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Liu Y, Xiao Y, Ni X, Huang P, Wu F, Zhou C, Xu J, Zeng M, Yang C. Value of magnetic resonance imaging for diagnosis of LR‑3 and LR-4 lesions coexisting with hepatocellular carcinoma. Abdom Radiol (NY) 2024; 49:2629-2638. [PMID: 38834779 DOI: 10.1007/s00261-024-04338-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE To explore which preoperative clinical data and conventional magnetic resonance imaging (MRI) features may indicate the presence of hepatocellular carcinoma (HCC) in HCC patients coexisting with LR-3 and LR-4 lesions. METHODS HCC Patients coexisting with LR-3 and LR-4 lesions who participated in a prospective clinical trial (XX) were included in this study. Two radiologists independently assessed the preoperative MRI features and each lesion was assigned according to the liver imaging reporting and data system (LI-RADS). The preoperative clinical data were also evaluated. The relative values of these parameters were assessed as potential predictors of HCC for coexisting LR-3 and LR-4 lesions. RESULTS We enrolled 102 HCC patients (58.1 ± 11.5 years; 84.3% males) coexisting with 110 LR-3 and LR-4 lesions (HCCs group [n = 66]; non-HCCs group [n = 44]). The presence of restricted diffusion (OR: 18.590, p < 0.001), delayed enhancement (OR: 0.113, p < 0.001), and mild-moderate T2 hyperintensity (OR: 3.084, p = 0.048) were found to be independent predictors of HCC diagnosis. The sensitivity and specificity of the above independent variables for the diagnosis of HCC ranged from 66.7 to 80.3% and 56.8 to 88.6%, respectively. ROC analysis showed that, in discriminating HCC, the AUCs of the above factors were 0.777, 0.686, and 0.670, respectively. Combining these three findings for the prediction of HCC resulted in a specificity greater than 97%, and the AUC further increased to 0.874. CONCLUSION The presence of restricted diffusion, delayed enhancement, and mild-moderate T2 hyperintensity can be useful features for risk stratification of coexisting LR-3 and LR-4 lesions in HCC patients. Trial registration a prospective clinical trial (ChiCTR2000036201).
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Affiliation(s)
- Yang Liu
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Radiology, The Affiliated Suzhou Hospital of Nanjing University Medical School, No. 1 Lijiang Road, Suzhou, 215153, Jiangsu, China
| | - Yuyao Xiao
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaoyan Ni
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Peng Huang
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Fei Wu
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Changwu Zhou
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Jianming Xu
- Department of Radiology, The Affiliated Suzhou Hospital of Nanjing University Medical School, No. 1 Lijiang Road, Suzhou, 215153, Jiangsu, China
| | - Mengsu Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China.
- Shanghai Institute of Medical Imaging, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China.
| | - Chun Yang
- Department of Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
- Department of Cancer Center, Zhongshan Hospital, Fudan University, Xuhui District, No. 180 Fenglin Road, Shanghai, 200032, China.
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Maino C, Vernuccio F, Cannella R, Franco PN, Giannini V, Dezio M, Pisani AR, Blandino AA, Faletti R, De Bernardi E, Ippolito D, Gatti M, Inchingolo R. Radiomics and liver: Where we are and where we are headed? Eur J Radiol 2024; 171:111297. [PMID: 38237517 DOI: 10.1016/j.ejrad.2024.111297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 02/10/2024]
Abstract
Hepatic diffuse conditions and focal liver lesions represent two of the most common scenarios to face in everyday radiological clinical practice. Thanks to the advances in technology, radiology has gained a central role in the management of patients with liver disease, especially due to its high sensitivity and specificity. Since the introduction of computed tomography (CT) and magnetic resonance imaging (MRI), radiology has been considered the non-invasive reference modality to assess and characterize liver pathologies. In recent years, clinical practice has moved forward to a quantitative approach to better evaluate and manage each patient with a more fitted approach. In this setting, radiomics has gained an important role in helping radiologists and clinicians characterize hepatic pathological entities, in managing patients, and in determining prognosis. Radiomics can extract a large amount of data from radiological images, which can be associated with different liver scenarios. Thanks to its wide applications in ultrasonography (US), CT, and MRI, different studies were focused on specific aspects related to liver diseases. Even if broadly applied, radiomics has some advantages and different pitfalls. This review aims to summarize the most important and robust studies published in the field of liver radiomics, underlying their main limitations and issues, and what they can add to the current and future clinical practice and literature.
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Affiliation(s)
- Cesare Maino
- Department of Radiology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy.
| | - Federica Vernuccio
- Institute of Radiology, University Hospital of Padova, Padova 35128, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo 90127, Italy
| | - Paolo Niccolò Franco
- Department of Radiology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy
| | - Valentina Giannini
- Department of Surgical Sciences, University of Turin, Turin 10126, Italy
| | - Michele Dezio
- Department of Radiology, Miulli Hospital, Acquaviva delle Fonti 70021, Bari, Italy
| | - Antonio Rosario Pisani
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari, Bari 70121, Italy
| | - Antonino Andrea Blandino
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo 90127, Italy
| | - Riccardo Faletti
- Department of Surgical Sciences, University of Turin, Turin 10126, Italy
| | - Elisabetta De Bernardi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, University of Milano Bicocca, Milano 20100, Italy; School of Medicine, University of Milano Bicocca, Milano 20100, Italy
| | - Davide Ippolito
- Department of Radiology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy; School of Medicine, University of Milano Bicocca, Milano 20100, Italy
| | - Marco Gatti
- Department of Surgical Sciences, University of Turin, Turin 10126, Italy
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli Hospital, Acquaviva delle Fonti 70021, Italy
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Suhail Najm Alareer H, Arian A, Fotouhi M, Taher HJ, Dinar Abdullah A. Evidence Supporting Diagnostic Value of Liver Imaging Reporting and Data System for CT- and MR Imaging-based Diagnosis of Hepatocellular Carcinoma: A Systematic Review and Meta-analysis. J Biomed Phys Eng 2024; 14:5-20. [PMID: 38357604 PMCID: PMC10862115 DOI: 10.31661/jbpe.v0i0.2211-1562] [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: 11/08/2022] [Accepted: 03/12/2023] [Indexed: 02/16/2024]
Abstract
Background Based on the Liver Imaging Data and Reporting System (LI-RADS) guidelines, Hepatocellular Carcinoma (HCC) can be diagnosed using imaging criteria in patients at risk of HCC. Objective This study aimed to assess the diagnostic value of LI-RADS in high-risk patients with HCC. Material and Methods This systematic review is conducted on international databases, including Google Scholar, Web of Science, PubMed, Embase, PROQUEST, and Cochrane Library, with appropriate keywords. Using the binomial distribution formula, the variance of each study was calculated, and all the data were analyzed using STATA version 16. The pooled sensitivity and specificity were determined using a random-effects meta-analysis approach. Also, we used the chi-squared test and I2 index to calculate heterogeneity among studies, and Funnel plots and Egger tests were used for evaluating publication bias. Results The pooled sensitivity was estimated at 0.80 (95% CI 0.76-0.84). According to different types of Liver Imaging Reporting and Data Systems (LI-RADS), the highest pooled sensitivity was in version 2018 (0.83 (95% CI 0.79-0.87) (I2: 80.6%, P of chi 2 test for heterogeneity <0.001 and T2: 0.001). The pooled specificity was estimated as 0.89 (95% CI 0.87-0.92). According to different types of LI-RADS, the highest pooled specificity was in version 2014 (93.0 (95% CI 89.0-96.0) (I2: 81.7%, P of chi 2 test for heterogeneity <0.001 and T2: 0.001). Conclusion LI-RADS can assist radiologists in achieving the required sensitivity and specificity in high-risk patients suspected to have HCC. Therefore, this strategy can serve as an appropriate tool for identifying HCC.
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Affiliation(s)
- Hayder Suhail Najm Alareer
- Department of Radiology, College of Health and Medical Technology, Al-Ayen University, Thi-Qar, 64001, Iraq
| | - Arvin Arian
- Cancer Institute ADIR, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Maryam Fotouhi
- Quantitative MR Imaging and Spectroscopy Group (QMISG), Research Centre for Molecular and Cellular Imaging (RCMCI), Advanced Medical Technologies and Equipment Institute (AMTEI), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | | | - Ayoob Dinar Abdullah
- Department of Radiology Technology, Al-Manara College for Medical Sciences, Missan, Iraq
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Chen J, Chen H, Zheng D, Yan C, Ye R, Wen L, Li Y. LI-RADS category 3, 4, and M observations: a multiple parameters diagnostic model for hepatocellular carcinoma. Acta Radiol 2023; 64:2977-2986. [PMID: 37753552 DOI: 10.1177/02841851231203830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Hepatic lesions categorized as LR-3, LR-4, and LR-M are challenging to accurately assess and diagnose. PURPOSE To combine potential clinical and/or magnetic resonance imaging (MRI) features for a more comprehensive hepatocellular carcinoma (HCC) versus non-HCC diagnosis for patients with LR-3, LR-4, and LR-M graded lesions. METHODS Data were consecutively retrieved from 82 at-risk patients with LR-3 (n = 43), LR-4 (n = 20), and LR-M (n = 23) lesions. Significant findings for the differentiation of HCC and non-HCC, including MRI features and clinical factors, were identified with univariable and multivariable analyses. The variables for a prediction model were selected through stepwise use of Akaike's Information Criterion (AIC) to build multivariable logistic regression model. RESULTS Serum alpha-fetoprotein (AFP) >16.2 ng/mL (odds ratio [OR] = 22.4; P = 0.006), septum (OR = 52.1; P = 0.011), and hepatobiliary phase (HBP) hypointensity (OR = 40.2; P = 0.001) were confirmed as independent predictors of HCC. When combining the three predictors and mild-moderate T2 hyperintensity, the model (AIC = 50.91) showed good accuracy with a C-index of 0.948. CONCLUSION In at-risk patients with LR-3, LR-4, or LR-M lesions, integrating AFP, septum, HBP hypointensity, and mild-moderate T2 hyperintensity achieved high diagnostic performance for the diagnosis of HCC.
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Affiliation(s)
- Jianwei Chen
- Department of Radiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, PR China
| | - Huizhen Chen
- Department of Good Clinical Practice, Fuzhou Pulmonary Hospital, Fuzhou, Fujian Province, PR China
| | - Dechun Zheng
- Department of Radiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, PR China
| | - Chuan Yan
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian Province, PR China
| | - Rongping Ye
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian Province, PR China
| | - Liting Wen
- Department of Radiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian Province, PR China
| | - Yueming Li
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian Province, PR China
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Goins SM, Adamo RG, Lam E, Costa AF, van der Pol CB, Salameh JP, Dawit H, McInnes MDF, Bashir MR. Conversion Strategy for LI-RADS Category 5 Observations across Versions 2014, 2017, and 2018. Radiology 2023; 307:e222971. [PMID: 37129488 DOI: 10.1148/radiol.222971] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Stacy M Goins
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Robert G Adamo
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Eric Lam
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Andreu F Costa
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Christian B van der Pol
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Jean-Paul Salameh
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Haben Dawit
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Matthew D F McInnes
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
| | - Mustafa R Bashir
- From the Department of Radiology, Duke University School of Medicine, Durham, NC (S.M.G.); Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (R.G.A.); The Ottawa Hospital Research Insitute, Clinical Epidemiology Program, Ottawa, ON, Canada (E.L., M.D.F.M.); Clinical Epidemiology Program (H.D.), and University of Ottawa Departments of Radiology and Epidemiology (M.D.F.M.), Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (A.F.C.); Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada (A.F.C.); Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada (C.B.v.d.P.); Faculty of Health Sciences, Queen's University, Kingston, ON, Canada (J.P.S.); Departments of Radiology and Medicine and Center for Advanced Magnetic Resonance Development, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27701 (M.R.B.); and Department of Radiology, University of North Carolina, Chapel Hill, NC (M.R.B.)
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Lyu R, Hu W, Wang D, Wang J, Gao Z, Jia K. LI-RADS v2018: utilizing ancillary features on gadoxetic acid-enhanced MRI to improve the diagnostic performance of small hapatocellular carcinoma (≤ 20 mm). Abdom Radiol (NY) 2023; 48:1987-1994. [PMID: 36939913 DOI: 10.1007/s00261-023-03871-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE To evaluate the role of ancillary features (AFs) of Liver Imaging Reporting and Data System (LI-RADS) in the diagnostic performance of small HCC (≤ 20 mm) on gadoxetic acid-enhanced MRI. METHODS A total of 154 patients with 183 hepatic observations were analysed in this retrospective study. Observations were categorized using only major features (MFs) and combined MFs and AFs. Independently significant AFs were identified through logistic regression analysis, and upgraded LR-5 criteria were developed using these as new MFs. The diagnostic performance of the modified LI-RADS (mLI-RADS) was calculated and compared with that of LI-RADS v2018 using McNemar's test. RESULTS Restricted diffusion, transitional and hepatobiliary phase hypointensity were independently significant AFs. The mLI-RADS a, c, e, g, h and i (upgraded LR-4 lesions that were categorized using only MFs to LR-5 using a certain or any one, two, three of the above AFs as new MFs) yielded a significantly greater sensitivity than that of the LI-RADS v2018 (68.0%, 69.1%, 69.1%, 69.1%, 69.1%, 68.0% vs. 61.9%, all p < 0.05), whereas the specificities were not significantly different (84.9%, 86.0%, 84.9%, 83.7%, 84.9%, 87.2% vs. 88.4% all p > 0.05). When independently significant AFs were used to upgrade the LR-4 nodules categorized by combined MFs and AFs (mLI-RADS b, d and f), the sensitivities were improved, but the specificities were decreased (all p < 0.05). CONCLUSIONS Independently significant AFs may be used to upgrade an observation from LR-4 (categorized only using MFs) to LR-5, which can improve diagnostic performance for small HCC.
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Affiliation(s)
- Rong Lyu
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Weijuan Hu
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Di Wang
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Jiao Wang
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Zhongsong Gao
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China
| | - Kefeng Jia
- Department of Radiology, Tianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, NO. 83 Jintang Road, Hedong District, Tianjin, 300170, China.
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Park S, Byun J, Hwang SM. Utilization of a Machine Learning Algorithm for the Application of Ancillary Features to LI-RADS Categories LR3 and LR4 on Gadoxetate Disodium-Enhanced MRI. Cancers (Basel) 2023; 15:cancers15051361. [PMID: 36900153 PMCID: PMC10000173 DOI: 10.3390/cancers15051361] [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: 02/09/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND This study aimed to identify the important ancillary features (AFs) and determine the utilization of a machine-learning-based strategy for applying AFs for LI-RADS LR3/4 observations on gadoxetate disodium-enhanced MRI. METHODS We retrospectively analyzed MRI features of LR3/4 determined with only major features. Uni- and multivariate analyses and random forest analysis were performed to identify AFs associated with HCC. A decision tree algorithm of applying AFs for LR3/4 was compared with other alternative strategies using McNemar's test. RESULTS We evaluated 246 observations from 165 patients. In multivariate analysis, restricted diffusion and mild-moderate T2 hyperintensity showed independent associations with HCC (odds ratios: 12.4 [p < 0.001] and 2.5 [p = 0.02]). In random forest analysis, restricted diffusion is the most important feature for HCC. Our decision tree algorithm showed higher AUC, sensitivity, and accuracy (0.84, 92.0%, and 84.5%) than the criteria of usage of restricted diffusion (0.78, 64.5%, and 76.4%; all p < 0.05); however, our decision tree algorithm showed lower specificity than the criterion of usage of restricted diffusion (71.1% vs. 91.3%; p < 0.001). CONCLUSION Our decision tree algorithm of applying AFs for LR3/4 shows significantly increased AUC, sensitivity, and accuracy but reduced specificity. These appear to be more appropriate in certain circumstances in which there is an emphasis on the early detection of HCC.
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Affiliation(s)
- Seongkeun Park
- Machine Intelligence Laboratory, Department of Smart Automobile, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Jieun Byun
- Department of Radiology, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea
- Correspondence:
| | - Sook Min Hwang
- Department of Radiology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul 07441, Republic of Korea
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8
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Lee S, Kim YY, Shin J, Son WJ, Roh YH, Choi JY, Sirlin CB, Chernyak V. Percentages of Hepatocellular Carcinoma in LI-RADS Categories with CT and MRI: A Systematic Review and Meta-Analysis. Radiology 2023; 307:e220646. [PMID: 36625748 DOI: 10.1148/radiol.220646] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The Liver Imaging Reporting and Data System (LI-RADS) CT and MRI algorithm applies equally to CT, MRI with extracellular contrast agents (ECA-MRI), and MRI with gadoxetate (Gx-MRI). Purpose To estimate pooled percentages of hepatocellular carcinoma (HCC) and overall malignancy for each LI-RADS category with CT and MRI. Materials and Methods MEDLINE and EMBASE databases were searched for research articles (January 2014-April 2021) reporting the percentages of observations in each LI-RADS category with use of versions 2014, 2017, or 2018. Study design, population characteristics, imaging modality, reference standard, and numbers of HCC and non-HCC malignancies in each category were recorded. A random-effects model evaluated the pooled percentage of HCC and overall malignancy for each category. Results There were 49 studies with 9620 patients and a total 11 562 observations, comprising 7921 HCCs, 1132 non-HCC malignancies, and 2509 benign entities. No HCC or non-HCC malignancies were reported with any modality in the LR-1 category. The pooled percentages of HCC for CT, ECA-MRI, and Gx-MRI, respectively, were 10%, 6%, and 1% for LR-2 (P = .16); 48%, 31%, and 38% for LR-3 (P = .42); 76%, 64%, and 77% for LR-4 (P = .62); 96%, 95%, and 96% for LR-5 (P = .76); 88%, 76%, and 78% for LR-5V or LR-TIV (tumor in vein) (P = .42); and 20%, 30%, and 35% for LR-M (P = .32). Most LR-M (93%-100%) and LR-5V or LR-TIV (99%-100%) observations were malignant, regardless of modality. Conclusion There was no difference in percentages of hepatocellular carcinoma and overall malignancy between CT, MRI with extracellular contrast agents, and MRI with gadoxetate for any Liver Imaging Reporting and Data System categories. © RSNA, 2023 Supplemental material is available for this article See also the editorial by Ronot in this issue.
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Affiliation(s)
- Sunyoung Lee
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Yeun-Yoon Kim
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Jaeseung Shin
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Won Jeong Son
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Yun Ho Roh
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Jin-Young Choi
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Claude B Sirlin
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
| | - Victoria Chernyak
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (S.L., Y.Y.K., J.S., J.Y.C.); Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (W.J.S., Y.H.R.); Liver Imaging Group, Department of Radiology, University of California San Diego, San Diego, Calif (C.B.S.); and Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (V.C.)
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Chartampilas E, Rafailidis V, Georgopoulou V, Kalarakis G, Hatzidakis A, Prassopoulos P. Current Imaging Diagnosis of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14163997. [PMID: 36010991 PMCID: PMC9406360 DOI: 10.3390/cancers14163997] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Simple Summary The role of imaging in the management of hepatocellular carcinoma (HCC) has significantly evolved and expanded beyond the plain radiological confirmation of the tumor based on the typical appearance in a multiphase contrast-enhanced CT or MRI examination. The introduction of hepatobiliary contrast agents has enabled the diagnosis of hepatocarcinogenesis at earlier stages, while the application of ultrasound contrast agents has drastically upgraded the role of ultrasound in the diagnostic algorithms. Newer quantitative techniques assessing blood perfusion on CT and MRI not only allow earlier diagnosis and confident differentiation from other lesions, but they also provide biomarkers for the evaluation of treatment response. As distinct HCC subtypes are identified, their correlation with specific imaging features holds great promise for estimating tumor aggressiveness and prognosis. This review presents the current role of imaging and underlines its critical role in the successful management of patients with HCC. Abstract Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer related death worldwide. Radiology has traditionally played a central role in HCC management, ranging from screening of high-risk patients to non-invasive diagnosis, as well as the evaluation of treatment response and post-treatment follow-up. From liver ultrasonography with or without contrast to dynamic multiple phased CT and dynamic MRI with diffusion protocols, great progress has been achieved in the last decade. Throughout the last few years, pathological, biological, genetic, and immune-chemical analyses have revealed several tumoral subtypes with diverse biological behavior, highlighting the need for the re-evaluation of established radiological methods. Considering these changes, novel methods that provide functional and quantitative parameters in addition to morphological information are increasingly incorporated into modern diagnostic protocols for HCC. In this way, differential diagnosis became even more challenging throughout the last few years. Use of liver specific contrast agents, as well as CT/MRI perfusion techniques, seem to not only allow earlier detection and more accurate characterization of HCC lesions, but also make it possible to predict response to treatment and survival. Nevertheless, several limitations and technical considerations still exist. This review will describe and discuss all these imaging modalities and their advances in the imaging of HCC lesions in cirrhotic and non-cirrhotic livers. Sensitivity and specificity rates, method limitations, and technical considerations will be discussed.
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Affiliation(s)
- Evangelos Chartampilas
- Radiology Department, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- Correspondence:
| | - Vasileios Rafailidis
- Radiology Department, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Vivian Georgopoulou
- Radiology Department, Ippokratio General Hospital of Thessaloniki, 54642 Thessaloniki, Greece
| | - Georgios Kalarakis
- Department of Diagnostic Radiology, Karolinska University Hospital, 14152 Stockholm, Sweden
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 14152 Stockholm, Sweden
- Department of Radiology, Medical School, University of Crete, 71500 Heraklion, Greece
| | - Adam Hatzidakis
- Radiology Department, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Panos Prassopoulos
- Radiology Department, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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10
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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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11
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Cannella R, Cammà C, Matteini F, Celsa C, Giuffrida P, Enea M, Comelli A, Stefano A, Cammà C, Midiri M, Lagalla R, Brancatelli G, Vernuccio F. Radiomics Analysis on Gadoxetate Disodium-Enhanced MRI Predicts Response to Transarterial Embolization in Patients with HCC. Diagnostics (Basel) 2022; 12:diagnostics12061308. [PMID: 35741118 PMCID: PMC9221802 DOI: 10.3390/diagnostics12061308] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 02/04/2023] Open
Abstract
Objectives: To explore the potential of radiomics on gadoxetate disodium-enhanced MRI for predicting hepatocellular carcinoma (HCC) response after transarterial embolization (TAE). Methods: This retrospective study included cirrhotic patients treated with TAE for unifocal HCC naïve to treatments. Each patient underwent gadoxetate disodium-enhanced MRI. Radiomics analysis was performed by segmenting the lesions on portal venous (PVP), 3-min transitional, and 20-min hepatobiliary (HBP) phases. Clinical data, laboratory variables, and qualitative features based on LI-RADSv2018 were assessed. Reference standard was based on mRECIST response criteria. Two different radiomics models were constructed, a statistical model based on logistic regression with elastic net penalty (model 1) and a computational model based on a hybrid descriptive-inferential feature extraction method (model 2). Areas under the ROC curves (AUC) were calculated. Results: The final population included 51 patients with HCC (median size 20 mm). Complete and objective responses were obtained in 14 (27.4%) and 29 (56.9%) patients, respectively. Model 1 showed the highest performance on PVP for predicting objective response with an AUC of 0.733, sensitivity of 100%, and specificity of 40.0% in the test set. Model 2 demonstrated similar performances on PVP and HBP for predicting objective response, with an AUC of 0.791, sensitivity of 71.3%, specificity of 61.7% on PVP, and AUC of 0.790, sensitivity of 58.8%, and specificity of 90.1% on HBP. Conclusions: Radiomics models based on gadoxetate disodium-enhanced MRI can achieve good performance for predicting response of HCCs treated with TAE.
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Affiliation(s)
- Roberto Cannella
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (C.C.); (P.G.); (M.E.); (C.C.)
- Correspondence: (R.C.); (F.V.)
| | - Carla Cammà
- University of Palermo, Piazza Marina, 61, 90133 Palermo, Italy;
| | - Francesco Matteini
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (C.C.); (P.G.); (M.E.); (C.C.)
- Department of Surgical, Oncological and Oral Sciences (D.C.O.S.), University of Palermo, 90133 Palermo, Italy
| | - Paolo Giuffrida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (C.C.); (P.G.); (M.E.); (C.C.)
| | - Marco Enea
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (C.C.); (P.G.); (M.E.); (C.C.)
| | - Albert Comelli
- Ri.MED Foundation, Via Bandiera 11, 90133 Palermo, Italy;
| | - Alessandro Stefano
- Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Contrada Pietrapollastra-Pisciotto, 90015 Cefalù, Italy;
| | - Calogero Cammà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (C.C.); (P.G.); (M.E.); (C.C.)
| | - Massimo Midiri
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
| | - Roberto Lagalla
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
| | - Giuseppe Brancatelli
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
| | - Federica Vernuccio
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (F.M.); (M.M.); (R.L.); (G.B.)
- Department of Radiology, University Hospital of Padova, Via Nicolò Giustiniani, 2, 35128 Padua, Italy
- Correspondence: (R.C.); (F.V.)
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12
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Vernuccio F, Cannella R, Cabibbo G, Greco S, Celsa C, Matteini F, Giuffrida P, Midiri M, Di Marco V, Cammà C, Brancatelli G. Role of LI-RADS Indeterminate Observations in the Risk of Hepatocellular Carcinoma after HCV Eradication with Direct-Acting Antivirals. Diagnostics (Basel) 2022; 12:diagnostics12051187. [PMID: 35626341 PMCID: PMC9140370 DOI: 10.3390/diagnostics12051187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: To assess whether HCC (LR-5) occurrence may be associated with the presence of Liver Imaging Reporting and Data System (LI-RADS) indeterminate observations in patients with hepatitis C virus infection treated with direct acting antiviral (DAA) therapy. Materials and methods: This retrospective study included patients with HCV-related cirrhosis who achieved sustained virologic response (SVR) after DAA therapy between 2015 and 2019 and submitted to CT/MRI follow-ups with a minimum interval time of six months before and after DAA. Two blinded readers reviewed CT/MRI to categorize observations according to LI-RADS version 2018. Differences in rate of LI-RADS 5 observations (i.e., LR-5) before and after SVR were assessed. Time to LR-5 occurrence and risk factors for HCC after DAAs were evaluated by using Kaplan-Meier method and Cox proportional hazard model, respectively. Results: Our final study population comprised 115 patients (median age 72 years) with a median CT/MRI follow-up of 47 months (IQR 26–77 months). Twenty-nine (25.2%) patients were diagnosed with LR-5 after DAA. The incidence of LR-5 after DAAs was 10.4% (12/115) at one year and 17.4% (20/115) at two years. LR-5 occurrence after DAA was significantly higher in patients with Child Pugh class B (log-rank p = 0.048) and with LR-3 or LR-4 observations (log-rank p = 0.024). At multivariate analysis, Child-Pugh class B (hazard ratio 2.62, p = 0.023) and presence of LR-3 or LR-4 observations (hazard ratio 2.40, p = 0.048) were independent risk factors for LR-5 occurrence after DAA therapy. Conclusions: The presence of LR-3 and LR-4 observations significantly increases HCC risk following the eradication of HCV infection.
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Affiliation(s)
- Federica Vernuccio
- Department of Radiology, University Hospital of Padova, Via Nicolò Giustiniani 2, 35128 Padova, Italy
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
- Correspondence: ; Tel.: +39-388-6332212
| | - Roberto Cannella
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
| | - Giuseppe Cabibbo
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
| | - Silvia Greco
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
| | - Ciro Celsa
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90127 Palermo, Italy
| | - Francesco Matteini
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
| | - Paolo Giuffrida
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
| | - Massimo Midiri
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
| | - Vito Di Marco
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
| | - Calogero Cammà
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy; (G.C.); (C.C.); (P.G.); (V.D.M.); (C.C.)
| | - Giuseppe Brancatelli
- Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University Hospital “Paolo Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (R.C.); (S.G.); (F.M.); (M.M.); (G.B.)
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Granata V, Fusco R, Belli A, Borzillo V, Palumbo P, Bruno F, Grassi R, Ottaiano A, Nasti G, Pilone V, Petrillo A, Izzo F. Conventional, functional and radiomics assessment for intrahepatic cholangiocarcinoma. Infect Agent Cancer 2022; 17:13. [PMID: 35346300 PMCID: PMC8961950 DOI: 10.1186/s13027-022-00429-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/18/2022] [Indexed: 02/08/2023] Open
Abstract
Background This paper offers an assessment of diagnostic tools in the evaluation of Intrahepatic Cholangiocarcinoma (ICC). Methods Several electronic datasets were analysed to search papers on morphological and functional evaluation in ICC patients. Papers published in English language has been scheduled from January 2010 to December 2021.
Results We found that 88 clinical studies satisfied our research criteria. Several functional parameters and morphological elements allow a truthful ICC diagnosis. The contrast medium evaluation, during the different phases of contrast studies, support the recognition of several distinctive features of ICC. The imaging tool to employed and the type of contrast medium in magnetic resonance imaging, extracellular or hepatobiliary, should change considering patient, departement, and regional features. Also, Radiomics is an emerging area in the evaluation of ICCs. Post treatment studies are required to evaluate the efficacy and the safety of therapies so as the patient surveillance. Conclusions Several morphological and functional data obtained during Imaging studies allow a truthful ICC diagnosis.
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Xie S, Zhang Y, Chen J, Jiang T, Liu W, Rong D, Sun L, Zhang L, He B, Wang J. Can modified LI-RADS increase the sensitivity of LI-RADS v2018 for the diagnosis of 10-19 mm hepatocellular carcinoma on gadoxetic acid-enhanced MRI? Abdom Radiol (NY) 2022; 47:596-607. [PMID: 34773467 DOI: 10.1007/s00261-021-03339-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate whether the Liver Imaging Reporting and Data System (LI-RADS) v2018 LR-5 criteria can be modified to increase sensitivity without reducing specificity for diagnosing 10-19 mm hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced magnetic resonance imaging (MRI). METHODS A total of 133 high-risk consecutive patients with 174 small observations (10-19 mm) detected on gadoxetic acid-enhanced MRI were retrospectively studied. LI-RADS MRI major features (MFs) and ancillary features (AFs) were reviewed by two independent radiologists in consensus. Observations were categorized using LI-RADS v2018 MFs. Independently significant AFs were identified through logistic regression analysis. Upgraded LR-5 criteria were developed by combining independently significant AFs with MFs of LR-3 or LR-4 v2018. The sensitivity and specificity of the new diagnostic criteria were compared with those of LR-5 v2018 using McNemar's test. RESULTS Three of the AFs favoring malignancy [mild-moderate T2 hyperintensity, transitional phase (TP) hypointensity and fat in mass] were independently significant features for diagnosing 10-19 mm HCC. The upgraded LR-5 criteria (mLI-RADS VII: LR-4 + mild-moderate T2 hyperintensity/TP hypointensity or LR-3 + fat in mass) yielded a significantly greater sensitivity than that of the LR-5 v2018 criteria (70.4% vs 55.1%; p < 0.001), whereas the specificity was not significantly different (94.7% vs 98.7%, p = 0.250). CONCLUSIONS Independently significant AFs may be used to upgrade an observation from LR-3/LR-4 to LR-5, which can improve the sensitivity without impairing the specificity for diagnosing 10-19 mm HCC on gadoxetic acid-enhanced MRI.
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Affiliation(s)
- Sidong Xie
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Yao Zhang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Jingbiao Chen
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Ting Jiang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Weimin Liu
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Dailin Rong
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Lin Sun
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Linqi Zhang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Bingjun He
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Jin Wang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University (SYSU), No 600, Tianhe Road, Guangzhou, 510630, Guangdong, People's Republic of China.
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Kim YY, Min JH, Hwang JA, Jeong WK, Sinn DH, Lim HK. Second-line Sonazoid-enhanced ultrasonography for Liver Imaging Reporting and Data System category 3 and 4 on gadoxetate-enhanced magnetic resonance imaging. Ultrasonography 2022; 41:519-529. [PMID: 35439873 PMCID: PMC9262668 DOI: 10.14366/usg.21198] [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: 09/18/2021] [Accepted: 01/28/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose This study investigated the utility of second-line contrast-enhanced ultrasonography (CEUS) using Sonazoid in Liver Imaging Reporting and Data System category 3 (LR-3) and 4 (LR-4) observations on gadoxetate-enhanced magnetic resonance imaging (MRI). Methods This retrospective study included LR-3 or LR-4 observations on gadoxetate-enhanced MRI subsequently evaluated with CEUS from 2013 to 2017. The presence of MRI features, CEUS-arterial phase hyperenhancement (CEUS-APHE), and Kupffer phase defect (KPD) was evaluated. Multivariable logistic regression analysis was performed to identify significant imaging features associated with the diagnosis of hepatocellular carcinoma (HCC). The optimal diagnostic criteria were investigated using the McNemar test. Results In total, 104 patients with 104 observations (63 HCCs) were included. The presence of both CEUS-APHE and KPD on CEUS enabled the additional detection of 42.3% (11/26) of LR-3 HCCs and 78.4% (29/37) of LR-4 HCCs. Transitional phase (TP) hypointensity (adjusted odds ratio [OR], 10.59; P<0.001), restricted diffusion (adjusted OR, 7.55; P=0.004), and KPD (adjusted OR, 7.16; P=0.003) were significant imaging features for HCC diagnosis. The presence of at least two significant imaging features was optimal for HCC diagnosis (sensitivity, specificity, and accuracy: 88.9%, 78.1%, and 84.6%, respectively), with significantly higher sensitivity than the presence of both CEUS-APHE and KPD (sensitivity, specificity, and accuracy: 63.5% [P=0.001], 92.7% [P=0.077], and 75.0% [P=0.089], respectively). Conclusion The combined interpretation of gadoxetate-enhanced MRI and second-line CEUS using Sonazoid, focusing on TP hypointensity, restricted diffusion, and KPD, may be optimal for further characterizing LR-3 and LR-4 observations.
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Affiliation(s)
- Yeun-Yoon Kim
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hye Min
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Ah Hwang
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo Keun Lim
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pan JM, Chen W, Zheng YL, Cheng MQ, Zeng D, Huang H, Huang Y, Xie XY, Lu MD, Kuang M, Hu HT, Chen LD, Wang W. Tumor size-based validation of contrast-enhanced ultrasound liver imaging reporting and data system (CEUS LI-RADS) 2017 for hepatocellular carcinoma characterizing. Br J Radiol 2021; 94:20201359. [PMID: 34545763 DOI: 10.1259/bjr.20201359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To validate the efficacy of contrast-enhanced ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) and its major features in diagnosing hepatocellular carcinoma (HCC) of different sizes in high-risk patients. METHODS Between January 2014 and December 2015, a total of 545 untreated liver nodules were included. These liver nodules were divided into two groups (<20 mm and ≥20 mm). Each nodule was classified based on CEUS LI-RADS. The diagnostic performance comparison was assessed by the chi-square test, with pathology results as the golden criterion. RESULTS The accuracy, sensitivity, specificity, and positive predictive value (PPV) of CEUS LR-5 criteria in <20 mm group vs ≥20 mm group in diagnosing HCC were 60.5% vs 59.8%, 55.6% vs 57.6%, 85.7% vs 88.6 and 95.2% vs 98.5%, respectively, without significant difference (all p > 0.05). The accuracy, sensitivity and PPV of LR5/M for malignancy in <20 mm group were lower than in ≥20 mm group, with values of 79.1% vs 95.0%, 84.2% vs 95.7 and 91.4% vs 99.2%, respectively (p < 0.05). CONCLUSIONS The CEUS LI-RADS has a comparable performance for diagnosing HCC between lesions ≥ 20 mm and <20 mm. For diagnosing malignancy including HCC, it has a higher efficacy for lesions ≥ 20 mm than <20 mm. ADVANCES IN KNOWLEDGE 1.For diagnosing HCC, CEUS LI-RADS has comparable performances between lesions ≥ 20 mm and <20 mm.2. For diagnosing malignancy including HCC, CEUS LI-RADS has a higher efficacy for lesions ≥ 20 mm than <20 mm.
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Affiliation(s)
- Jia-Min Pan
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Chen
- Departments of Hepatobiliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yan-Ling Zheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mei-Qing Cheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dan Zeng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Hui Huang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Yan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming-De Lu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Departments of Hepatobiliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming Kuang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Departments of Hepatobiliary Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Hang-Tong Hu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Li-Da Chen
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Park JH, Chung YE, Seo N, Choi JY, Park MS, Kim MJ. Hepatobiliary phase signal intensity: A potential method of diagnosing HCC with atypical imaging features among LR-M observations. PLoS One 2021; 16:e0257308. [PMID: 34516587 PMCID: PMC8437291 DOI: 10.1371/journal.pone.0257308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
Herein, we assessed whether hepatobiliary phase (HBP) signal intensity (SI) can be used to differentiate HCC and non-HCC malignancies within LR-M observations. 106 LR-M patients based on LI-RADS v2018 who underwent gadoxetate-disodium magnetic resonance imaging and surgery from January 2009 to December 2018 were included. SI of LR-M observation on HBP was analyzed by two radiologists and categorized into dark, low and iso-to-high groups. Tumor was classified as dark when more than 50% of tumor showed hypointensity compared to spleen, as low when more than 50% of tumor showed hyperintensity compared to spleen but hypointensity compared to liver parenchyma, and as iso-to-high if there was even a focal iso-intensity or hyperintensity compared to liver parenchyma. Analysis of clinicopathological factors and association between imaging and histology was performed. Out of 106 LR-M, 42 (40%) were showed dark, 61 (58%) showed low, and 3 (3%) showed iso-to-high SI in HBP. Three iso-to-high SI LR-M were HCCs (P = 0.060) and their major histologic differentiation was Edmondson grade 1 (P = 0.001). 43 out of 61 (71%) low SI LR-M were iCCA or cHCC-CCA (P = 0.002). Inter-reader agreement of HBP SI classification was excellent, with a kappa coefficient of 0.872. LR-M with iso-to-high SI in HBP is prone to being HCC while LR-M with low SI in HBP is prone to being tumor with fibrous stroma such as iCCA and cHCC-CCA. Classification of LR-M based on HBP SI may be a helpful method of differentiating HCC from non-HCC malignancies.
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Affiliation(s)
- Jae Hyon Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Nieun Seo
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Choi
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi-Suk Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
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18
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Enhancing capsule in hepatocellular carcinoma: intra-individual comparison between CT and MRI with extracellular contrast agent. Diagn Interv Imaging 2021; 102:735-742. [PMID: 34284951 DOI: 10.1016/j.diii.2021.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/10/2021] [Accepted: 06/12/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to compare the value of contrast-enhanced computed tomography (CT) to that of magnetic resonance imaging obtained with extracellular contrast agent (ECA-MRI) for the diagnosis of a tumor capsule in hepatocellular carcinoma (HCC) using histopathologic findings as the standard of reference. MATERIALS AND METHODS This retrospective study included patients with pathologically-proven resected HCCs with available preoperative contrast-enhanced CT and ECA-MRI examinations. Two blinded radiologists independently reviewed contrast-enhanced CT and ECA-MRI examinations to assess the presence of an enhancing capsule. The histopathological analysis of resected specimens was used as reference for the diagnosis of a tumor capsule. The sensitivity and specificity of CT and ECA-MRI for the diagnosis of a tumor capsule were determined, and an intra-individual comparison of imaging modalities was performed using McNemar test. Inter-reader agreement was assessed using Kappa test. RESULTS The study population included 199 patients (157 men, 42 women; mean age: 61.3 ± 13.0 [SD] years) with 210 HCCs (mean size 56.7 ± 43.7 [SD] mm). A tumor capsule was present in 157/210 (74.8%) HCCs at histopathologic analysis. Capsule enhancement was more frequently visualized on ECA-MRI (R1, 68.6%; R2, 71.9%) than on CT (R1, 44.3%, P < 0.001; R2, 47.6%, P < 0.001). The sensitivity of ECA-MRI was better for the diagnosis of histopathological tumor capsule (R1, 76.4%; R2, 79.6%; P < 0.001), while CT had a greater specificity (R1, 84.9%; R2, 83.0%; P < 0.001). Inter-reader agreement was moderate both on CT (kappa = 0.55; 95% confidence interval [CI]: 0.43-0.66) and ECA-MRI (kappa = 0.57; 95% CI: 0.45-0.70). CONCLUSION Capsule enhancement was more frequently visualized on ECA-MRI than on CT. The sensitivity of ECA-MRI was greater than that of CT, but the specificity of CT was better than that of ECA-MRI.
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Wan Y, Zheng Z, Liu R, Zhu Z, Zhou H, Zhang X, Boumaraf S. A Multi-Scale and Multi-Level Fusion Approach for Deep Learning-Based Liver Lesion Diagnosis in Magnetic Resonance Images with Visual Explanation. Life (Basel) 2021; 11:life11060582. [PMID: 34207262 PMCID: PMC8234101 DOI: 10.3390/life11060582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 02/08/2023] Open
Abstract
Many computer-aided diagnosis methods, especially ones with deep learning strategies, of liver cancers based on medical images have been proposed. However, most of such methods analyze the images under only one scale, and the deep learning models are always unexplainable. In this paper, we propose a deep learning-based multi-scale and multi-level fusing approach of CNNs for liver lesion diagnosis on magnetic resonance images, termed as MMF-CNN. We introduce a multi-scale representation strategy to encode both the local and semi-local complementary information of the images. To take advantage of the complementary information of multi-scale representations, we propose a multi-level fusion method to combine the information of both the feature level and the decision level hierarchically and generate a robust diagnostic classifier based on deep learning. We further explore the explanation of the diagnosis decision of the deep neural network through visualizing the areas of interest of the network. A new scoring method is designed to evaluate whether the attention maps can highlight the relevant radiological features. The explanation and visualization make the decision-making process of the deep neural network transparent for the clinicians. We apply our proposed approach to various state-of-the-art deep learning architectures. The experimental results demonstrate the effectiveness of our approach.
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Affiliation(s)
- Yuchai Wan
- Beijing Key Laboratory of Big Data Technology for Food Safety, Beijing Technology and Business University, Beijing 100048, China; (H.Z.); (X.Z.)
- Correspondence: (Y.W.); (Z.Z.)
| | - Zhongshu Zheng
- Beijing Lab of Intelligent Information Technology, School of Computer Science, Beijing Institute of Technology, Beijing 100081, China;
| | - Ran Liu
- China South-to-North Water Diversion Corporation Limited, Beijing 100038, China;
| | - Zheng Zhu
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17, Panjiayuan NanLi, Chaoyang District, Beijing 100021, China
- Correspondence: (Y.W.); (Z.Z.)
| | - Hongen Zhou
- Beijing Key Laboratory of Big Data Technology for Food Safety, Beijing Technology and Business University, Beijing 100048, China; (H.Z.); (X.Z.)
| | - Xun Zhang
- Beijing Key Laboratory of Big Data Technology for Food Safety, Beijing Technology and Business University, Beijing 100048, China; (H.Z.); (X.Z.)
| | - Said Boumaraf
- Centre d’Exploitation des Systèmes de Télécommunications Spatiales (CESTS), Agence Spatiale Algérienne, Algiers, Algeria;
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20
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Jeon SK, Joo I, Bae JS, Park SJ, Lee JM. LI-RADS v2018: how to appropriately use ancillary features in category adjustment from intermediate probability of malignancy (LR-3) to probably HCC (LR-4) on gadoxetic acid-enhanced MRI. Eur Radiol 2021; 32:46-55. [PMID: 34132875 DOI: 10.1007/s00330-021-08116-0] [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] [Received: 05/03/2021] [Revised: 05/22/2021] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the appropriate use of ancillary features (AFs) in upgrading LI-RADS category 3 (LR-3) to category 4 (LR-4) for hepatic nodules on gadoxetic acid-enhanced MRI. METHODS We retrospectively analyzed MRI features of solid hepatic nodules (≤ 30 mm) categorized as LR-3/4 on gadoxetic acid-enhanced MRI. In LI-RADS diagnostic table-based-LR-3 observations, logistic regression analyses were performed to identify AFs suggestive of hepatocellular carcinomas (HCCs) rather than non-malignant nodules. Using McNemar's test, the sensitivities and specificities of the final-LR-4 category for HCC diagnosis were compared according to the principles of AF application in category adjustment. RESULTS A total of 336 hepatic nodules (191 HCCs; 145 non-malignant) in 252 patients were evaluated. Based on major HCC features, 248 nodules (123 HCCs) were assigned as table-based-LR-3 and 88 nodules (68 HCCs) as table-based-LR-4. In table-based-LR-3 observations, mild-moderate T2 hyperintensity was identified as an independent predictor of HCC as opposed to non-malignant nodules (odds ratio = 3.01, p = 0.002). For HCC diagnosis, different criteria of final-LR-4: only table-based-LR-4, allowing category upgrade using only T2 hyperintensity, or using any AFs favoring malignancy resulted in sensitivities of 35.6% (68/191), 53.9% (103/191), and 88.5% (169/191), and specificities of 86.2% (125/145), 75.9% (110/145), and 21.4% (31/145), respectively, which differed from each other (all p < 0.001). CONCLUSIONS While the application of MRI AF in LI-RADS category adjustment increases the sensitivity of LR-4 category for HCC diagnosis, it is accompanied by a significant decrease in specificity. Mild-moderate T2 hyperintensity, a significant AF indicative of HCC, may be more appropriate for upgrading LR-3 to LR-4. KEY POINTS • When upgrading from LR-3 to LR-4 using any MRI ancillary features favoring malignancy, LR-4 sensitivity increases but specificity decreased for HCC diagnosis. • By upgrading LR-3 to LR-4 based on MRI ancillary features found to suggest HCC rather than non-malignant nodules in multivariate analysis (i.e., mild-moderate T2 hyperintensity), LR-4 demonstrated a more balanced sensitivity and specificity for HCC diagnosis (53.9% and 75.9%, respectively).
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Affiliation(s)
- Sun Kyung Jeon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea. .,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Sae-Jin Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
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21
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Zhang L, Cai P, Hou J, Luo M, Li Y, Jiang X. Radiomics Model Based on Gadoxetic Acid Disodium-Enhanced MR Imaging to Predict Hepatocellular Carcinoma Recurrence After Curative Ablation. Cancer Manag Res 2021; 13:2785-2796. [PMID: 33790652 PMCID: PMC8006953 DOI: 10.2147/cmar.s300627] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022] Open
Abstract
Background A practical prognostic prediction model is absent for hepatocellular carcinoma (HCC) patients after curative ablation. We aimed to develop a radiomics model based on gadoxetic acid disodium-enhanced magnetic resonance (MR) images to predict HCC recurrence after curative ablation. Methods We retrospectively enrolled 132 patients with HCC who underwent curative ablation. Patients were randomly divided into the training (n = 92) and validation (n = 40) cohorts. Radiomic features were extracted from gadoxetic acid disodium-enhanced MR images of the liver before curative ablation, and various baseline clinical characteristics were collected. Cox regression and random survival forests were used to construct models that incorporated radiomic features and/or clinical characteristics. The predictive performance of the different models was compared using the concordance index (C-index) and decision curves analysis (DCA). A cutoff derived from the combined model was used for risk categorization, and recurrence-free survival (RFS) was compared between groups using the Kaplan-Meier survival curve analysis. Results Twenty radiomic features and four clinical characteristics were identified and used for model construction. The radiomics model constructed by tumoral and peritumoral radiomic features had better predictive performance (C-index 0.698, 95% confidence interval [CI] 0.640-0.755) compared with the clinical model (C-index 0.614, 95% CI 0.499-0.695), while the combined model had the best predictive performance (C-index 0.706, 95% CI 0.638-0.763). A better net benefit was observed with the combined model compared with the other two models according to the DCA. Distinct RFS distributions were observed when patients were categorized based on the cutoff derived from the combined model (Log rank test, p = 0.007). Conclusion The radiomics model which combined radiomic features extracted from gadoxetic acid disodium-enhanced MR images with clinical characteristics could predict HCC recurrence after curative ablation.
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Affiliation(s)
- Ling Zhang
- Department of Radiology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Peiqiang Cai
- Department of Radiology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Jingyu Hou
- Department of Liver Surgery, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Ma Luo
- Department of Radiology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Yonggang Li
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People's Republic of China
| | - Xinhua Jiang
- Department of Radiology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
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22
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Vernuccio F, Gagliano DS, Cannella R, Ba-Ssalamah A, Tang A, Brancatelli G. Spectrum of liver lesions hyperintense on hepatobiliary phase: an approach by clinical setting. Insights Imaging 2021; 12:8. [PMID: 33432491 PMCID: PMC7801550 DOI: 10.1186/s13244-020-00928-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022] Open
Abstract
Hepatobiliary MRI contrast agents are increasingly being used for liver imaging. In clinical practice, most focal liver lesions do not uptake hepatobiliary contrast agents. Less commonly, hepatic lesions may show variable signal characteristics on hepatobiliary phase. This pictorial essay reviews a broad spectrum of benign and malignant focal hepatic observations that may show hyperintensity on hepatobiliary phase in various clinical settings. In non-cirrhotic patients, focal hepatic observations that show hyperintensity in the hepatobiliary phase are usually benign and typically include focal nodular hyperplasia. In patients with primary or secondary vascular disorders, focal nodular hyperplasia-like lesions arise as a local hyperplastic response to vascular alterations and tend to be iso- or hyperintense in the hepatobiliary phase. In oncologic patients, metastases and cholangiocarcinoma are hypointense lesions in the hepatobiliary phase; however, occasionally they may show a diffuse, central and inhomogeneous hepatobiliary paradoxical uptake with peripheral rim hypointensity. Post-chemotherapy focal nodular hyperplasia-like lesions may be tricky, and their typical hyperintense rim in the hepatobiliary phase is very helpful for the differential diagnosis with metastases. In cirrhotic patients, hepatocellular carcinoma may occasionally appear hyperintense on hepatobiliary phase.
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Affiliation(s)
- Federica Vernuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy. .,University Paris Diderot, Sorbonne Paris Cité, Paris, France. .,I.R.C.C.S. Centro Neurolesi Bonino Pulejo, Contrada Casazza, SS113, 98124, Messina, Italy. .,Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - Domenico Salvatore Gagliano
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Roberto Cannella
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy.,Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - Ahmed Ba-Ssalamah
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, General Hospital of Vienna (AKH), Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - An Tang
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.,Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Montreal, Canada
| | - Giuseppe Brancatelli
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital of Palermo, Via del Vespro 129, 90127, Palermo, Italy
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23
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Kim YY, Choi JY, Kim SU, Lee M, Park MS, Chung YE, Kim MJ. MRI Ancillary Features for LI-RADS Category 3 and 4 Observations: Improved Categorization to Indicate the Risk of Hepatic Malignancy. AJR Am J Roentgenol 2020; 215:1354-1362. [PMID: 33052732 DOI: 10.2214/ajr.20.22802] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
OBJECTIVE. The purpose of this study was to investigate whether ancillary features can help stratify malignancy risk in Liver Imaging Reporting and Data System (LI-RADS) category 3 (LR-3) and 4 (LR-4) observations. MATERIALS AND METHODS. This retrospective longitudinal study included 106 LR-3 or LR-4 observations on gadolinium-enhanced MRI obtained from January 2014 to December 2015 in 80 patients who were treatment naïve and at risk (mean age, 58.0 ± 10.7 [SD] years; 60 men). The presence of major and ancillary features, the category determined using only major features, and the final category adjusted by the application of ancillary features were retrospectively analyzed. MRI features were compared using generalized estimating equations, and cumulative incidence curves for malignancy were compared using log-rank tests with a resampling extension. RESULTS. At 6-month follow-up, the cumulative incidence of observations initially categorized as LR-4, observations upgraded to LR-4, observations initially categorized as LR-3, and observations downgraded to LR-3 were 62.5%, 29.7%, 6.2%, and 0%, respectively. The cumulative incidence of malignancy did not differ between observations categorized by major feature as LR-3 and LR-4 (p = 0.12), but was higher in final observations categorized as LR-4 than in those categorized as LR-3 (p < 0.001). Among observations categorized by major feature as LR-3, the cumulative incidence of malignancy was higher in observations upgraded to LR-4 than in observations that were initially graded as LR-3 (p = 0.03), which showed differences in the frequency of restricted diffusion and mild-to-moderate T2-weighted hyperintensity (p < 0.001 for both). CONCLUSION. Final categories determined with ancillary features, instead of categories determined by major features only, can help indicate malignancy risk in LR-3 and LR-4 observations on MRI.
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Affiliation(s)
- Yeun-Yoon Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Jin-Young Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine and Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeongjee Lee
- Department of Biomedical Systems Informatics, Biostatistics Collaboration Unit, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi-Suk Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
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24
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Vernuccio F, Cannella R, Gozzo C, Greco V, Midiri M, Furlan A, Tang A, Brancatelli G. Hepatic enhancement in cirrhosis in the portal venous phase: what are the differences between gadoxetate disodium and gadobenate dimeglumine? Abdom Radiol (NY) 2020; 45:2409-2417. [PMID: 32435849 DOI: 10.1007/s00261-020-02578-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE To compare the level of parenchymal and portal venous enhancement in the portal venous phase (PVP) in cirrhotic patients undergoing gadoxetate disodium- and gadobenate dimeglumine-enhanced MRI. METHODS In this retrospective study, 84 cirrhotic patients (mean age ± SD: 66 ± 13 years) who underwent contrast-enhanced MRI with both gadoxetate disodium and gadobenate dimeglumine between 2012 and 2018 were included. Two readers measured signal intensities of hepatic parenchyma, portal vein and psoas muscle on precontrast and PVP. Relative enhancement (RE), image contrast, and portal vein-to-liver contrast difference were calculated. Intraindividual differences were compared with the Wilcoxon signed rank-sum test and inter-reader differences with the intraclass correlation coefficient (ICC). RESULTS In PVP, gadoxetate disodium provided lower RE than gadobenate dimeglumine (Reader 1: 42.4 ± 44.6 vs. 56.1 ± 58.8, p = 0.044; Reader 2: 42.4 ± 42.9 vs. 57.7 ± 60.5, p = 0.027;), lower image contrast (Reader 1: 0.27 ± 0.11 vs. 0.35 ± 0.11, respectively; p < 0.001; Reader 2: 0.29 ± 0.10 vs. 0.37 ± 0.07, respectively; p < 0.001), and lower portal vein-to-liver contrast difference (Reader 1: 0.89 ± 0.39 vs. 1.42 ± 0.90, p < 0.001; Reader 2: 0.95 ± 0.40 vs. 1.28 ± 0.37, p < 0.001). ICC was 0.94, 0.79, and 0.69 for RE, image contrast, and portal vein-to-liver contrast difference, respectively. CONCLUSION In cirrhotic patients, gadoxetate disodium yielded lower enhancement of the hepatic parenchyma and lower contrast of the portal vein than gadobenate dimeglumine in PVP.
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25
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Ichikawa S, Isoda H, Shimizu T, Tamada D, Taura K, Togashi K, Onishi H, Motosugi U. Distinguishing intrahepatic mass-forming biliary carcinomas from hepatocellular carcinoma by computed tomography and magnetic resonance imaging using the Bayesian method: a bi-center study. Eur Radiol 2020; 30:5992-6002. [PMID: 32500195 DOI: 10.1007/s00330-020-06972-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/07/2020] [Accepted: 05/20/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine imaging hallmarks for distinguishing intrahepatic mass-forming biliary carcinomas (IMBCs) from hepatocellular carcinoma (HCC) and to validate their diagnostic ability using Bayesian statistics. METHODS Study 1 retrospectively identified clinical and imaging hallmarks that distinguish IMBCs (n = 41) from HCC (n = 247) using computed tomography (CT) and magnetic resonance imaging (MRI). Study 2 retrospectively assessed the diagnostic ability of these hallmarks to distinguish IMBCs (n = 37) from HCC (n = 111) using Bayesian statistics with images obtained from a different institution. We also assessed the diagnostic ability of the hallmarks in the patient subgroup with high diagnostic confidence (≥ 80% of post-test probability). Two radiologists independently evaluated the imaging findings in studies 1 and 2. RESULTS In study 1, arterial phase peritumoral parenchymal enhancement on CT/MRI, delayed enhancement on CT/MRI, diffusion-weighted imaging peripheral hyperintensity, and bile duct dilatation were hallmarks indicating IMBCs, whereas chronic liver disease, non-rim arterial phase hyperenhancement on CT/MRI, enhancing capsule on CT/MRI, and opposed-phase signal drop were hallmarks indicating HCC (p = 0.001-0.04). In study 2, Bayesian statistics-based post-test probability combining all hallmark features had a diagnostic accuracy of 89.2% (132/148) in distinguishing IMBCs from HCC for both readers. In the high diagnostic confidence subgroup (n = 120 and n = 124 for readers 1 and 2, respectively), the accuracy improved (95.0% (114/120) and 93.5% (116/124) for readers 1 and 2, respectively). CONCLUSIONS Combined interpretation of CT and MRI to identify hallmark features is useful in discriminating IMBCs from HCCs. High post-test probability by Bayesian statistics allows for a more reliable non-invasive diagnosis. KEY POINTS • Combined interpretation of CT and MRI to identify hallmark features was useful in discriminating intrahepatic mass-forming biliary carcinomas from hepatocellular carcinoma. • Bayesian method-based post-test probability combining all hallmark features determined in study 1 showed high (> 90%) sensitivity and specificity for distinguishing intrahepatic mass-forming biliary carcinomas from hepatocellular carcinoma. • If the post-test probability or the confidence was ≥ 80% when combining the imaging features of CT and MRI, the high specificity of > 95% was achieved without any loss of sensitivity to distinguish hepatocellular carcinoma from intrahepatic mass-forming biliary carcinomas.
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Affiliation(s)
- Shintaro Ichikawa
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan.
| | - Hiroyoshi Isoda
- Preemptive Medicine and Lifestyle-related Disease Research Center, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tatsuya Shimizu
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Daiki Tamada
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Division Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Utaroh Motosugi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
- Department of Diagnostic Radiology, Kofu Kyoritsu Hospital, 1-9-1 Takara, Kofu-shi, Yamanashi, 400-0034, Japan
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26
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Hepatobiliary phase hypointensity predicts progression to hepatocellular carcinoma for intermediate-high risk observations, but not time to progression. Eur J Radiol 2020; 128:109018. [PMID: 32388318 DOI: 10.1016/j.ejrad.2020.109018] [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] [Received: 02/11/2020] [Revised: 04/04/2020] [Accepted: 04/12/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine whether hepatobiliary phase hypointensity, enhancing "capsule" and size provide prognostic information regarding the risk of progression to hepatocellular carcinoma (HCC), as well as the time to progression, of intermediate to high risk observations ≥ 10 mm with arterial phase hyperenhancement (APHE). METHOD This retrospective dual-institution study included 160 LR-3 and 26 LR-4 observations measuring more than 10 mm and having APHE in 136 patients (mean age [SD], 57 [11] years old). A composite reference standard of pathologic analysis and imaging follow-up was used. The prognostic performance of hepatobiliary phase hypointensity, enhancing "capsule" and size (cut-off: 20 mm) for the prediction of probability of progression to HCC and median time to progression to HCC was assessed and compared by means of Log-rank test, Cox-regression and Kaplan-Meier curves. RESULTS 110 (59%) of 186 of observations progressed to HCC, 29.1% (32) progressed within 6 months, 60% (66) within 1 year and 84.5% (93) within 2 years. Hepatobiliary phase hypointensity was a significant predictor of progression to HCC (p < 0.0001, odds ratio: 20.62) but not of time to progression (p = 0.17). Median time to progression to HCC was 284 days [IQR: 266-363] and was shorter - though not significantly - for observations with enhancing "capsule" (118 days vs 301 days; p = 0.19). CONCLUSIONS Hepatobiliary phase hypointensity is an independent predictor of progression to HCC in intermediate to high risk APHE observations ≥ 10 mm.
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27
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Cannella R, Vernuccio F, Sagreiya H, Choudhury KR, Iranpour N, Marin D, Furlan A. Liver Imaging Reporting and Data System (LI-RADS) v2018: diagnostic value of ancillary features favoring malignancy in hypervascular observations ≥ 10 mm at intermediate (LR-3) and high probability (LR-4) for hepatocellular carcinoma. Eur Radiol 2020; 30:3770-3781. [PMID: 32107603 DOI: 10.1007/s00330-020-06698-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/08/2019] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study was conducted in order to assess the diagnostic accuracy of LI-RADS v2018 ancillary features (AFs) favoring malignancy applied to LR-3 and LR-4 observations on gadoxetate-enhanced MRI. METHODS In this retrospective dual-institution study, we included consecutive patients at high risk for hepatocellular carcinoma (HCC) imaged with gadoxetate disodium-enhanced MRI between 2009 and 2014 fulfilling the following criteria: (i) at least one LR-3 or LR-4 observation ≥ 10 mm; (ii) nonrim arterial phase hyperenhancement; and (iii) confirmation of benignity or malignancy by pathology or imaging follow-up. We compared the distribution of AFs between HCCs and benign observations and the diagnostic performance for the diagnosis of HCC using univariate and multivariate analyses. Significance was set at p value < 0.05. RESULTS Two hundred five observations were selected in 155 patients (108 M, 47 F) including 167 (81.5%) LR-3 and 38 (18.5%) LR-4. There were 126 (61.5%) HCCs and 79 (28.5%) benign lesions. A significantly larger number of AFs favoring malignancy were found in LR-3 and LR-4 lesions that progressed to HCC compared to benign lesions (p < 0.001 and p = 0.003, respectively). The most common AFs favoring malignancy in HCCs were hepatobiliary phase (HBP) hypointensity (p < 0.001), transitional phase hypointensity (p < 0.001), and mild-moderate T2 hyperintensity (p < 0.001). Sensitivity and specificity of AFs for the diagnosis of HCC ranged 0.8-76.2% and 86.1-100%, respectively. HBP hypointensity yielded the highest sensitivity but also the lowest specificity and was the only AF remaining independently associated with the diagnosis of HCC at multivariate logistic regression analysis (OR 14.83, 95% CI 5.81-42.76, p < 0.001). CONCLUSIONS Among all AFs, HBP hypointensity yields the highest sensitivity for the diagnosis of HCC. KEY POINTS • LR-3 and LR-4 observations diagnosed as HCC have a significantly higher number of ancillary features favoring malignancy compared to observations proven to be benign. • The presence of three or more ancillary features favoring malignancy has a high specificity (96.2%) for the diagnosis of HCC. • Among all ancillary features favoring malignancy, hepatobiliary phase hypointensity yields the highest sensitivity, but also the lowest specificity for the diagnosis of HCC.
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Affiliation(s)
- Roberto Cannella
- Section of Radiology - BiND, University Hospital "Paolo Giaccone", Via del Vespro 127, 90127, Palermo, Italy.,Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Federica Vernuccio
- Section of Radiology - BiND, University Hospital "Paolo Giaccone", Via del Vespro 127, 90127, Palermo, Italy.,Department of Radiology, Duke University Medical Center, Durham, NC, USA.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties) University Hospital of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Hersh Sagreiya
- Department of Radiology, Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 190104, USA
| | - Kingshuk Roy Choudhury
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Negaur Iranpour
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Daniele Marin
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Alessandro Furlan
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
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28
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Zech CJ, Ba-Ssalamah A, Berg T, Chandarana H, Chau GY, Grazioli L, Kim MJ, Lee JM, Merkle EM, Murakami T, Ricke J, B. Sirlin C, Song B, Taouli B, Yoshimitsu K, Koh DM. Consensus report from the 8th International Forum for Liver Magnetic Resonance Imaging. Eur Radiol 2020; 30:370-382. [PMID: 31385048 PMCID: PMC6890618 DOI: 10.1007/s00330-019-06369-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/27/2019] [Accepted: 07/12/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The 8th International Forum for Liver Magnetic Resonance Imaging (MRI), held in Basel, Switzerland, in October 2017, brought together clinical and academic radiologists from around the world to discuss developments in and reach consensus on key issues in the field of gadoxetic acid-enhanced liver MRI since the previous Forum held in 2013. METHODS Two main themes in liver MRI were considered in detail at the Forum: the use of gadoxetic acid for contrast-enhanced MRI in patients with liver cirrhosis and the technical performance of gadoxetic acid-enhanced liver MRI, both opportunities and challenges. This article summarises the expert presentations and the delegate voting on consensus statements discussed at the Forum. RESULTS AND CONCLUSIONS It was concluded that gadoxetic acid-enhanced MRI has higher sensitivity for the diagnosis of hepatocellular carcinoma (HCC), when compared with multidetector CT, by utilising features of hyperenhancement in the arterial phase and hypointensity in the hepatobiliary phase (HBP). Recent HCC management guidelines recognise an increasing role for gadoxetic acid-enhanced MRI in early diagnosis and monitoring post-resection. Additional research is needed to define the role of HBP in predicting microvascular invasion, to better define washout during the transitional phase in gadoxetic acid-enhanced MRI for HCC diagnosis, and to reduce the artefacts encountered in the arterial phase. Technical developments are being directed to shortening the MRI protocol for reducing time and patient discomfort and toward utilising faster imaging and non-Cartesian free-breathing approaches that have the potential to improve multiphasic dynamic imaging. KEY POINTS • Gadoxetic acid-enhanced MRI provides higher diagnostic sensitivity than CT for diagnosing HCC. • Gadoxetic acid-enhanced MRI has roles in early-HCC diagnosis and monitoring post-resection response. • Faster imaging and free-breathing approaches have potential to improve multiphasic dynamic imaging.
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Affiliation(s)
- Christoph J. Zech
- grid.410567.1Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Ahmed Ba-Ssalamah
- grid.22937.3d0000 0000 9259 8492Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Berg
- grid.411339.d0000 0000 8517 9062Section of Hepatology, Clinic for Neurology; Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Hersh Chandarana
- grid.137628.90000 0004 1936 8753Center for Advanced Imaging Innovation and Research (CAI2R), Department of Radiology, New York University School of Medicine, New York, NY 10016 USA
- grid.137628.90000 0004 1936 8753Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University School of Medicine, New York, NY 10016 USA
| | - Gar-Yang Chau
- grid.260770.40000 0001 0425 5914Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, 112 Taiwan
| | - Luigi Grazioli
- grid.412725.7Department of Radiology, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Myeong-Jin Kim
- grid.15444.300000 0004 0470 5454Department of Radiology, Yonsei University College of Medicine, Seoul, 120-752 South Korea
| | - Jeong Min Lee
- grid.412484.f0000 0001 0302 820XDepartment of Radiology, Seoul National University Hospital, Seoul, 110-744 South Korea
| | - Elmar M. Merkle
- grid.410567.1Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Takamichi Murakami
- grid.31432.370000 0001 1092 3077Department of Diagnostic and Interventional Radiology, Kobe University Graduate School of Medicine, Kobe, 650-0017 Japan
| | - Jens Ricke
- grid.5252.00000 0004 1936 973XKlinik und Poliklinik für Radiologie, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Claude B. Sirlin
- grid.266100.30000 0001 2107 4242Liver Imaging Group, University of California San Diego, San Diego, CA 92093-0888 USA
| | - Bin Song
- grid.13291.380000 0001 0807 1581Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Bachir Taouli
- grid.59734.3c0000 0001 0670 2351Department of Diagnostic, Molecular and Interventional Radiology and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 USA
| | - Kengo Yoshimitsu
- grid.411497.e0000 0001 0672 2176Department of Radiology, Fukuoka University Faculty of Medicine, Fukuoka City, 801-1011 Japan
| | - Dow-Mu Koh
- grid.18886.3f0000 0001 1271 4623Department of Radiology, Royal Marsden Hospital and The Institute of Cancer Research, London, SM2 5NG UK
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