Liver Imaging Reporting And Data System Research Articles

Primary hepatic neuroendocrine neoplasms: imaging characteristics and misdiagnosis analysis.

To analyze the CT and MR features of Primary hepatic neuroendocrine neoplasms (PHNENs) in order to enhance the diagnostic accuracy of this disease. A retrospective analysis was conducted on patients diagnosed with hepatic neuroendocrine neoplasms, excluding other sites of origin through general examination and postoperative follow-up. The CT and MR signs were analyzed according to the 2018 version of Liver Imaging Reporting and Data System (LI-RADS), along with causes of misdiagnosis. Twelve patients, including 6 males and 6 females, were enrolled in this study. There was no significant increase in liver tumor markers among all cases. Most masses were multiple (9/12), exhibiting low attenuation on pre-contrast CT scans, T1-hypointense signal, T2-hyperintense signal, and restricted diffusion. The majority of these masses (7/10) demonstrated similar rim arterial phase hyper-enhancement as well as peripheral "washout" during venous portal phase and delayed phase imaging. Three cases had incomplete capsules while one case had a complete capsule. Cyst/necrosis was observed in 7 out of all cases following administration of contrast agent, with 5 mainly distributed in the periphery. All masses lacked fat, calcification, vascular or bile duct tumor thrombus formation. The imaging findings associated with PHNENs possess certain specificity, often presenting as multiple masses within the liver accompanied by peripheral cyst/necrosis, similar rim arterial phase hyper-enhancement during venous portal phase and delayed phase imaging.

Locoregional Therapies for Hepatocellular Carcinoma prior to Liver Transplant: Comparative Pathologic Necrosis, Radiologic Response, and Recurrence

PurposeTo compare pathologic tumor necrosis rates after locoregional therapies (LRTs) for hepatocellular carcinoma (HCC) prior to liver transplantation and evaluate radiologic-pathologic correlation along with posttransplant HCC recurrence. Materials and MethodsConsecutive patients with solitary HCC bridged or downstaged with LRT from 2010 to 2022 were included. LRTs were transarterial chemoembolization (TACE), radioembolization (yttrium-90 [90Y]), ablation, and stereotactic body radiotherapy (SBRT). Upfront combination therapy options were TACE/ablation and TACE/SBRT. Subsequent therapy crossover due to local recurrence was allowed. Posttreatment imaging closest to the time of transplant, explant histopathologic necrosis, and tumor recurrence after transplant were reviewed. ResultsSeventy-three patients met inclusion criteria, of whom 5 (7%) required downstaging. 90Y alone (n = 36) and multimodal therapy (pooled upfront combination and crossover therapy, n = 23) resulted in significantly greater pathologic necrosis compared with TACE alone (n = 14; P = .01). High dose 90Y radiation segmentectomy (≥190 Gy; n = 27) and TACE/ablation (n = 7) showed highest rates of complete pathologic necrosis (CPN)—63% (n = 17) and 71% (n = 5), respectively. Patients with CPN had a mean lesion size of 2.5 cm, compared with 3.2 cm without CPN (P = .04), irrespective of LRT modality. HCC recurrence was more common in patients without CPN (16%, 6/37) than in those with CPN (3%, 1/36; P = .11). Using Liver Imaging Reporting and Data System (LI-RADS), a nonviable imaging response was 75% sensitive and 57% specific for CPN. ConclusionsRadiation segmentectomy and multimodal therapy significantly improved CPN rates compared with TACE alone. A LI-RADS treatment response of nonviable did not confidently predict CPN.

Complementary Role of CEUS and CT/MR LI-RADS for Diagnosis of Recurrent HCC.

We retrospectively compared the diagnostic performance of contrast-enhanced ultrasonography (CEUS) and contrast-enhanced computer tomography-magnetic resonance imaging (CT/MRI) for recurrent hepatocellular carcinoma (HCC) after curative treatment. After curative treatment with 421 ultrasound (US) detected lesions, 303 HCC patients underwent both CEUS and CT/MRI. Each lesion was assigned a Liver Imaging Reporting and Data System (LI-RADS) category according to CEUS and CT/MRI LI-RADS. Receiver-operating characteristic (ROC) curves were computed to determine the optimal diagnosis algorithms for CEUS, CT and MRI. The diagnostic accuracy, sensitivity, specificity, and area under the curve (AUC) were compared between CEUS and CT/MRI. Among the 421 lesions, 218 were diagnosed as recurrent HCC, whereas 203 lesions were diagnosed as benign. In recurrent HCC, CEUS detected more arterial hyperenhancement (APHE) and washout than CT and more APHE than MRI. CEUS yielded better diagnostic performance than CT (AUC: 0.981 vs. 0.958) (p = 0.024) comparable diagnostic performance to MRI (AUC: 0.952 vs. 0.933) (p > 0.05) when using their optimal diagnostic criteria. CEUS missed 12 recurrent HCCs, CT missed one, and MRI missed none. The detection rate of recurrent HCC on CEUS (94.8%, 218/230) was lower than that on CT/MRI (99.6%, 259/260) (p = 0.001). Lesions located on the US blind spots and visualization score C would hinder the ability of CEUS to detect recurrent HCC. CEUS demonstrated excellent diagnostic performance but an inferior detection rate for recurrent HCC. CEUS and CT/MRI played a complementary role in the detection and characterization of recurrent HCC.

Threshold growth has a limited role in differentiating hepatocellular carcinoma from other focal hepatic lesions

Background and ObjectiveThe role of threshold growth, as one of the major features (MFs) of hepatocellular carcinoma (HCC) in the Liver Imaging Reporting and Data System (LI-RADS) is inconsistent. This study evaluated the LI-RADS diagnostic performance for HCC when threshold growth was removed or replaced by independently significant ancillary features (AFs).Materials and MethodsThis retrospective institutional review board-approved study included patients with a high HCC risk who underwent gadoxetic acid-enhanced MRIs. The MRI findings were consistent with pathologically proven focal hepatic observations. The pathological results were used as the gold standard reference. The sizes of the lesions with and without threshold growth were compared. Univariate and multivariate logistic regression analyses were used to confirm the independently significant AFs of HCC. In addition to the classification criteria of LI-RADS version 2018 (LI-RADS v2018), the lesions were also reclassified according to the following two schemes: scheme A, using all MFs except threshold growth, with threshold growth feature treated as an AF favouring malignancy; and scheme B, replacing the threshold growth feature with independently significant AFs and treated them as new MFs. The diagnostic performance of the above two LI-RADS schemes for HCC was calculated and compared with that of LI-RADS v2018.ResultsA total of 379 patients and 426 observations were included. Threshold growth was not an independent significant MF for HCC diagnosis [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.6–1.8; p = 0.927]. For all three groups of observations (HCCs, non-HCC malignancies, and benign lesions), the mean size with threshold growth was smaller than that without threshold growth (all p < 0.05). The nodule-in-nodule feature was an independent significant AF (OR, 9.8; 95% CI, 1.2–79.3; p = 0.032) and was used to replace threshold growth as a new MF in scheme B. The sensitivities of schemes A and B were 74.0% and 75.6%, respectively. The specificities of schemes A and B were the same (88.6%). None of the diagnostic performance metrics for HCC (sensitivity, specificity, accuracy) of either scheme A or B was significantly different from those of LI-RADS v2018 (all p > 0.05).ConclusionThreshold growth is not an independently significant MF for HCC diagnosis. The diagnostic performance of LI-RADS for HCC is not affected regardless of whether threshold growth is removed from the list of MFs or replaced with an independently significant and more HCC-specific AF, which is the nodule-in-nodule feature.

Individual Participant Data Meta-Analysis of LR-5 in LI-RADS Version 2018 versus Revised LI-RADS for Hepatocellular Carcinoma Diagnosis.

Background A simplification of the Liver Imaging Reporting and Data System (LI-RADS) version 2018 (v2018), revised LI-RADS (rLI-RADS), has been proposed for imaging-based diagnosis of hepatocellular carcinoma (HCC). Single-site data suggest that rLI-RADS category 5 (rLR-5) improves sensitivity while maintaining positive predictive value (PPV) of the LI-RADS v2018 category 5 (LR-5), which indicates definite HCC. Purpose To compare the diagnostic performance of LI-RADS v2018 and rLI-RADS in a multicenter data set of patients at risk for HCC by performing an individual patient data meta-analysis. Materials and Methods Multiple databases were searched for studies published from January 2014 to January 2022 that evaluated the diagnostic performance of any version of LI-RADS at CT or MRI for diagnosing HCC. An individual patient data meta-analysis method was applied to observations from the identified studies. Quality Assessment of Diagnostic Accuracy Studies version 2 was applied to determine study risk of bias. Observations were categorized according to major features and either LI-RADS v2018 or rLI-RADS assignments. Diagnostic accuracies of category 5 for each system were calculated using generalized linear mixed models and compared using the likelihood ratio test for sensitivity and the Wald test for PPV. Results Twenty-four studies, including 3840 patients and 4727 observations, were analyzed. The median observation size was 19 mm (IQR, 11-30 mm). rLR-5 showed higher sensitivity compared with LR-5 (70.6% [95% CI: 60.7, 78.9] vs 61.3% [95% CI: 45.9, 74.7]; P < .001), with similar PPV (90.7% vs 92.3%; P = .55). In studies with low risk of bias (n = 4; 1031 observations), rLR-5 also achieved a higher sensitivity than LR-5 (72.3% [95% CI: 63.9, 80.1] vs 66.9% [95% CI: 58.2, 74.5]; P = .02), with similar PPV (83.1% vs 88.7%; P = .47). Conclusion rLR-5 achieved a higher sensitivity for identifying HCC than LR-5 while maintaining a comparable PPV at 90% or more, matching the results presented in the original rLI-RADS study. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Sirlin and Chernyak in this issue.

Hepatocellular Carcinoma: Optimal Radiological Evaluation before Liver Transplantation.

Liver transplantation (LT) is the recommended curative-intent treatment for patients with early or intermediate-stage hepatocellular carcinoma (HCC) who are ineligible for resection. Imaging plays a central role in staging and for selecting the best LT candidates. This review will discuss recent developments in pre-LT imaging assessment, in particular LT eligibility criteria on imaging, the technical requirements and the diagnostic performance of imaging for the pre-LT diagnosis of HCC including the recent Liver Imaging Reporting and Data System (LI-RADS) criteria, the evaluation of the response to locoregional therapy, as well as the non-invasive prediction of HCC aggressiveness and its impact on the outcome of LT. We will also briefly discuss the role of nuclear medicine in the pre-LT evaluation and the emerging role of artificial intelligence models in patients with HCC.

Diagnostic Performance of Modified Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System in Patients Without Risk Factors for Hepatocellular Carcinoma: Comparison With World Federation for Ultrasound in Medicine and Biology Guideline

The aim of this study was to assess the ability of the modified contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) to distinguish malignancy in patients without known hepatocellular carcinoma (HCC) risk factors and compare diagnostic accuracy with that of the World Federation for Ultrasound in Medicine and Biology (WFUMB) guideline across radiologists with different levels of CEUS experience. A total of 848 individuals with no hepatitis infection presenting with 870 lesions in non-cirrhotic livers were included and divided into the Testing and Validation groups. The modified CEUS LI-RADS was proposed, including downgrading of focal nodular hyperplasia with typical features. Diagnostic performance of the modified CEUS LI-RADS was assessed in the Testing group. In the Validation group, two radiologists with more than 9 y of CEUS experience (Experts) and two radiologists with less than 6 mo of CEUS experience (Novices) used both the modified CEUS LI-RADS and the WFUMB guideline to evaluate performance in diagnosis of the lesions. LR-5+M (combination of modified LR-5 and modified LR-M) revealed optimal performance with a sensitivity, specificity and area under the curve (AUC) of 99.3%, 81.6% and 0.904, respectively. Novices using the modified CEUS LI-RADS outperformed those using the WFUMB guideline (AUC: 0.858 vs. 0.767, p=0.005). Additionally, the sensitivity, specificity and AUC of Novices were comparable to those of Experts using the modified CEUS LI-RADS (94.1%, 77.6% and 0.858 vs. 96.1%, 77.6% and 0.868 for experts, respectively). The modified CEUS LI-RADS is a valuable method for distinguishing hepatic malignancy in patients without HCC risk factors. This is particularly beneficial for radiologists with limited CEUS expertise.

A surveillance for advanced liver disease and characterization of hyperechogenic lesions after Fontan surgery in a prospective cohort of cases with congenital univentricular heart

Abstract Background The congenital univentricular heart (UH) is a rare disease corrected with the palliative Fontan’s intervention, that restores the survival of most child and young patients up to adultwood. Unlikely, these patients develop a series of complications, among all, the Fontan associated liver disease (FALD), that causes the occurrence of liver cirrhosis and hepatocellular carcinoma (HCC), that negatively impacts the life expectancy in the majority of cases. Purpose Our primary aim was to identify the presence of severe FALD in our patients by liver fibrosis and portal hypertension scores (FORNS, liver and spleen-platelet score or LSPS and SSPS), and by liver (LS) and spleen (SS) stiffness measurement in relation to time since Fontan, and secondarly to characterize all the abdominal-US hyperechogenic lesions (US-HL) according to the LI-RADS (LR) CT/MRI categories. Method One-hundred-46 outpatients (83 m/63 f, aged 25,2±11.0 yrs) born with UH corrected with Fontan circuit have been recruited prospectively from 2019 to 2023 (FUmean 24.5±15.1 mos). Each patient underwent a complete clinical history and instrumental examination, by imaging obtained with US, CT and MRI, a specific lab-test profile, and the LS and SS evaluation by transient elastography (VCTE, Fibroscan). ROC curves were built to select the scores cut-off proved to be the most accurate to diagnose and grade FALD. Based on the presence of US-HL found in 43 cases (29,5%), we grouped: 23 cases with LR-1 or 2 (benign), 15 with LR-3 (suspect) and 5 with LR-4 or 5 (malign). Results Features for definition of failing-Fontan appeared in 17.5%, 47.5% and 80% of cases with &amp;lt;15; 15-25 or &amp;gt;25yrs since Fontan surgery, respectively (p&amp;lt;0.01). All the scores used (FORNS with cut-off ≥4, LSPS ≥1.4, SSPS ≥2.3, LS ≥20.2 and SS ≥30.7) showed high sensitivity and specificity, improving FALD diagnostic accuracy and staging (all p&amp;lt;0.001). Moreover by identification of selective criteria related to advanced liver disease and portal hypertension, we applied a novel risk-score for failing-Fontan, that predicted a low-moderate risk profile (HR 0.30;CI 0.18-0.52) in 72 patients and a high risk profile (HR 3,29,CI 1.93-5.60) in 74 (51%). During FU, 13 patients (8.9%) died, 5 received OHT (3.4%) and 5 had HCC occurrence (3.4%). Finally, cases with US-HL stratified by classes LR-3-4-5 (20 cases, 46.5%) appeared significantly associated with a more advanced FALD (16/4, 75% vs. 68/58, 46%; p=0,004) and a longer time since Fontan (26.3±9.4 vs. 19.8±10.8; p=0,025). Conclusion The novel risk score proposed may help to predict the development of cirrhosis in high risk patients and focussed on the need for surveillance by imaging methods to characterized the US-HL, that appeared at risk of malignity (nodule size &amp;gt;20mm and/or presence of wash-out into portal-hepatocellular phase or into LR ≥3 classes).

Machine Learning-Based CEMRI Radiomics Integrating LI-RADS Features Achieves Optimal Evaluation of Hepatocellular Carcinoma Differentiation.

To develop and compare various machine learning (ML) classifiers that employ radiomics extracted from contrast-enhanced magnetic resonance imaging (CEMRI) for diagnosing pathological differentiation of hepatocellular carcinoma (HCC), and validate the performance of the best model. A total of 251 patients with HCCs (n = 262) were assigned to a training (n = 200) cohort and a validation (n = 62) cohort. A collectionof 5502 radiomics signatures were extracted from the CEMRI images for each HCC nodule. To reduce redundancy and dimensionality, Spearman rank correlation, minimum redundancy maximum relevance (mRMR), and the least absolute shrinkage and selection operator (LASSO) approach were employed. Eight ML classifiers were trained to obtain the best radiomics model. The performance of each model was evaluated based on the area under the receiver operating characteristic curve (AUC). The radiomics model was integrated with liver imaging reporting and data system (LI-RADS) features to design a combined model. The eXtreme Gradient Boosting (XGBoost)-based radiomics model outperformed other ML classifiers in evaluating pHCC, achieving an AUC of 1.00 and accuracy of 1.00 in the training cohort. The LI-RADS model demonstrated an AUC value of 0.77 and 0.82 in the training and validation cohorts. The combined model exhibited best performance in both the training and validation cohorts, with AUCs of 1.00 and 0.86 for evaluating HCC differentiation, respectively. CEMRI radiomics integrating LI-RADS features demonstrated excellent performance in evaluating HCC differentiation, suggesting an optimal clinical decision tool for individualized diagnosis of HCC differentiation.

A model incorporating clinicopathologic and liver imaging reporting and data system-based magnetic resonance imaging features to identify hepatocellular carcinoma in LR-M observations.

To evaluate the predictive value of a combination model of Liver Imaging Reporting and Data System (LI-RADS)-based magnetic resonance imaging (MRI) and clinicopathologic features to identify atypical hepatocellular carcinoma (HCC) in LI-RADS category M (LR-M) observations. A total of 105 patients with HCC based on surgery or biopsy who underwent preoperative MRI were retrospectively reviewed in the training group from hospital-1 between December 2016 and November 2020. The LI-RADS-based MRI features and clinicopathologic data were compared between LR-M HCC and non-HCC groups. Univariate and least absolute shrinkage and selection operator regression analyses were used to select the features. Binary logistic regression analysis was then conducted to estimate potential predictors of atypical HCC. A predictive nomogram was established based on the combination of MRI and clinicopathologic features and further validated using an independent external set of data from hospital-2. Of 113 observations from 105 patients (mean age, 61 years; 77 men) in the training set, 47 (41.59%) were classified as LR-M HCC. Following multivariate analysis, aspartate aminotransferase >40 U/L [odds ratio (OR): 4.65], alpha-fetoprotein >20 ng/mL (OR: 13.04), surface retraction (OR: 0.16), enhancing capsule (OR: 5.24), blood products in mass (OR: 8.2), and iso/hypoenhancement on delayed phase (OR: 10.26) were found to be independently correlated with LR-M HCC. The corresponding area under the curve for a combined model-based nomogram was 0.95 in the training patients (n = 113) and 0.90 in the validation cohort (n = 53). The combined model incorporating clinicopathologic and MRI features demonstrated a satisfactory prediction result for LR-M HCC.

Evaluation Of Patients With Liver Biopsy According To The Liver Imaging- Reporting And Data System (LIRADS)

Evaluation Of Patients With Liver Biopsy According To The Liver Imaging- Reporting And Data System (LIRADS)

Hepatocellular Carcinoma: Surveillance, Diagnosis, Evaluation and Management.

Hepatocellular carcinoma (HCC) ranks fourth in cancer-related deaths worldwide. Semiannual surveillance of the disease for patients with cirrhosis or hepatitis B virus allows for early detection with more favorable outcomes. The current underuse of surveillance programs demonstrates the need for intervention at both the patient and provider level. Mail outreach along with navigation provision has proven to increase surveillance follow-up in patients, while provider-targeted electronic medical record reminders and compliance reports have increased provider awareness of HCC surveillance. Imaging is the primary mode of diagnosis in HCC with The Liver Imaging Reporting and Data System (LI-RADS) being a widely accepted comprehensive system that standardizes the reporting and data collection for HCC. The management of HCC is complex and requires multidisciplinary team evaluation of each patient based on their preference, the state of the disease, and the available medical and surgical interventions. Staging systems are useful in determining the appropriate intervention for HCC. Early-stage HCC is best managed by curative treatment modalities, such as liver resection, transplant, or ablation. For intermediate stages of the disease, transarterial local regional therapies can be applied. Advanced stages of the disease are treated with systemic therapies, for which there have been recent advances with new drug combinations. Previously sorafenib was the mainstay systemic treatment, but the recent introduction of atezolizumab plus bevacizumab proves to have a greater impact on overall survival. Although there is a current lack of improved outcomes in Phase III trials, neoadjuvant therapies are a potential avenue for HCC management in the future.

Proliferative hepatocellular carcinomas in cirrhosis: patient outcomes of LI-RADS category 4/5 and category M.

We aimed to compare Liver Imaging Reporting and Data System (LI-RADS) category 4/5 and category M (LR-M) of proliferative hepatocellular carcinomas (HCCs) in cirrhotic patients and evaluate their impacts on prognosis. This retrospective multi-reader study included cirrhotic patients with single treatment-naïve HCC ≤ 5.0cm who underwent contrast-enhanced CT, MRI, and subsequent hepatic resection within 2months. The percentages of CT/MRI LR-4/5 and LR-M in proliferative and non-proliferative HCCs were compared. Univariable and multivariable Cox proportional hazards regression analyses were performed to assess the association of LI-RADS categories (LR-4/5 vs. LR-M) and pathologic classification (proliferative vs. non-proliferative) with overall survival (OS) and recurrence-free survival (RFS). Subgroups of patients with proliferative and non-proliferative HCCs were analyzed to compare OS and RFS between LR-4/5 and LR-M. Of the 204 included patients, 38 were classified as having proliferative HCC. The percentages of LR-M were higher in proliferative than non-proliferative HCC on both CT (15.8% vs. 3.0%, p = 0.007) and MRI (26.3% vs. 9.6%, p = 0.016). Independent of pathologic classification, CT and MRI LR-M were significantly associated with poorer OS (hazard ratio (HR) = 4.58, p = 0.013, and HR = 6.45, p < 0.001) and RFS (HR = 3.66, p = 0.005, and HR = 6.44, p < 0.001) than LR-4/5. MRI LR-M was associated with significantly poorer OS (p ≤ 0.003) and RFS (p < 0.001) than MRI LR-4/5 in both proliferative and non-proliferative HCCs. This multi-reader study showed that the percentages of LR-M were significantly higher in proliferative than non-proliferative HCCs. CT/MRI LR-M was significantly associated with poor OS and RFS, independent of the pathologic classification of proliferative versus non-proliferative HCCs. CT and MRI LI-RADS category M can be clinically useful in predicting poor outcomes in patients with proliferative and non-proliferative hepatocellular carcinomas. • The percentages of LR-M tumors on both CT and MRI were significantly higher in proliferative than non-proliferative hepatocellular carcinomas. • Independent of pathologic classification, CT/MRI LR-M categories were correlated with poor overall survival and recurrence-free survival. • Patients with both proliferative and non-proliferative hepatocellular carcinomas categorized as MRI LR-M had significantly poorer overall survival and recurrence-free survival than those categorized as MRI LR-4/5.

Best Practice for MRI Diagnostic Accuracy Research With Lessons and Examples from the LI-RADS Individual Participant Data Group.

Medical imaging diagnostic test accuracy research is strengthened by adhering to best practices for study design, data collection, data documentation, and study reporting. In this review, key elements of such research are discussed, and specific recommendations provided for optimizing diagnostic accuracy study execution to improve uniformity, minimize common sources of bias and avoid potential pitfalls. Examples are provided regarding study methodology and data collection practices based on insights gained by the liver imaging reporting and data system (LI-RADS) individual participant data group, who have evaluated raw data from numerous MRI diagnostic accuracy studies for risk of bias and data integrity. The goal of this review is to outline strategies for investigators to improve research practices, and to help reviewers and readers better contextualize a study's findings while understanding its limitations. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 3.

Liver Imaging Reporting and Data System version 2018 for diagnosing hepatocellular carcinoma in alcoholic liver cirrhosis and virus-related cirrhosis

PurposeWe aimed to evaluate and compare the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS) v2018 for hepatocellular carcinoma (HCC) ≤ 3.0 cm on gadoxetic acid-enhanced MRI according to the etiology of cirrhosis. MethodsThirty-eight patients with alcoholic liver cirrhosis (ALC) and 37 with hepatitis C virus-related cirrhosis (HCV) who underwent preoperative MRI and subsequent surgical resection or transplantation were included. For comparison groups, patients with hepatitis B virus-related cirrhosis (HBV) were included by 1:1 matching with HCV and ALC groups according to age, lesion size, and Child–Pugh classification. The imaging characteristics of background liver and focal lesions were analyzed. The diagnostic performance of LI-RADS was compared between HCV and HBV groups, and between ALC and HBV groups. ResultsALC group showed significantly higher frequency of hepatic steatosis (25.8 % vs. 6.1 %, p =.04) and lower frequency of nonperipheral washout on portal venous-phase in HCC (63.2 % vs. 97.1 %, p <.001) compared with HBV group. ALC group showed significantly lower sensitivity than HBV group (52.6 % vs. 88.6 %, p<.001). No significant differences in diagnostic performance were found between HCV and HBV groups. In ALC group, hepatobiliary-phase hypointensity provided significantly higher sensitivity (76.3 % vs. 52.6 %, p =.008). ConclusionThe sensitivity of LI-RADS for diagnosing HCC ≤ 3.0 cm was significantly lower in the ALC group than in the HBV group.

Can absolute arterial phase hyperenhancement improve sensitivity of detection of hepatocellular carcinoma in indeterminate nodules on CT?

To determine if quantitative assessment of relative (R) and absolute (A) arterial phase hyperenhancement (APHE) and washout (WO) applied to indeterminate nodules on CT would improve the overall sensitivity of detection of hepatocellular carcinoma (HCC). One-hundred and fourteen patients (90 male; mean age, 65years) with 210 treatment-naïve HCC nodules (190 HCCs, 20 benign) who underwent 4-phase CT were included in this retrospective study. Four radiologists independently assigned a qualitative LR (LI-RADS) category per nodule. LR-3/4 nodules were then quantitatively analyzed by the 4 readers, placing ROIs within nodules and adjacent liver parenchyma. A/R-APHE and WO were calculated, and per-reader sensitivity and specificity updated. Interobserver agreement and AUCs were calculated per reader. Qualitative readers 1-4 categorized 57, 69, 57, and 63 nodules as LR-3/4 respectively with moderate to substantial agreement in LR category (kappa 0.56-0.69, p < 0.0001); their diagnostic performances in the detection of HCC were 80%, 73.2%, 77.4%, and 77.4% sensitivity, and 100%, 95%, 70%, and 100% specificity, respectively. A threshold of ≥ 20 HU for A-APHE increased overall sensitivity of HCC detection by 0.5-3.1% without changing specificity for the subset of nodules APHE - /WO + on qualitative read, with 2, 6, 6, and 1 additional HCC detected by readers 1-4. Relative and various A-WO formulae and thresholds all increased sensitivity, but with a drop in specificity for some/all readers. Quantitatively assessed A-APHE showed potential to increase sensitivity and maintain specificity of HCC diagnosis when selectively applied to indeterminate nodules demonstrating WO without subjective APHE. Quantitatively assessed R and A-WO increased sensitivity, however reduced specificity. A workflow using selective quantification of absolute arterial enhancement is routinely employed in the CT assessment of renal and adrenal nodules. Quantitatively assessed absolute arterial enhancement is a simple tool which may be used as an adjunct to help increase sensitivity and maintain specificity of HCC diagnosis in indeterminate nodules demonstrating WO without subjective APHE. • In indeterminate nodules categorized as LI-RADS 3/4 due to absent subjective arterial phase hyperenhancement, a cut-off for absolute arterial phase hyperenhancement of ≥ 20 HU may increase the overall sensitivity of detection of HCC by 0.5-3.1% without affecting specificity. • Relative and various absolute washout formulae and cut-offs increased sensitivity of HCC detection, but with a drop in specificity for some/all readers.

A multivariate model based on gadoxetic acid-enhanced MRI using Li-RADS v2018 and other imaging features for preoperative prediction of dual‑phenotype hepatocellular carcinoma.

To investigate the diagnostic value of liver imaging reporting and data system (LI-RADS) v2018 and other imaging features in dual-phenotype hepatocellular carcinoma (DPHCC), establish a prediagnostic model based on gadoxetic acid-enhanced MRI, and explore the prognostic significance after surgery of the DPHCC. Preoperative enhanced MRI findings and the clinical and pathological data of patients with surgically confirmed HCC were analysed retrospectively. Image analysis was based on LI-RADS v2018 and other image features. Univariate analysis was used to screen for predictive factors of DPHCC, and multivariate logistic regression analysis was used to determine the predictive factors. A regression diagnostic model was established. Receiver operating characteristic (ROC) curve analysis was used to determine the critical value, area under curve (AUC), and the corresponding 95% confidence interval (95% CI). The diagnostic performance was verified by fivefold cross-validation. Cox regression analysis was used to determine the prognostic factors associated with early recurrence after surgical resection. In total, 158 patients were included, of whom 79 had DPHCC and 79 had non-DPHCC. Multivariate analysis showed that rim arterial phase hyperenhancement (Rim APHE) and targetoid restriction were independent risk factors for DPHCC (P < 0.05). The AUC (95% CI) of the model was 0.862 (0.807-0.918), sensitivity was 81.01%, and specificity was 89.874%. Cox regression analysis showed that DPHCC, microvascular invasion, tumour diameter, and an increase of alpha-fetoprotein were independent factors for recurrence. Rim APHE and targetoid restriction were sensitive imaging features of DPHCC before surgery, and the identification of DPHCC has important prognostic significance for early recurrence.

Quantification of Hepatocellular Carcinoma Vascular Dynamics With Contrast-Enhanced Ultrasound for LI-RADS Implementation.

The aim of this study is to describe a comprehensive contrast-enhanced ultrasound (CEUS) imaging protocol and analysis method to implement CEUS LI-RADS (Liver Imaging Reporting and Data System) in a quantifiable manner. The methods that are validated with a prospective single-center study aim to simplify CEUS LI-RADS evaluation, remove observer bias, and potentially improve the sensitivity of CEUS LI-RADS. This prospective single-center study enrolled patients with hepatocellular carcinoma (April 2021-June 2022; N = 31; mean age ± SD, 67 ± 6 years; 24 men/7 women). For each patient, at least 2 CEUS loops spanning over 5 minutes were collected for different lesion scan planes using an articulated arm to hold the transducer. Automatic respiratory gating and motion compensation algorithms removed errors due to breathing motion. The long axis of the lesion was measured in the contrast and fundamental images to capture nodule size. Parametric processing of time-intensity curve analysis on linearized data provided quantifiable information of the wash-in and washout dynamics via rise time ( RT ) and degree of washout ( DW ) parameters extracted from the time-intensity curve, respectively. A Welch t test was performed between lesion and parenchyma RT for each lesion to confirm statistically significant differences. P values for bootstrapped 95% confidence intervals of the relative degree of washout ( rDW ), ratio of DW between the lesion and surrounding parenchyma, were computed to quantify lesion washout. Coefficient of variation (COV) of RT , DW , and rDW was calculated for each patient between injections for both the lesion and surrounding parenchyma to gauge reproducibility of these metrics. Spearman rank correlation tests were performed among size, RT , DW , and rDW values to evaluate statistical dependence between the variables. The mean ± SD lesion diameter was 23 ± 8 mm. The RT for all lesions, capturing arterial phase hyperenhancement, was shorter than that of surrounding liver parenchyma ( P < 0.05). All lesions also demonstrated significant ( P < 0.05) but variable levels of washout at both 2-minute and 5-minute time points, quantified in rDW . The COV of RT for the lesion and surrounding parenchyma were both 11%, and the COV of DW and rDW at 2 and 5 minutes ranged from 22% to 31%. Statistically significant relationships between lesion and parenchyma RT and between lesion RT and lesion DW at the 2- and 5-minute time points were found ( P < 0.05). The imaging protocol and analysis method presented provide robust, quantitative metrics that describe the dynamic vascular patterns of LI-RADS 5 lesions classified as hepatocellular carcinomas. The RT of the bolus transit quantifies the arterial phase hyperenhancement, and the DW and rDW parameters quantify the washout from linearized CEUS intensity data. This unique methodology is able to implement the CEUS-LIRADS scheme in a quantifiable manner for the first time and remove its existing issues of currently being qualitative and suffering from subjective evaluations.

Surveillance and treatment of primary hepatocellular carcinoma (aka. STOP HCC): protocol for a prospective cohort study of high-risk patients for HCC using GALAD-score

BackgroundVietnam and Saudi Arabia have high disease burden of primary hepatocellular carcinoma (HCC). Early detection in asymptomatic patients at risk for HCC is a strategy to improve survival outcomes in HCC management. GALAD score, a serum-based panel, has demonstrated promising clinical utility in HCC management. However, in order to ascertain its potential role in the surveillance of the early detection of HCC, GALAD needs to be validated prospectively for clinical surveillance of HCC (i.e., phase IV biomarker validation study). Thus, we propose to conduct a phase IV biomarker validation study to prospectively survey a cohort of patients with advanced fibrosis or compensated cirrhosis, irrespective of etiologies, using semi-annual abdominal ultrasound and GALAD score for five years.MethodsWe plan to recruit a cohort of 1,600 patients, male or female, with advanced fibrosis or cirrhosis (i.e., F3 or F4) and MELD ≤ 15, in Vietnam and Saudi Arabia (n = 800 each). Individuals with a liver mass ≥ 1 cm in diameter, elevated alpha-fetoprotein (AFP) (≥ 9 ng/mL), and/or elevated GALAD score (≥ -0.63) will be scanned with dynamic contrast-enhanced magnetic resonance imaging (MRI), and a diagnosis of HCC will be made by Liver Imaging Reporting and Data System (LiRADS) assessment (LiRADS-5). Additionally, those who do not exhibit abnormal imaging findings, elevated AFP titer, and/or elevated GALAD score will obtain a dynamic contrast-enhanced MRI annually for five years to assess for HCC. Only MRI nearest to the time of GALAD score measurement, ultrasound and/or AFP evaluation will be included in the diagnostic validation analysis. MRI will be replaced with an abdominal computed tomography scan when MRI results are poor due to patient conditions such as movement etc. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced MRI will not be carried out in study sites in both countries. Bootstrap resampling technique will be used to account for repeated measures to estimate standard errors and confidence intervals. Additionally, we will use the Cox proportional hazards regression model with covariates tailored to the hypothesis under investigation for time-to-HCC data as predicted by time-varying biomarker data.DiscussionThe present work will evaluate the performance of GALAD score in early detection of liver cancer. Furthermore, by leveraging the prospective cohort, we will establish a biorepository of longitudinally collected biospecimens from patients with advanced fibrosis or cirrhosis to be used as a reference set for future research in early detection of HCC in the two countries.Trial registrationName of the registry: ClinicalTrials.govRegistration date: 22 April 2022Trial registration number: NCT05342350URL of trial registry record

Differences between CEUS LI-RADS and CECT LI-RADS in the diagnosis of focal liver lesions in patients at risk for HCC

ObjectivesTo compare the inter-modality consistency and diagnostic performances of the contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) and contrast-enhanced computed tomography (CECT) LI-RADS in patients at risk for hepatocellular carcinoma (HCC), so as to help clinicians to select a more appropriate modality to follow the focal liver lesions (FLLs).MethodsThis retrospective study included untreated 277 FLLs from 247 patients who underwent both CEUS and CECT within 1 month. The ultrasound contrast medium used was SonoVue. FLL categories were independently assigned by two ultrasound physicians and two radiologists using CEUS LI-RADS v2017 and CECT LI-RADS v2018, respectively. The diagnostic performances of CEUS and CECT LI-RADS were evaluated using sensitivity, specificity, positive predictive value (PPV), and negative predictive value. Cohen’s Kappa was employed to evaluate the concordance of the LI-RADS category.ResultsThe inter-modality consistency for CEUS and CECT LI-RADS was 0.31 (p < 0.001). HCC was more frequently observed in CECT LR-3 and LR-4 hepatic lesions than in CEUS (7.3% vs. 19.5%, p < 0.001). The specificity and PPV of CEUS and CECT LR-5 for the diagnosis of HCC were 89.5%, 95.0%, and 82.5%, 94.4%, respectively. The sensitivity of CEUS LR-5 + LR-M for the diagnosis of hepatic malignancies was higher than that of CECT (93.7% vs. 82.7%, p < 0.001). The specificity and PPV of CEUS LR-M for the diagnosis of non-HCC malignancies were lower than those of CECT (59.7% vs. 95.5%, p < 0.001; 23.4% vs. 70.3%, p < 0.001).ConclusionsThe inter-modality consistency between the CEUS and CECT LI-RADS categories is fair. CEUS LI-RADS was more sensitive than CECT LI-RADS in terms of identifying hepatic malignancies, but weaker in terms of separating HCC from non-HCC malignancies.