Diagnostic imaging of hepatocellular carcinoma at community hospitals and their tertiary referral center in the era of LI-RADS: a quality assessment study

PURPOSE

To assess guideline compliance and quality of hepatocellular carcinoma, (HCC) diagnostic imaging within community hospitals (CH) and their Tertiary referral center (TRC) in a moderately high incidence region.

METHODS

Initial diagnostic workup CT/MRI scans of 251 patients (122 CH, 112 TRC, 17 Non-TRC academic) with HCC over a 15-month period were assessed for Liver reporting and Data System (LI-RADS) guideline compliance. 269 scans (182 CT, 87 MRI) were qualitatively evaluated by 2 independent blinded radiologists for arterial timing, overall image quality, noise and sharpness, with quantification of interobserver variability. The contrast enhancement ratio (CER) for the largest HCC on each scan was calculated using pre- and post-contrast images.

RESULTS

103/104 (99%) of TRC and 44/78 (56%) of CH CTs adhered to LI-RADS imaging guidelines (P < 0.0001). Lack of delayed phase accounted for 32/34 (94%) of noncompliant CH CTs. Regarding MRI, 19/19 (100%) of TRC and 60/68 (88%) of CH scans were adherent (P = 0.12). For both modalities, overall image quality, noise and sharpness were rated significantly higher for TRC than CH. There was moderate interobserver agreement with intraclass correlation coefficient of 0.73, 0.70 and 0.63, respectively. Arterial-phase timing was rated adequate for CT in 75/104 TRC (72%) and 10/68 (14%) CH scans (P < 0.0001) and for MRI in 8/19 (42%) TRC and 23/68 (33%) CH scans (P = 0.17). The CER was significantly higher for TRC versus CH (2.9 vs. 1.9, P < 0.001) and MRI (0.9 vs. 0.7, P = 0.03).

CONCLUSIONS

Community hospital HCC diagnostic scans significantly lag in critical quality parameters of tumor enhancement, arterial phase timing, perceived image quality, and LI-RADS CT technique compliance compared to a TRC.

MRI features of combined hepatocellular- cholangiocarcinoma versus mass forming intrahepatic cholangiocarcinoma

BACKGROUND

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver tumor, which has overlapping imaging features with mass forming intra-hepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC). Previous studies reported imaging features more closely resemble ICC and the aim of our study was to examine the differential MRI features of cHCC-CC and ICC with emphasis on enhancement pattern observations of gadolinium enhanced MRI.

METHODS

Institutional review board approval with consent waiver was obtained for this retrospective bi-centric study. Thirty-three patients with pathologically proven cHCC-CC and thirty-eight patients with pathologically proven ICC, who had pre-operative MRI, were identified. MRI images were analyzed for tumor location and size, T1 and T2 signal characteristics, the presence/absence of: cirrhosis, intra-lesional fat, hemorrhage/hemosiderin, scar, capsular retraction, tumor thrombus, biliary dilatation, degree of arterial enhancement, enhancement pattern, pseudocapsule and washout. Associations between MRI features and tumor type were examined using the Fisher's exact and chi-square tests.

RESULTS

Strong arterial phase enhancement and the presence of: washout, washout and progression, intra-lesional fat and hemorrhage were all strongly associated with cHCC-CC (P < 0.001). While cHCC-CC had a varied enhancement pattern, the two most common enhancement patterns were peripheral persistent (n = 6) and heterogeneous hyperenhancement with washout (n = 6), compared to ICC where the most common enhancement patterns were peripheral hypoenhancement with progression (n = 18) followed by heterogeneous hypoenhancement with progression (n = 14) (P < 0.001).

CONCLUSION

The cHCC-CC enhancement pattern seems to more closely resemble HCC with the degree of arterial hyperenhancement and the presence of washout being valuable in differentiating cHCC-CC from ICC. However the presence of washout and progression, in the same lesion or a predominantly peripheral /rim hyperenhancing mass were also seen as important features that should alert the radiologist to the possibility of a cHCC-CC.

Magnetic resonance imaging appearance of soft-tissue metastases: our experience at an orthopedic oncology center

OBJECTIVE

To assess the prevalence and magnetic resonance imaging appearance of metastasis presenting as a soft-tissue mass.

MATERIALS AND METHODS

A retrospective chart review was performed on 51 patients who presented to an orthopedic oncology center with soft-tissue masses, with a histology-proven diagnosis of soft-tissue metastasis, over a 14-year period. Their magnetic resonance imaging, primary origin, and follow-up have been assessed.

RESULTS

Soft-tissue metastasis was identified in patients ranging from 18 to 85 years old. Most (80%) of the masses were located deep to the deep fascia. In our cohort of patients, melanoma was the most common primary malignancy contributing to soft-tissue metastasis (21.8%). Among soft-tissue metastasis from solid organs, breast and lung were the most frequent (9.1% each). Five patients had soft-tissue metastases from an unknown primary.

CONCLUSION

Imaging diagnosis of soft-tissue metastases is challenging as it can demonstrate imaging appearances similar to primary soft-tissue sarcoma. The presence of a known malignancy may not be evident in everyone, and even if available, histopathology will be necessary for diagnosis if this is the only site of recurrence/metastasis to differentiate from a primary soft-tissue sarcoma. Moreover, soft-tissue metastasis may be the initial presentation of a malignancy. Primary malignancies with soft-tissue metastasis carry a poor prognosis; hence, prompt diagnosis and management in essential.

Non-contrast CT at comparable dose to an abdominal radiograph in patients with acute renal colic; impact of iterative reconstruction on image quality and diagnostic performance

OBJECTIVES

The aim was to assess the performance of low-dose non-contrast CT of the urinary tract (LD-CT) acquired at radiation exposures close to that of abdominal radiography using adaptive statistical iterative reconstruction (ASiR).

METHODS

Thirty-three patients with clinically suspected renal colic were prospectively included. Conventional dose (CD-CT) and LD-CT data sets were contemporaneously acquired. LD-CT images were reconstructed with 40 %, 70 % and 90 % ASiR. Image quality was subjectively and objectively measured. Images were also clinically interpreted.

RESULTS

Mean ED was 0.48 ± 0.07 mSv for LD-CT compared with 4.43 ± 3.14 mSv for CD-CT. Increasing the percentage ASiR resulted in a step-wise reduction in mean objective noise (p < 0.001 for all comparisons). Seventy % ASiR LD-CT images had higher diagnostic acceptability and spatial resolution than 90 % ASiR LD-CT images (p < 0.001). Twenty-seven calculi (diameter = 5.5 ± 1.7 mm), including all ureteric stones, were correctly identified using 70 % ASiR LD-CT with two false positives and 16 false negatives (diameter = 2.3 ± 0.7 mm) equating to a sensitivity and specificity of 72 % and 94 %. Seventy % ASiR LD-CT had a sensitivity and specificity of 87 % and 100 % for detection of calculi >3 mm.

CONCLUSION

Reconstruction of LD-CT images with 70 % ASiR resulted in superior image quality than FBP, 40 % ASIR and 90 % ASIR. LD-CT with ASIR demonstrates high sensitivity and specificity for detection of calculi >3 mm.

TEACHING POINTS

• Low-dose CT studies for urinary calculus detection were performed with a mean dose of 0.48 ± 0.07 mSv • Low-dose CT with 70 % ASiR detected calculi >3 mm with a sensitivity and specificity of 87 % and 100 % • Reconstruction with 70 % ASiR was superior to filtered back projection, 40 % ASiR and 90 % ASiR images.

Image-guided percutaneous splenic biopsy and drainage

Percutaneous splenic biopsy and drainage are relatively safe and accurate procedures. The risk of major complication (1.3%) following percutaneous splenic biopsy does not exceed that of other solid intra-abdominal organ biopsies, and it has less morbidity and mortality than splenectomy. Both computed tomography and ultrasound can be used to provide image guidance for biopsy and drainage. The safety profile of fine-needle aspiration cytology is better than core needle biopsy, but core biopsy has superior diagnostic accuracy.

Phase II study of Spherex (degradable starch microspheres) injected into the hepatic artery in conjunction with doxorubicin and cisplatin in the treatment of advanced-stage hepatocellular carcinoma: interim analysis

Patients with advanced-stage unresectable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial doxorubicin 30 mg/m2 plus escalating doses of cisplatin up to 100 mg/m2 in conjunction with rapid bolus injection of Spherex (degradable starch microspheres; Kabi Pharmacia, Lund, Sweden) into the hepatic artery, until slowing or reversal of blood flow. Treatments were repeated every 4 to 6 weeks until progression, or were continued indefinitely if there was disease stability or response. Thirty-five evaluable patients have so far been accrued to the study. Objective tumor responses have occurred in 22 patients (63%), of whom 20 had partial responses and two had complete responses. Four of the patients had reversal of tumor-induced portal vein thrombus. Toxicities included death, one patient (and a death of uncertain cause in an additional patient); hepatitis, two patients; pancreatitis, one patient; dyspnea/hypotension, two patients; and hepatic artery nontransient thrombosis in four patients. Six patients have survived 2 years and an additional 10 patients have survived 1 year. The addition of Spherex to intrahepatic arterial chemotherapy for advanced-stage HCC appears to be relatively safe and is well tolerated even in patients with portal vein thrombosis, which represent the majority of patients with advanced-stage HCC.

Treatment of hepatic-metastatic colorectal cancer with a chemotherapeutic emulsion: interim results of a phase I trial

BACKGROUND

Hepatic arterial infusion of 5-fluoro-2-deoxyuridine (FUdR) is associated with a 60% response rate among previously untreated patients who have hepatic-metastatic colorectal cancer. One obstacle to further dose escalation has been concomitant hepatic toxicity. We are evaluating a FUdR-containing chemotherapeutic emulsion to further dose intensify therapy without associated toxicity.

METHODS

The in vitro pharmacokinetics of the emulsion were determined using high-pressure liquid chromatography (HPLC). The rate at which FUdR is released from emulsion into an overlying aqueous phase was determined in static and dynamic assays. Fifteen patients with hepatic-metastatic colorectal cancer were treated with intrahepatic arterial infusions of emulsion on a phase I dose-escalating clinical protocol. Serum collection determined systemic drug levels using HPLC.

RESULTS

In vitro studies demonstrate that FUdR is slowly released from emulsion into overlying aqueous medium. The emulsion serves as a depot for FUdR. Therapy was well tolerated. Emulsion was sequestered in the liver after infusion in all treated patients.

CONCLUSIONS

This Ethiodol-based, oil-in-water emulsion serves as a sustained-release preparation of FUdR. An Ethiodol-based oil-in-water emulsion is a clinically effective vehicle for delivering FUdR to hepatic-metastatic colorectal tumors.