Focal Liver Lesions Research Articles

Shear-wave elastography combined with contrast-enhanced ultrasound algorithm for noninvasive characterization of focal liver lesions.

To establish shear-wave elastography (SWE) combined with contrast-enhanced ultrasound (CEUS) algorithm (SCCA) and improve the diagnostic performance in differentiating focal liver lesions (FLLs). We retrospectively selected patients with FLLs between January 2018 and December 2019 at the First Affiliated Hospital of Sun Yat-sen University. Histopathology was used as a standard criterion except for hemangiomas and focal nodular hyperplasia. CEUS with SonoVue (Bracco Imaging) and SCCA combining CEUS and maximum value of elastography with < 20kPa and > 90kPa thresholds were used for the diagnosis of FLLs. The diagnostic performance of CEUS and SCCA was calculated and compared. A total of 171 FLLs were included, with 124 malignant FLLs and 47 benign FLLs. The area under curve (AUC), sensitivity, and specificity in detecting malignant FLLs were 0.83, 91.94%, and 74.47% for CEUS, respectively, and 0.89, 91.94%, and 85.11% for SCCA, respectively. The AUC of SCCA was significantly higher than that of CEUS (P = 0.019). Decision curves indicated that SCCA provided greater clinical benefits. The SCCA provided significantly improved prediction of clinical outcomes, with a net reclassification improvement index of 10.64% (P = 0.018) and integrated discrimination improvement of 0.106 (P = 0.019). For subgroup analysis, we divided the FLLs into a chronic-liver-disease group (n = 88 FLLs) and a normal-liver group (n = 83 FLLs) according to the liver background. In the chronic-liver-disease group, there were no differences between the CEUS-based and SCCA diagnoses. In the normal-liver group, the AUC of SCCA and CEUS in the characterization of FLLs were 0.89 and 0.83, respectively (P = 0.018). SCCA is a feasible tool for differentiating FLLs in patients with normal liver backgrounds. Further investigations are necessary to validate the universality of this algorithm.

The Role of Computed Tomography Perfusion in Various Focal Liver Lesions.

Background This study aims to identify the potential advantages of quantitative determination of various focal liver pathologies, identify lesion hemodynamics, and distinguish benign and malignant pathologies based on CT perfusion (CTP) parameters. Methodology In this study, we examined 36 patients using contrast-enhanced CT (CECT) and proposed inclusion and exclusion criteria. Of the 36 patients, 18 had malignant lesions and 14 had benign lesions. CTP was performed on patients comprising cases of hepatocellular carcinoma (HCC), metastasis, hemangiomas, hepatic cysts, and hepatic abscess. Images were post-processed and analyzed to calculate various perfusion parameters such as blood flow (BF), blood volume (BV), permeability surface (PS), mean transit time (MTT), the hepatic arterial fraction (HAF), and induced residue fraction time of onset (IRFTO). Parameters were compared between benign and malignant lesions, and descriptive analysis was performed for individual lesions. Results Data were analyzed with IBM SPSS Statistics (IBM Corp., Armonk, NY, USA). IRFTO showed the area of the curve (AOC) = 0.659, P-value = 0.040, sensitivity 66.7%, and specificity 64.3%. BV showed AOC = 0.659, P-value = 0.040, with a cutoff value of 1.26, sensitivity of 66.7%, and specificity of 64.3%. BF showed AOC = 0.786 andP-value = 0.006, with a cutoff value of 171.2, sensitivity of 83.3%, and specificity of 78.6%. MTT showed AOC = 0.778 andP-value = 0.008, with a cutoff value of 6.94, sensitivity of 77.8%, and specificity of 78.6%. Statistically significant changes were observed in the perfusion parameters in the BV, BF, MTT, and IRFTO. Conclusions The noninvasive CT liver perfusion technique makes it possible to compare the hemodynamic changes in healthy and sick liver tissues, identify focal liver lesions, and evaluate the effectiveness of tumor therapy.

Applicability of multidimensional convolutional neural networks on automated detection of diverse focal liver lesions in multiphase CT images.

To investigate the applicability of multidimensional convolutional neural networks (CNNs) together with multiphase contrast-enhanced CT images on automated detection of diverse focal liver lesions (FLLs). We trained detection models based on 2.5D and 3D CNN frameworks using 567 patients with 3892 FLLs and validated on a relatively large independent cohort of 1436 patients with 4723 lesions. The detection performance across different phases (arterial, portal venous [PV], and combined phases) was assessed for the 2.5D model. The lesions were divided into two groups with a cutoff size of 20mm, and further subdivided into four subgroups of<10, 10-20, 20-50, and ≥50mm, to verify the detection rates for lesions of different sizes for the 2.5D and 3D models. McNemar's test was used to compare the detection sensitivities among different methods. In addition, sensitivity with 95% confidence intervals and free-response receiver operating characteristics (FROC) curves were plotted for visualization of the detectability. In the 2.5D model, the detection rate of PV phase outperformed arterial phase, and a combination of the two phases further improved the performance over a single phase. The detection sensitivities in the arterial, PV, and combined phases were 0.737versus 0.802versus 0.832 for all lesions. The 3D model was superior to the 2.5D model for detecting benign lesions (0.896vs. 0.807, p<0.001), malignant lesions (0.940vs. 0.918, p=0.013), and all lesions (0.902vs. 0.832, p<0.001) regardless of size division. Particularly, the 3D model showed higher sensitivity than the 2.5D model in detecting lesions smaller than 20mm (0.868vs. 0.759, p<0.001). For lesions larger than 20mm, both the 3D and the 2.5D models achieved excellent detection performance. The proposed CNN detection model was demonstrated to adaptively learn the feature representations of diverse FLLs and generalize well to a large-scale validation dataset. The use of multiphase significantly improved the detectability of FLLs compared to single phase. 3D CNN framework showed an enhanced capability over the 2.5D in the detection of FLLs, particularly small lesions. The promising performance shows that the proposed CNN detection system could be a powerful clinical tool for the early detection of hepatic tumors.

Diagnostic Performance of Contrast Enhanced CT Alone or in Combination with (Non-)Enhanced MRI for Colorectal Liver Metastasis

To compare the diagnostic performance of contrast enhanced CT (CE-CT), CE-CT combined with non-enhanced MRI (NE-MRI) or contrast enhanced MRI (CE-MRI) for colorectal liver metastasis (CRLM). Sixty-six colorectal cancer patients with 198 focal liver lesions who underwent preoperative abdominal CE-CT and MRI examinations were included respectively. The images were assessed independently by two readers in three protocols (1: CE-CT, 2: CE-CT+NE-MRI, 3: CE-CT+CE-MRI). The diagnostic performance of each protocol was analyzed by receiver operating characteristic (ROC) curve and the areas under ROC (AUCs) were calculated and compared. The detection rates of protocol 2 were 90.9%-92.9% for liver lesions and 86.4%-89.6% for CRLM, and both significantly higher than protocol 1 of 82.8%-85.4% and 76.8%-80.8% (p<0.001-0.001), whereas similar to protocol 3 of 91.9%-94.4% and 87.2%-91.2% (p 0.250-1.000). The AUCs of protocol 2 were greater than protocol 1 for all lesions (0.914-0.934 vs. 0.779-0.799, p<0.001) and lesions < 10mm (0.726-0.776 vs. 0.528-0.561, p<0.001), and were not inferior to that of protocol 3 (0.929-0.949 in all lesions and 0.754-0.821 in lesion < 10mm, p 0.053-0.162). CE-CT combined with NE-MRI offered superior diagnostic performance for CRLM compared to CE-CT alone and showed comparable performance to CE-CT combined with CE-MRI.

Artificial intelligence-based ultrasound imaging technologies for hepatic diseases

Ultrasound (US) imaging is a non-invasive, real-time, economical, and convenient imaging modality that has been widely used in diagnosing and treating hepatic diseases. Artificial intelligence (AI) technology can predict or make decisions based on the experience of clinical experts and knowledge obtained from training data. This technology can help clinicians improve the detection efficiency and evaluate hepatic diseases, promote clinical treatment of the liver, and predict the response of the liver after treatment. This review summarizes the current rapid development of US technology and related AI methods in the diagnosis and treatment of hepatic diseases. Covered topics include steatosis grading, fibrosis staging, detection of focal liver lesions, US image segmentation, multimodal image registration, and other applications. At present, the field of AI in US imaging is still in its early stages. With future progress of AI technology, AI-based US imaging can further improve diagnosis, reduce medical costs, and optimize US-based clinical workflow. This technology has broad prospects for application to hepatic diseases.

Can Shearwave Elastography as an Adjunct Non-Invasive Technique to Ultrasound Help in Better Characterization of Focal Liver Lesions?

Can Shearwave Elastography as an Adjunct Non-Invasive Technique to Ultrasound Help in Better Characterization of Focal Liver Lesions?

Diagnostic Accuracy of Triphasic CT in the Characterization of Incidental Focal Liver Lesions

Objectives: To determine the diagnostic accuracy of triphasic CT in the diagnosis of focal liver lesions as benign or malignant by using histopathology as the gold standard. Methods: This descriptive cross-sectional study was carried out at the diagnostic radiology department of the Pakistan Institute of Medical Sciences (P.I.M.S.) in Islamabad.110 individuals with localized liver lesions between the ages of 15 and 65 years and both genders were included. All of the study subjects were then undergoing triphasic CT scan of the liver. The CT findings were recorded as benign or malignant and correlated with histopathology findings. Data collection was done by using the self-structured proforma. Results: Patient’s mean age was 43.92 ± 12.87 years. Out of all, males were 68 (61.82%) and females were 42 (38.18%), with a female-to-male ratio of 1:1.6. Malignant lesions were 73 (66.36%) and 37 (33.54%) patients had benign lesions as per Triphasic CT diagnosis. Furthermore, in these 73 malignant cases, 67 cases were observed with malignant lesions and 6 cases had benign lesions on histopathology, while among the 37 CT cases of benign lesions, 8 cases had malignant lesions as per the histopathological diagnosis. Although triphasic CT showed 89.33% sensitivity and 82.86% specificity in the diagnosis of focal liver lesions by using histopathology as the gold standard. Conclusion: Triphasic CT was observed to be a non-invasive, accurate, and highly sensitive imaging technique in the diagnosis of focal liver lesions, whether (benign or malignant). Therefore, it can be used frequently to lower the number of pure diagnostic biopsies. Keywords: Malignant hepatic lesions, non-invasive, imaging modality, sensitivity

18F]FAPI PET/CT in the evaluation of focal liver lesions with [18F]FDG non-avidity.

This prospective study was aimed to investigate the potential utility of [18F]fibroblast activation protein inhibitor (FAPI) PET/CT for evaluating focal liver lesions (FLLs) with [18F]FDG non-avidity. From January 2021 to March 2022, this prospective study included 80 FLLs that were not avid on [18F]FDG PET/CT from 37 patients, then underwent [18F]FAPI PET/CT. All patients with FLL(s) with biopsy-proof or follow-up confirmation were categorized into four subgroups (20 hepatocellular carcinomas [HCCs]/5 non-HCC malignancies/4 inflammatory FLLs/8 benign noninflammatory FLLs). The diagnostic value of [18F]FAPI for detecting liver malignancy was determined by visual evaluation. Differences in the maximum standardized uptake value (SUVmax) and lesion-to-background ratio (LBR) obtained from [18F]FAPI PET/CT among the four subgroups were analyzed by semiquantitative analysis. Among the thirty-seven enrolled participants (34 males; median age 57years, range 48-67years), on visual evaluation, the sensitivity, specificity, and accuracy of [18F]FAPI PET for detecting liver malignancy in the patient-based analysis were 96.0% (24/25), 58.3% (7/12), and 83.8% (31/37), respectively. On semiquantitative analysis, the SUVmax and LBR of [18F]FAPI PET in liver malignancy (33 HCC lesions; 19 non-HCC malignant lesions) were significantly higher than those in 11 benign noninflammatory FLLs [HCC: SUVmax: 6.4 vs. 4.5, P = 0.017; LBR: 5.1 vs. 1.5, P = 0.003; non-HCC: SUVmax: 5.5 vs. 4.5, P = 0.008; LBR: 4.4 vs. 1.5, P = 0.042]. Notably, there was no significant difference in the SUVmax of [18F]FAPI PET between 33 HCC lesions and 17 inflammatory FLLs (6.4 vs. 8.2, P = 0.37), but the LBR of [18F]FAPI PET in HCC were significantly lower than that in inflammatory FLLs (5.1 vs. 9.1, P = 0.003). [18F]FAPI PET/CT shows high sensitivity in detecting HCC and non-HCC malignancy with [18F]FDG non-avidity. [18F]FAPI might be a promising radiopharmaceutical for the differential diagnosis of benign noninflammatory FLLs and liver malignancy with [18F]FDG non-avidity.

MR imaging of hepatocellular carcinoma: prospective intraindividual head-to-head comparison of the contrast agents gadoxetic acid and gadoteric acid

The routine use of dynamic-contrast-enhanced MRI (DCE-MRI) of the liver using hepatocyte-specific contrast agent (HSCA) as the standard of care for the study of focal liver lesions is not widely accepted and opponents invoke the risk of a loss in near 100% specificity of extracellular contrast agents (ECA) and the need for prospective head-to-head comparative studies evaluating the diagnostic performance of both contrast agents. The Purpose of this prospective intraindividual study was to conduct a quantitative and qualitative head-to-head comparison of DCE-MRI using HSCA and ECA in patients with liver cirrhosis and HCC. Twenty-three patients with liver cirrhosis and proven HCC underwent two 3 T-MR examinations, one with ECA (gadoteric acid) and the other with HSCA (gadoxetic acid). Signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), wash-in, wash-out, image quality, artifacts, lesion conspicuity, and major imaging features of LI-RADS v2018 were evaluated. Wash-in and wash-out were significantly stronger with ECA compared to HSCA (P < 0.001 and 0.006, respectively). During the late arterial phase (LAP), CNR was significantly lower with ECA (P = 0.005), while SNR did not differ significantly (P = 0.39). In qualitative analysis, ECA produced a better overall image quality during the portal venous phase (PVP) and delayed phase (DP) compared to HSCA (P = 0.041 and 0.008), showed less artifacts in the LAP and PVP (P = 0.003 and 0.034) and a higher lesion conspicuity in the LAP and PVP (P = 0.004 and 0.037). There was no significant difference in overall image quality during the LAP (P = 1), in artifacts and lesion conspicuity during the DP (P = 0.078 and 0.073) or in the frequency of the three major LI-RADS v2018 imaging features. In conclusion, ECA provides superior contrast of HCC—especially hypervascular HCC lesions—in DCE-MR in terms of better perceptibility of early enhancement and a stronger washout.

Evaluation of HASTE T2 weighted image with reduced echo time for detecting focal liver lesions in patients at risk of developing hepatocellular carcinoma

PurposeTo compare the image quality and performance of half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences, using compressed sensing (HASTE-CS) and deep-learning based reconstruction (HASTE-DL) in detecting focal liver lesions (FLLs), to those of T2-weighted image using BLADE sequence (T2WI) in patients at risk of developing hepatocellular carcinoma (HCC). Materials and methodsThis retrospective study included patients at risk of developing HCC who underwent liver MRI including HASTE-DL, HASTE-CS, T2WI and DWI between January and June 2020. Three radiologists independently reviewed the image quality along with FLL detection in the three T2-based sequences and DWI. Reference lesion characterization was done using the complete set of MRI sequences according to the Liver Imaging Reporting and Data System (LI-RADS) v2018. ResultsA total of 227 patients with 88 of whom had FLLs (n = 194, mean size 11.7 ± 10.9 mm) were included. HASTE-DL yielded the highest overall image quality, followed by HASTE-CS and T2WI (3.4 ± 0.5, 3.1 ± 0.6, 2.4 ± 0.5, respectively, P < 0.001 for all). In the detection of FLLs, HASTE-DL showed significantly higher sensitivity than T2WI (51.5 % vs 43.6 %, P = 0.007) whereas HASTE-CS and T2WI bore respectively little difference (P > 0.017) on per-patient basis. For LR-4, -5, -M lesions, HASTE-DL had significantly higher figure of merit than that of T2WI (0.58 vs 0.52, P < 0.001) in per-lesion basis. ConclusionHASTE-DL demonstrated better image quality and higher performance for FLL detection than conventional T2WI in patients at risk of developing HCC.

A Comprehensive Motion Compensation Method for In-Plane and Out-of-Plane Motion in Dynamic Contrast-Enhanced Ultrasound of Focal Liver Lesions.

Contrast-enhanced ultrasound (CEUS) acquisitions of focal liver lesions are affected by motion, which has an impact on contrast signal quantification. We therefore developed and tested, in a large patient cohort, a motion compensation algorithm called the Iterative Local Search Algorithm (ILSA), which can correct for both periodic and non-periodic in-plane motion and can reject frames with out-of-plane motion. CEUS cines of 183 focal liver lesions in 155 patients from three hospitals were used to develop and test ILSA. Performance was evaluated through quantitative metrics, including the root mean square error and R2 in fitting time-intensity curves and standard deviation value of B-mode intensities, computed across cine frames), and qualitative evaluation, including B-mode mean intensity projection images and parametric perfusion imaging. The median root mean square error significantly decreased from 0.032 to 0.024 (p < 0.001). Median R2 significantly increased from 0.88 to 0.93 (p < 0.001). The median standard deviation value of B-mode intensities significantly decreased from 6.2 to 5.0 (p < 0.001). B-Mode mean intensity projection images revealed improved spatial resolution. Parametric perfusion imaging also exhibited improved spatial detail and better differentiation between lesion and background liver parenchyma. ILSA can compensate for all types of motion encountered during liver CEUS, potentially improving contrast signal quantification of focal liver lesions.

Identification of the origin of tumor in vein: comparison between CEUS LI-RADS v2017 and v2016 for patients at high risk

ObjectivesTo compare the diagnostic performance of the Contrast-Enhanced Ultrasound (CEUS) Liver Imaging Report and Data System (LI-RADS) v2016 and v2017 in identifying the origin of tumor in vein (TIV).MethodsFrom April 2014 to December 2018, focal liver lesions (FLLs) accompanied by TIV formation in patients at high risk for hepatocellular carcinoma (HCC) were enrolled. Histologic evaluation or composite imaging reference standard were served as the reference standard. Each case was categorized according to the CEUS LI-RADS v2016 and v2017, respectively. Diagnostic performance of CEUS LI-RADS v2016 and v2017 in identifying the originated tumor of TIV was validated via sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value.ResultsA total of 273 FLLs with TIV were analyzed finally, including 266 HCCs and 7 non-HCCs. In v2016, when adopting all TIV as LR-5V, the accuracy and PPV in identifying the originated tumor were both 97.4%. In v2017, when assigning TIV according to contiguous FLLs CEUS LI-RADS category, the accuracy and PPV were 61.9% and 99.4% in subclass of LR-5 as the diagnostic criteria of HCC, and 64.1% and 99.4% in subclass of LR-4/5 as the criteria of HCC diagnosis. There were significant differences in diagnostic accuracy between CEUS LI-RADS v2016 and v2017 in identifying the originated tumor of TIV (p < 0.001).ConclusionsCEUS LI-RADS v2016 could be better than v2017 in identifying the originated tumor of TIV.

Optimizing Imaging of Pediatric Liver Lesions: Guidelines from the Pediatric LI-RADS Working Group.

A differential diagnosis based on a patient's age, clinical presentation, and serum α-fetoprotein level will help guide the initial imaging workup in children with a liver lesion. Children vary significantly in size, the ability to stay still, and the ability to breath hold for imaging examinations. Choosing and tailoring imaging techniques and protocols for each indication and age group is important for optimal care with minimal invasiveness. The need for sedation or anesthesia can be obviated by using techniques like feed and bundle, distraction, contrast-enhanced US, and motion-insensitive sequences for MRI. US is often the first imaging modality used in children with a suspected abdominal mass. Once a hepatic lesion is confirmed, multiphasic contrast-enhanced MRI is recommended for most lesions as the next imaging modality allowing full characterization of the lesion and assessment of the liver parenchyma. Contrast-enhanced CT can also be performed for assessment of pediatric focal liver lesions, especially in patients who have a contraindication to MRI. Contrast-enhanced US has shown promise to decrease the need for MRI or CT in some lesions such as hemangioma and focal nodular hyperplasia. Children with a history of malignancy can develop multiple types of hepatic lesions at various stages, including infections during an immunocompromised state, manifesting as focal liver lesions. Based on available limited data in the literature and the collective experiences of the Liver Imaging and Reporting Data System Pediatric Working Group, the authors provide guidelines for the imaging workup of pediatric focal liver lesions with an indication- and age-based approach and discuss the selection and performance of various imaging techniques and modalities. ©RSNA, 2022 See the invited commentary by Chojniak and Boaventura in this issue.

Hepatic benign and malignant masses in children: a single UK tertiary centre experience.

The aim of this study was to review the incidence, spectrum and investigation of liver masses presenting to our tertiary liver unit. A retrospective single-centre cohort study of paediatric patients (age < 16years) diagnosed with a liver mass who were investigated at a UK paediatric hepatobiliary tertiary referral centre. Data relating to the clinical findings at presentation, source of referral, diagnostic investigations and histopathology findings were recorded and analysed. 107 patients were identified between July 2012 and July 2019 (55 females). 69 (64%) patients had benign liver lesions, whereas the remaining 38 (36%) were found to have malignant masses. The liver lesions were most commonly detected incidentally (33%) with the second most common presentation being with palpable mass(29%). 82 (77%) patients were referred from other hospitals. All patients underwent USS, 74% MRI, 36% CT, 5% CEUS, 1% PET and 5% HIDA scan with 47% ultimately undergoing biopsy. 72% of patients had AFP measured. The most common benign liver masses were haemangioma 33 (48%), hepatic cyst 17 (25%) and FNH 12 (19%). Amongst the malignant lesions, 29 (76%) were hepatoblastoma and 3 (8%) were hepatocellular carcinoma. This large review series demonstrates that just over 1/3 of patients presenting to a paediatric tertiary referral centre with a focal liver lesion had neoplastic liver lesions, despite the published literature commonly stating that 2/3 of paediatric liver masses are malignant.

Massive Single Lesion in a Patient With Sickle Cell Disease

Massive Single Lesion in a Patient With Sickle Cell Disease

Ultrasound-based artificial intelligence in gastroenterology and hepatology.

Artificial intelligence (AI), especially deep learning, is gaining extensive attention for its excellent performance in medical image analysis. It can automatically make a quantitative assessment of complex medical images and help doctors to make more accurate diagnoses. In recent years, AI based on ultrasound has been shown to be very helpful in diffuse liver diseases and focal liver lesions, such as analyzing the severity of nonalcoholic fatty liver and the stage of liver fibrosis, identifying benign and malignant liver lesions, predicting the microvascular invasion of hepatocellular carcinoma, curative transarterial chemoembolization effect, and prognoses after thermal ablation. Moreover, AI based on endoscopic ultrasonography has been applied in some gastrointestinal diseases, such as distinguishing gastric mesenchymal tumors, detection of pancreatic cancer and intraductal papillary mucinous neoplasms, and predicting the preoperative tumor deposits in rectal cancer. This review focused on the basic technical knowledge about AI and the clinical application of AI in ultrasound of liver and gastroenterology diseases. Lastly, we discuss the challenges and future perspectives of AI.

High frame-rate contrast enhanced ultrasound (HIFR-CEUS) in the characterization of small hepatic lesions in cirrhotic patients.

To show the effectiveness of plane wave HighFrame-Rate CEUS (HiFR-CEUS) compared with "conventional" (plane wave) CEUS (C-CEUS) in the characterization of small (< 2cm) focal liver lesions (FLLs) not easily detected by CT in cirrhotic patients. HiFR-CEUS exploit an ultra-wideband nonlinear process to combine fundamental, second and higher-order harmonic signals generated by ultrasound contrast agents to increase the frame rate. C-CEUS is limited by the transmission principle, and its frame-rate is around 10 FPS. With HiFR-CEUS (Shenzhen Mindray Bio-Medical Electronics Co., China), the frame-rate reached 60 FPS. Ultrasound detected small FLLs (< 2cm) in 63 cirrhotic patients during follow-up (June 2019-February 2020); (7 nodules < 1cm and were not evaluable by spiral CT). Final diagnosis was obtained with MRI (47) or fine needle aspiration (16 cases) C-CEUS was performed and HiFR-CEUS was repeated after 5min; 0.8-1.2ml of contrast media (SonoVue, Bracco, Italy) was used. 57 nodules were better evaluable with HiFR-CEUS; 6 nodules were equally evaluable by both techniques; final diagnosis was: 44 benign lesions (29 hemangiomas, 1 amartoma, 2 hepatic cysts; 2 focal nodular hyperplasias, 3 regenerative macronodules, 3 AV-shunts, 3 hepatic sparing areas and 1 focal steatosis) and 19 malignant one (17 HCCs, 1 cholangioca, 1 metastasis); statistical evaluation for better diagnosis with X2 test (SPSS vers. 26); we used LI-RADS classification for evaluating sensitivity, specificity PPV, NPV and diagnostic accuracy of C- and HFR-CEUS. Corrispective AU-ROC were calculated. C-CEUS and HiFR-CEUS reached the same diagnosis in 29 nodules (13 nodules > 1 < 1.5cm; 16 nodules > 1.5 < 2cm); HiFR-CEUS reached a correct diagnosis in 32 nodules where C-CEUS was not diagnostic (6 nodules < 1cm; 17 nodules > 1 < 1.5cm; 9 nodules > 1.5 < 2cm); C-CEUS was better in 2 nodules (1 < 1cm and 1 > 1 < 1.5cm). Some patient's (sex, BMI, age) and nodule's characteristics (liver segment, type of diagnosis, nodule's dimensions (p = 0.65)) were not correlated with better diagnosis (p ns); only better visualization (p 0.004) was correlated; C-CEUS obtained the following LI-RADS: type-1: 18 Nodules, type-2: 21; type-3: 7, type-4: 7; type-5: 8; type-M: 2; HiFR-CEUS: type-1: 38 Nodules, type-2: 2; type-3:4, type-4: 2; type-5: 15; type-M: 2; In comparison with final diagnosis: C-CEUS: TP: 17; TN: 39; FP: 5; FN:2; HIFR-CEUS: TP: 18; TN: 41; FP: 3; FN:1; C-CEUS: sens: 89.5%; Spec: 88.6%, PPV: 77.3%; NPV: 95.1%; Diagn Acc: 88.6% (AU-ROC: 0.994 ± SEAUC: 0.127; CI: 0.969-1.019); HiHFR CEUS: sens: 94.7%; Spec: 93.2%, PPV: 85.7%; NPV: 97.6%; Diagn Acc: 93.2% (AU-ROC: 0.9958 ± SEAUC: 0.106; CI: 0.975-1.017) FLL vascularization in the arterial phase was more visible with HiFR-CEUS than with C-CEUS, capturing the perfusion details in the arterial phase due to a better temporal resolution. With a better temporal resolution, the late phase could be evaluated longer with HiFR-CEUS (4min C-CEUS vs. 5min HiFR-CEUS). Both C-CEUS and HIFR-CEUS are good non invasive imaging system for the characterization of small lesions detected during follow up of cirrhotic patients. HiFR-CEUS allowed better FLL characterization in cirrhotic patients with better temporal and spatial resolution capturing the perfusion details that cannot be easily observed with C-CEUS.

The Preliminary Application of Simultaneous Display of Contrast-Enhanced Ultrasound and Micro-Flow Imaging Technology in the Diagnosis of Hepatic Tumors.

To evaluate the value of simultaneous display of contrast-enhanced ultrasound and micro-flow imaging technology (CEUS-MFI) in intra-tumoral vessel detection and hepatic tumor diagnosis. A total of 82 patients with 82 focal liver lesions were enrolled in this study. Each patient received ultrasound exams including color Doppler flow imaging (CDFI), micro-flow imaging (MFI), contrast-enhanced ultrasound (CEUS), and CEUS-MFI with a Philips EPIQ7 ultrasound imaging system. The intra-tumoral vessels detected by CDFI, MFI, and CEUS-MFI were compared, respectively. The accuracy and confidence of using CEUS and CEUS-MFI in diagnosing hepatic tumors were also compared. CEUS-MFI was capable of detecting more hepatic intra-tumoral vessels than MFI (P=.000) and CDFI (P=.000). Compared with CEUS, CEUS-MFI improved the diagnostic accuracy of hepatic lesions (P=.009). Particularly, among the correctly diagnosed hepatic lesions, the number of cases where radiologists diagnosed with great confidence was increased from 88.4% (61/69) with CEUS only to 92.4% (73/79) with CEUS-MFI (P=.041). CEUS-MFI is sensitive in detecting hepatic intra-tumoral vessels and can improve the accuracy and confidence of radiologists in diagnosing hepatic lesions.

Application Progress of Gd-EOB-DTPA-Enhanced MRI T1 Mapping in Hepatic Diffuse Diseases.

In recent years, T1 mapping imaging based on Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) has resulted in new research and clinical applications in hepatic diseases. The objective of the study is to analyze, prospect, and summarize the Gd-EOB-DTPA- enhanced MRI T1 mapping technology in hepatic diseases in recent years. Gd-EOB-DTPA-enhanced T1 mapping has been used more frequently in liver diseases regardless of 1.5T or 3.0T MRI equipment. Volume interpolated body examination (VIBE) mapping sequence seems to be the recommended MRI scan sequence. In the evaluation of T1 value on liver function, the hepatobiliary phase 10 minutes after enhancement is the recommended time point. The fat fraction and hepatic steatosis grade based on MRI-derived biomarkers are easier to implement and popularize than a liver biopsy. Gd-EOB-DTPA-enhanced MRI T1 mapping can not only be used to evaluate the degree of liver injury, the stage of liver fibrosis, and the liver reserve function of patients with liver cirrhosis but also to distinguish focal liver lesions and predict the differentiation degree of hepatocellular carcinoma. At the same time, it has some value in predicting tumor immunohistochemical indexes, such as Ki67, CD34. Gd-EOB-DTPA-enhanced MRI T1 mapping has great potential in the application of diffuse and focal liver lesions. It is a quantitative study, trying to select homogeneous research objects and try to use the same standards in scanning sequence and scanning time, especially for the study of liver function, which is a focus of future research. The research on the relationship between T1 value and tumor immunohistochemical indexes is worth consideration.

S3098 Vanishing Bile Duct Syndrome in the Setting of Newly Diagnosed Hodgkin Lymphoma

Introduction: Vanishing bile duct syndrome (VBDS) is characterized by cholestatic liver disease in the setting of disappearing intra-hepatic bile ducts. It can resemble other forms of cholestatic liver disease; however, imaging and biochemical tests will be unrevealing. We describe a case of a woman with Hodgkin lymphoma (HL) who developed cholestatic hepatitis with loss of intra-hepatic bile ducts. Case Description/Methods: A 23-year-old woman with a history of HL who presented for evaluation and treatment of HL. Two months prior she had been treated for CMV-associated gastroenteritis and sepsis. Initial examination revealed jaundice and bilateral conjunctival icterus. Lab results showed total bilirubin of 18.1 mg/dL, ALT 363 U/L, AST 149 U/L, alkaline phosphatase (ALP) of 2392 U/L, direct bilirubin of 15.5 mg/dL, INR of 2.07, and cytomegalovirus (CMV) PCR at 670 IU/mL. Other acute viral hepatitis studies, tests for intrinsic liver disease, and autoimmune markers were negative. Computerized tomography (CT) of the abdomen and pelvis showed extensive lymphadenopathy, sclerotic changes throughout the skeleton, splenomegaly, and hepatomegaly without focal liver lesions. Magnetic resonance cholangiopancreatography (MRCP) of the abdomen showed no evidence of biliary ductal dilatation. Treatment for her HL was initiated, as well as foscarnet for her CMV viremia. Liver biopsy showed benign liver parenchyma with marked cholestasis and paucity of bile ducts, no cirrhosis, and no viral inclusions. The patient was initiated on ursodeoxycholic acid (UDCA) at 15 mg/kg/d without resolution of symptoms or cholestasis. Given no improvement in her cholestasis, the prospects of liver transplantation (LT) were discussed, but the patient was not a candidate (Figure 1). Discussion: Liver involvement in HL typically manifests as parenchymal invasion, external compression, or paraneoplastic destruction of bile ducts (VBDS). VBDS tends to signify a poor prognosis with patients frequently progressing to liver failure. The pathogenesis of VBDS in HL is not yet defined with current evidence suggesting an immune-mediated response. Typically, viral causes should be excluded. In this case, the patient did have CMV viremia. Given her prior treatment, low viral load, and absence of viral inclusions on liver biopsy, CMV was excluded as a cause. Treatment for VBDS revolves around treating the underlying cause. UDCA can be used as a temporizing measure, but, if no improvement is observed over time, patients are referred for liver transplant.Figure 1.: Parenchymal liver biopsy: (A) and (B) Lobular cholestasis. The hepatic lobules show cholestasis within the hepatocytes and bile canaliculi. (C) Paucity of intrahepatic bile duct. No bile duct is seen in the portal tract. (D) CK-7 positive hepatocytes in chronic cholestasis. The hepatocytes in this case stain positive for CK-7.