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Kim TK, Noh SY, Wilson SR, Kono Y, Piscaglia F, Jang HJ, Lyshchik A, Dietrich CF, Willmann JK, Vezeridis A, Sirlin CB. Contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) 2017 - a review of important differences compared to the CT/MRI system. Clin Mol Hepatol 2017; 23:280-289. [PMID: 28911220 PMCID: PMC5760002 DOI: 10.3350/cmh.2017.0037] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 12/12/2022] Open
Abstract
Medical imaging plays an important role in the diagnosis and management of hepatocellular carcinoma (HCC). The Liver Imaging Reporting and Data System (LI-RADS) was initially created to standardize the reporting and data collection of CT and MR imaging for patients at risk for HCC. As contrast-enhanced ultrasound (CEUS) has been widely used in clinical practice, it has recently been added to the LI-RADS. While CEUS LI-RADS shares fundamental concepts with CT/MRI LI-RADS, there are key differences between the modalities reflecting dissimilarities in the underlying methods of image acquisition and types of contrast material. This review introduces a recent update of CEUS LI-RADS and explains the key differences from CT/MRI LI-RADS.
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Affiliation(s)
- Tae Kyoung Kim
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Seung Yeon Noh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea
| | - Stephanie R Wilson
- Diagnostic Imaging, Department of Radiology, University of Calgary, Calgary, Canada
| | - Yuko Kono
- Department of Medicine and Radiology, University of California, San Diego, USA
| | - Fabio Piscaglia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Hyun-Jung Jang
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Andrej Lyshchik
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | | | | | | | - Claude B Sirlin
- Department of Radiology, University of California, San Diego, USA
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23
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Jo PC, Jang HJ, Burns PN, Burak KW, Kim TK, Wilson SR. Integration of Contrast-enhanced US into a Multimodality Approach to Imaging of Nodules in a Cirrhotic Liver: How I Do It. Radiology 2017; 282:317-331. [PMID: 28099108 DOI: 10.1148/radiol.2016151732] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Accurate characterization of cirrhotic nodules and early diagnosis of hepatocellular carcinoma (HCC) are of vital importance. Currently, computed tomography (CT) and magnetic resonance (MR) imaging are standard modalities for the investigation of new nodules found at surveillance ultrasonography (US). This article describes the successful integration of contrast material-enhanced US into a multimodality approach for diagnosis of HCC and its benefits in this population. The application of contrast-enhanced US immediately following surveillance US allows for prompt dynamic contrast-enhanced evaluation, removing the need for further imaging of benign lesions. Contrast-enhanced US also provides dynamic real-time assessment of tumor vascularity so that contrast enhancement can be identified regardless of its timing or duration, allowing for detection of arterial hypervascularity and portal venous washout. The purely intravascular nature of US contrast agents is valuable as the rapid washout of nonhepatocyte malignancies is highly contributory to their differentiation from HCC. The authors believe contrast-enhanced US provides complementary information to CT and MR imaging in the characterization of nodules in high-risk patients. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Patricia C Jo
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
| | - Hyun-Jung Jang
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
| | - Peter N Burns
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
| | - Kelly W Burak
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
| | - Tae Kyoung Kim
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
| | - Stephanie R Wilson
- From the Department of Radiology (P.C.J., S.R.W.) and Department of Medicine, Division of Gastroenterology (K.W.B., S.R.W.), Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, Canada T2N 2T9; Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada (H.J.J., T.K.K.); and Department of Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont, Canada (P.N.B.)
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Granata V, Fusco R, Avallone A, Catalano O, Filice F, Leongito M, Palaia R, Izzo F, Petrillo A. Major and ancillary magnetic resonance features of LI-RADS to assess HCC: an overview and update. Infect Agent Cancer 2017; 12:23. [PMID: 28465718 PMCID: PMC5410075 DOI: 10.1186/s13027-017-0132-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/21/2017] [Indexed: 12/23/2022] Open
Abstract
Liver Imaging Reporting and Data System (LI-RADS) is a system for interpreting and reporting of imaging features on multidetector computed tomography (MDCT) and magnetic resonance (MR) studies in patients at risk for hepatocellular carcinoma (HCC). American College of Radiology (ACR) sustained the spread of LI-RADS to homogenizing the interpreting and reporting data of HCC patients. Diagnosis of HCC is due to the presence of major imaging features. Major features are imaging data used to categorize LI-RADS-3, LI-RADS-4, and LI-RADS-5 and include arterial-phase hyperenhancement, tumor diameter, washout appearance, capsule appearance and threshold growth. Ancillary are features that can be used to modify the LI-RADS classification. Ancillary features supporting malignancy (diffusion restriction, moderate T2 hyperintensity, T1 hypointensity on hapatospecifc phase) can be used to upgrade category by one or more categories, but not beyond LI-RADS-4. Our purpose is reporting an overview and update of major and ancillary MR imaging features in assessment of HCC.
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Affiliation(s)
- Vincenza Granata
- Radiology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Roberta Fusco
- Radiology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Antonio Avallone
- Abdominal Oncology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Orlando Catalano
- Radiology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Francesco Filice
- Radiology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Maddalena Leongito
- Hepatobiliary Surgery Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Raffaele Palaia
- Hepatobiliary Surgery Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Francesco Izzo
- Hepatobiliary Surgery Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
| | - Antonella Petrillo
- Radiology Division, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Via Mariano Semmola, Naples, Italy
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25
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Critical analysis of the major and ancillary imaging features of LI-RADS on 127 proven HCCs evaluated with functional and morphological MRI: Lights and shadows. Oncotarget 2017; 8:51224-51237. [PMID: 28881643 PMCID: PMC5584244 DOI: 10.18632/oncotarget.17227] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/22/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To report a critical analysis of major and ancillary MR imaging features in assessment of HCC. METHODS Retrospectively we evaluated 70 cirrhotic patients with 173 nodules, which were subjected to MR study at 0 time (MR0), after 3 (MR3) and 6 months (MR6) using two different contrast media. EOB-GD-DTPA was injected at MR0 and MR6, while Gd-BT-DO3A at MR3. Three expert hepatic radiologists reviewed all images, recording, according to LI-RADS, the size, the presence and quality of arterial-phase hyperenhancement, washout and capsule appearance, threshold growth. Additionally, we recorded signal intensity (SI) on T2-W images, on DWI, on apparent diffusion coefficient (ADC) maps and SI on T1-W images of EOB-GD-BPTA hepatospecific phase. Median value of ADC and of Intravoxel incoherent motion related parameters were assessed. RESULTS 127 HCCs and 24 dysplastic nodules were assessed. Hypervascular on arterial phase was found in 84 HCCs, washout appearance in 124, capsule appearance in 111, hypointensity on hepatospecific phase in 127, hyperintensity on T2-W sequences and restricted diffusion in 107. Hyper vascular on arterial phase was found in 17 dysplastic nodules, wash-out appearance in 2, hypointensity on hepatospecific phase in 7 while no dysplastic nodules showed capsule appearance, hyperintensity on T2-W and restricted diffusion. Highest accuracy was obtained by washout appearance and hypointense signal on hepatospecific phase (97% and 95%). CONCLUSIONS Hypointensity on hepatospecific phase and washout appearance are the most relevant diagnostic sign for differentiating low-risk from high-risk HCC nodules. The capsule appearance, T2-W hyperintensity and restricted diffusion have high positive predictive value.
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26
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Diagnosis of Hepatocellular Carcinoma with Gadoxetic Acid-Enhanced MRI: 2016 Consensus Recommendations of the Korean Society of Abdominal Radiology. Korean J Radiol 2017; 18:427-443. [PMID: 28458595 PMCID: PMC5390612 DOI: 10.3348/kjr.2017.18.3.427] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/21/2017] [Indexed: 12/13/2022] Open
Abstract
Diagnosis of hepatocellular carcinoma (HCC) with gadoxetic acid-enhanced liver magnetic resonance imaging (MRI) poses certain unique challenges beyond the scope of current guidelines. The regional heterogeneity of HCC in demographic characteristics, prevalence, surveillance, and socioeconomic status necessitates different treatment approaches, leading to variations in survival outcomes. Considering the medical practices in Korea, the Korean Society of Abdominal Radiology (KSAR) study group for liver diseases has developed expert consensus recommendations for diagnosis of HCC by gadoxetic acid-enhanced MRI with updated perspectives, using a modified Delphi method. During the 39th Scientific Assembly and Annual Meeting of KSAR (2016), consensus was reached on 12 of 16 statements. These recommendations might serve to ensure a more standardized diagnosis of HCC by gadoxetic acid-enhanced MRI.
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27
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Differences in Liver Imaging and Reporting Data System Categorization Between MRI and CT. AJR Am J Roentgenol 2016; 206:307-12. [PMID: 26797357 DOI: 10.2214/ajr.15.14788] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study is to determine whether focal liver observations are categorized differently by CT and MRI using the Liver Imaging and Reporting Data System (LI-RADS). MATERIALS AND METHODS We performed a retrospective review of 58 patients at risk for hepatocellular carcinoma who underwent liver protocol CT and MRI within 1 month of each other. Two readers assigned a LI-RADS category for all focal liver observations in consensus. A significant category upgrade was defined as a change from LI-RADS categories 1 and 2 or nonvisualization to LI-RADS categories 3-5, from LI-RADS category 3 to category 4 or 5, from LI-RADS category 4 to category 5, or from any category to LI-RADS category 5V. A significant downgrade was defined as a change from LI-RADS category 5 to categories 1-4, from LI-RADS category 4 to categories 1-3, or from LI-RADS category 3 to categories 1 or 2. RESULTS The LI-RADS category was different between CT and MRI for 77.2% (176/228) of observations. A significant upgrade occurred on MRI for 42.5% (97/228) of observations because of nonvisualization by CT (n = 78), capsule (n = 8), arterial hyperenhancement (n = 4), intratumoral fat (n = 2), larger size (n = 2), tumor in portal vein (n = 2), and wash-out (n = 1). Of these 97 upgraded observations, two were upgraded to LI-RADS category 5V, 15 were upgraded to category 5, and 13 were upgraded to category 4. A significant downgrade occurred on MRI for 8.8% (20/228) of observations because of marked T2 hyperintensity (n = 14), smaller size (n = 2), wedge shape (n = 2), and marked T2 hypointensity (n = 2). CONCLUSION LI-RADS categorization of focal liver observations is dependent on imaging modality. MRI results in both upgraded and downgraded categorization compared with CT in an important proportion of observations.
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Review of imaging techniques in the diagnosis of hepatocellular carcinoma in patients who require a liver transplant. Eur J Gastroenterol Hepatol 2016; 28:412-20. [PMID: 26760587 DOI: 10.1097/meg.0000000000000528] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of the study was to retrospectively compare the diagnostic performance of ultrasound (US), contrast-enhanced multidetector computed tomography (MDCT) and contrast-enhanced MRI in cirrhotic patients who were candidates for liver transplantation. MATERIALS AND METHODS A total of 273 consecutive patients with 218 hepatocellular carcinoma (HCC) nodules, who underwent imaging and subsequent transplantation, were examined. Diagnosis of HCC was based on explant correlation of the whole liver. Three different imaging data sets were evaluated: US, MDCT and MRI unenhanced and dynamic phases. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value, with corresponding 95% confidence intervals, were determined. Statistical analysis was performed for all lesions and for two lesion subgroups (≤2 and >2 cm). Preoperative tumour staging was analysed. RESULTS Patient sensitivity to US, MDCT and MRI was 80.4, 81.1 and 90.5%, respectively. Specificity was 96.3, 96.2 and 82.1%. Combined US and MDCT improved sensitivity (88%) without significant loss in specificity (95.7%). Imaging tests resulted in accurate tumour staging in 83.4% of the patients. In per-nodule analysis, technique sensitivity was 55.6, 52.4 and 65.9%, respectively. Sensitivity figures improved when the nodule was larger than 2 cm. CONCLUSION Combining imaging techniques is a good strategy for pretransplant HCC diagnosis and provides more accurate cancer staging in patients, which is necessary to decide the correct therapeutic approach.
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Review of Commonly Used Serum Tumor Markers and Their Relevance for Image Interpretation. J Comput Assist Tomogr 2016; 39:825-34. [PMID: 26248153 DOI: 10.1097/rct.0000000000000297] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Serum tumor markers are firmly entrenched as one of the primary tools in an oncologist's armamentarium. They can be implemented in a broad range of applications from diagnostic assistance, assessing prognosis, or guiding therapeutic decisions. However, tumor markers also have limitations, which significantly impact how they should be used. Radiologists should be familiar with the following most prevalent tumor markers, which will all be discussed here: prostate-specific antigen (prostate), carcinoembryonic antigen (colon), α-fetoprotein (hepatocellular and testicular), carbohydrate antigen 19.9 (pancreas), cancer antigen 125 (ovarian), human chorionic gonadotropin/lactic dehydrogenase (testicular), and chromogranin A (neuroendocrine). This knowledge should avoid needless intervention, enhance image interpretation, and ultimately provide optimal patient care.
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Affiliation(s)
- Rafel Tappouni
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Michelle D Sakala
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC
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Jang HJ, Kim TK, Burns PN, Wilson SR. CEUS: An essential component in a multimodality approach to small nodules in patients at high-risk for hepatocellular carcinoma. Eur J Radiol 2015; 84:1623-35. [DOI: 10.1016/j.ejrad.2015.05.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/11/2015] [Indexed: 02/07/2023]
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Galia M, Taibbi A, Marin D, Furlan A, Dioguardi Burgio M, Agnello F, Cabibbo G, Van Beers BE, Bartolotta TV, Midiri M, Lagalla R, Brancatelli G. Focal lesions in cirrhotic liver: what else beyond hepatocellular carcinoma? Diagn Interv Radiol 2015; 20:222-8. [PMID: 24509186 DOI: 10.5152/dir.2014.13184] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Detection and characterization of focal lesions in the cirrhotic liver may pose a diagnostic dilemma. Several benign and malignant lesions may be found in a cirrhotic liver along with hepatocellular carcinoma (HCC), and may exhibit typical or atypical imaging features. In this pictorial essay, we illustrate computed tomography and magnetic resonance imaging findings of lesions such as simple bile duct cysts, hemangioma, focal nodular hyperplasia-like nodules, peribiliary cysts, intrahepatic cholangiocarcinoma, lymphoma, and metastases, all of which occur in cirrhotic livers with varying prevalences. Pseudolesions, such as perfusion anomalies, focal confluent fibrosis, and segmental hyperplasia, will also be discussed. Imaging characterization of non-HCC lesions in cirrhosis is important in formulating an accurate diagnosis and triaging the patient towards the most appropriate management.
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Affiliation(s)
- Massimo Galia
- From the Section of Radiology -Di.Bi.Me.F. Beaujon University Hospital Paris, Clichy, France.
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Affiliation(s)
- Helen L Reeves
- Northern Institute for Cancer Research, Newcastle University and Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom.
| | - Alex M Aisen
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana
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Kircher A, Bongartz G, Merkle EM, Zech CJ. [Rational imaging of hepatocellular carcinoma. The challenge of multimodal diagnostic criteria]. Radiologe 2015; 54:664-72. [PMID: 25047522 DOI: 10.1007/s00117-014-2652-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
CLINICAL/METHODICAL ISSUE Both computed tomography (CT) and magnetic resonance imaging (MRI) constitute the gold standard in radiological imaging of hepatocellular carcinoma (HCC). In cases of typical contrast behavior each modality as a single dynamic technique allows the diagnosis of HCC. There is still a challenge in detection of small HCCs < 2 cm, in differentiating HCC and high-grade dysplasia from other benign liver lesions as well as the evaluation of hypovascular liver lesions in the cirrhotic liver. PERFORMANCE Nowadays, both modalities achieve high detection rates of 90-100 % for lesions > 2 cm. Regarding lesions between 1 and 2 cm there is a higher sensitivity for MRI ranging between 80 and 90 % compared to 60-75 % with CT. Besides the multimodal diagnostic criteria, MRI provides significant benefits with the use of hepatobiliary contrast. Especially in combination with diffusion- weighted imaging (DWI) increased sensitivity and diagnostic accuracy compared to CT has been described for lesions sized < 2 cm. Regarding the differentiation from other hepatic nodules in the cirrhotic liver there is strong evidence that the coexistence of arterial enhancement and hypointensity on hepatobiliary imaging is specific for HCC. Moreover, hypointensity on hepatobiliary imaging is associated with a high positive predictive value (PPV) of up to 100 % for the presence of high-grade dysplasia and HCC. ACHIEVEMENTS The use of MRI including hepatobiliary imaging and DWI has to be regarded as the best non-invasive imaging modality for the detection of HCC and for the characterization of nodules in patients with liver cirrhosis. In comparison to CT there are benefits regarding detection of small lesions < 2 cm and evaluation of hypovascular liver lesions in the context of the hepatocarcinogenesis including prognostic values of premalignant lesions. PRACTICAL RECOMMENDATIONS Both MRI and CT provide a high diagnostic performance in evaluation of HCC in liver cirrhosis. With MRI there are considerable advantages regarding the detection rate and specificity. For daily clinical routine, CT offers a fast, reliable and easy available modality with benefits for patients in reduced general state of health and restricted compliance.
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Affiliation(s)
- A Kircher
- Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz
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Choi JY, Lee JM, Sirlin CB. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features. Radiology 2015; 273:30-50. [PMID: 25247563 DOI: 10.1148/radiol.14132362] [Citation(s) in RCA: 356] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Computed tomography (CT) and magnetic resonance (MR) imaging play critical roles in the diagnosis and staging of hepatocellular carcinoma (HCC). The second article of this two-part review discusses basic concepts of diagnosis and staging, reviews the diagnostic performance of CT and MR imaging with extracellular contrast agents and of MR imaging with hepatobiliary contrast agents, and examines in depth the major and ancillary imaging features used in the diagnosis and characterization of 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.)
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Jensen PR, Serra SC, Miragoli L, Karlsson M, Cabella C, Poggi L, Venturi L, Tedoldi F, Lerche MH. Hyperpolarized [1,3-13C2]ethyl acetoacetate is a novel diagnostic metabolic marker of liver cancer. Int J Cancer 2014; 136:E117-26. [DOI: 10.1002/ijc.29162] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 06/20/2014] [Accepted: 07/23/2014] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Luigi Miragoli
- Centro Ricerche Bracco; Bracco Imaging Spa; Colleretto Giacosa (TO) Italy
| | | | - Claudia Cabella
- Centro Ricerche Bracco; Bracco Imaging Spa; Colleretto Giacosa (TO) Italy
| | - Luisa Poggi
- Centro Ricerche Bracco; Bracco Imaging Spa; Colleretto Giacosa (TO) Italy
| | - Luca Venturi
- Center of Preclinical Imaging; University of Torino (Italy); Colleretto Giacosa (TO) Italy
| | - Fabio Tedoldi
- Centro Ricerche Bracco; Bracco Imaging Spa; Colleretto Giacosa (TO) Italy
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Barr DC, Hussain HK. MR Imaging in Cirrhosis and Hepatocellular Carcinoma. Magn Reson Imaging Clin N Am 2014; 22:315-35. [DOI: 10.1016/j.mric.2014.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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LI-RADS Categorization of Benign and Likely Benign Findings in Patients at Risk of Hepatocellular Carcinoma: A Pictorial Atlas. AJR Am J Roentgenol 2014; 203:W48-69. [DOI: 10.2214/ajr.13.12169] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yu MH, Kim JH, Yoon JH, Kim HC, Chung JW, Han JK, Choi BI. Small (≤1-cm) Hepatocellular Carcinoma: Diagnostic Performance and Imaging Features at Gadoxetic Acid–enhanced MR Imaging. Radiology 2014; 271:748-60. [DOI: 10.1148/radiol.14131996] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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40
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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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41
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Indeterminate Observations (Liver Imaging Reporting and Data System Category 3) on MRI in the Cirrhotic Liver: Fate and Clinical Implications. AJR Am J Roentgenol 2013; 201:993-1001. [DOI: 10.2214/ajr.12.10007] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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42
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Dohan A, Gavini JP, Placé V, Sebbag D, Vignaud A, Herbin C, Hamzi L, Boudiaf M, Soyer P. T2-weighted MR imaging of the liver: Qualitative and quantitative comparison of SPACE MR imaging with turbo spin-echo MR imaging. Eur J Radiol 2013; 82:e655-61. [DOI: 10.1016/j.ejrad.2013.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/18/2013] [Accepted: 07/23/2013] [Indexed: 11/17/2022]
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Cha DI, Lee MW, Kim YK, Kim SH, Park HJ, Rhim H, Lim HK. Assessing patients with hepatocellular carcinoma meeting the Milan criteria: Is liver 3 tesla MR with gadoxetic acid necessary in addition to liver CT? J Magn Reson Imaging 2013; 39:842-52. [PMID: 24115384 DOI: 10.1002/jmri.24237] [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: 12/12/2012] [Accepted: 05/01/2013] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To determine the added value of 3 Tesla liver MR in patients with hepatocellular carcinoma (HCC) within the liver computed tomography (CT) -based Milan criteria. MATERIALS AND METHODS Liver CT and MR images of 130 patients with HCC within the Milan criteria based on liver CT were retrospectively reviewed. The number of MR-diagnosed HCCs and that of high risk hypervascular nodules (HRHNs), the effect of obtaining MR on patient management and CT appearances of MR-diagnosed HCCs and those of HRHNs were evaluated. Independent predictor for diagnosing additional HCCs on liver MR was analyzed. RESULTS A total of 18.5% (24/130) of patients had additional 39 HCCs on MR, with a 5.4% (7/130) dropout rate from the Milan criteria. 28.5% (37/130) of patients had additional 78 HRHNs. Overall, 39.2% (51/130) of patients required changes in management. The common CT appearances of MR-diagnosed HCCs were arterial enhancing lesions ≥ 0.5cm (38.4%, 15/39), low density nodules < 1.5 cm (30.8%, 12/39) and invisibility (28.2%, 11/39). For MR-diagnosed HRHNs, 55.1% (43/78) were invisible on CT. The presence of inconclusive lesions on CT was an independent predictor for diagnosing additional HCCs on MR. CONCLUSION For patients with HCCs within the Milan criteria on liver CT, liver MR may be necessary to detect additional HCCs and HRHNs.
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Affiliation(s)
- Dong Ik Cha
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul, Republic of Korea
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Diffusion-weighted MRI of hepatocellular carcinoma in cirrhosis. Clin Radiol 2013; 69:1-10. [PMID: 24034549 DOI: 10.1016/j.crad.2013.07.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 07/16/2013] [Accepted: 07/18/2013] [Indexed: 12/17/2022]
Abstract
The internationally accepted diagnostic criteria for hepatocellular carcinoma (HCC) in cirrhosis are highly accurate for large tumours, but offer relatively low sensitivity for small (<2 cm) tumours. Diffusion-weighted imaging (DWI) is a functional magnetic resonance imaging (MRI) technique that has been studied extensively as an aid to visualize various abdominal malignancies, including HCC in cirrhosis. DWI maps water diffusivity, which in HCC may be restricted as a result of changes ensuing from hepatocarcinogenesis. The present review is based on up-to-date evidence and describes the strengths and weaknesses of DWI, both as a standalone technique and as an adjunct sequence to conventional protocols, in the diagnosis, staging, prognostication, and assessment of treatment response of HCC in cirrhosis.
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45
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Kim BS, Hayashi PH, Kim SH, Angthong W, Srirattanapong S, Woosley JT, Semelka RC. Outcomes of Patients with Elevated α-Fetoprotein Level and Initial Negative Findings at MR Imaging. Radiology 2013; 268:109-19. [DOI: 10.1148/radiol.13121314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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46
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Purysko AS, Remer EM, Coppa CP, Leão Filho HM, Thupili CR, Veniero JC. LI-RADS: a case-based review of the new categorization of liver findings in patients with end-stage liver disease. Radiographics 2013; 32:1977-95. [PMID: 23150853 DOI: 10.1148/rg.327125026] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Hepatocellular carcinoma (HCC) is a global health problem, with the burden of disease expected to increase in the coming years. Patients who are at increased risk for developing HCC undergo routine imaging surveillance, and once a focal abnormality is detected, evaluation with multiphasic contrast material-enhanced computed tomography or magnetic resonance imaging is necessary for diagnosis and staging. Currently, findings at liver imaging are inconsistently interpreted and reported by most radiologists. The Liver Imaging-Reporting and Data System (LI-RADS) is an initiative supported by the American College of Radiology that aims to reduce variability in lesion interpretation by standardizing report content and structure; improving communication with clinicians; and facilitating decision making (eg, for transplantation, ablative therapy, or chemotherapy), outcome monitoring, performance auditing, quality assurance, and research. Five categories that follow the diagnostic thought process are used to stratify individual observations according to the level of concern for HCC, with the most worrisome imaging features including a masslike configuration, arterial phase hyperenhancement, portal venous phase or later phase hypoenhancement, an increase of 10 mm or more in diameter within 1 year, and tumor within the lumen of a vein. LI-RADS continues to evolve and is expected to integrate a series of improvements in future versions that will positively affect the care of at-risk patients.
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Affiliation(s)
- Andrei S Purysko
- Abdominal Imaging Section, Imaging Institute, HB6, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
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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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Jang HJ, Khalili K, Yu H, Kim TK. Perfusion and parenchymal changes related to vascular alterations of the liver. ACTA ACUST UNITED AC 2012; 37:404-21. [PMID: 21667327 DOI: 10.1007/s00261-011-9767-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Imaging plays a significant role in the diagnosis of vascular abnormalities of the liver and sometimes provides the only clue to the correct diagnosis. With advances of imaging techniques and multiphasic acquisition of liver imaging, various perfusion changes are frequently encountered. Correct imaging diagnosis of significant vascular diseases can prompt appropriate work-up and timely management. Accurate differentiation of clinically insignificant perfusion phenomena from clinically significant findings including neoplastic conditions and in the setting of post-transplantation is essential. This pictorial essay illustrates various perfusion and parenchymal changes associated with portal venous inflow, hepatic venous outflow, and non-portal venous third inflow and describes brief background pathophysiology and differential points.
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Affiliation(s)
- Hyun-Jung Jang
- Department of Medical Imaging, Toronto General Hospital, University of Toronto, ON, Canada.
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Quaia E, Pizzolato R, De Paoli L, Angileri R, Ukmar M, Assunta Cova M. Arterial enhancing-only nodules less than 2 cm in diameter in patients with liver cirrhosis: Predictors of hepatocellular carcinoma diagnosis on gadobenate dimeglumine-enhanced mr imaging. J Magn Reson Imaging 2012; 37:892-902. [DOI: 10.1002/jmri.23873] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 09/11/2012] [Indexed: 12/30/2022] Open
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Parente DB, Perez RM, Eiras-Araujo A, Oliveira Neto JA, Marchiori E, Constantino CP, Amorim VB, Rodrigues RS. MR imaging of hypervascular lesions in the cirrhotic liver: a diagnostic dilemma. Radiographics 2012; 32:767-87. [PMID: 22582358 DOI: 10.1148/rg.323115131] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cirrhosis is characterized by a spectrum of hepatocellular nodules that mark the progression from regenerative nodules to low- and high-grade dysplastic nodules, followed by small and large hepatocellular carcinomas (HCCs). Characterization of small nodules on the basis of imaging and histopathologic findings is complicated by an overlap in findings associated with each type of nodule, a reflection of their multistep transitions. Vascularity patterns change gradually as the nodules evolve, with an increasing shift from predominantly venous to predominantly arterial perfusion. Regenerative and low-grade dysplastic nodules demonstrate predominantly portal perfusion and contrast enhancement similar to that of surrounding parenchyma. Differentiation of high-grade dysplastic nodules and well-differentiated HCCs on the basis of dynamic imaging and histologic findings is challenging, with a high rate of false-negative results. Some small nodules that lack hypervascularity may be early HCCs. Progressed small and large HCCs usually present no diagnostic difficulty because of their characteristic findings. Although characterization of hypervascular lesions in the cirrhotic liver is difficult, it is a key step in disease management and is the radiologist's responsibility.
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Affiliation(s)
- Daniella B Parente
- Federal University of Rio de Janeiro, Av. Lineu de Paula Machado 896/601, Jardim Botânico, CEP 22470-040, Rio de Janeiro, Brazil.
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