Liver Imaging Reporting Research Articles

Association of LI-RADS and Histopathologic Features with Survival in Patients with Solitary Resected Hepatocellular Carcinoma.

Background Both Liver Imaging Reporting and Data System (LI-RADS) and histopathologic features provide prognostic information in patients with hepatocellular carcinoma (HCC), but whether LI-RADS is independently associated with survival is uncertain. Purpose To assess the association of LI-RADS categories and features with survival outcomes in patients with solitary resected HCC. Materials and Methods This retrospective study included patients with solitary resected HCC from three institutions examined with preoperative contrast-enhanced CT and/or MRI between January 2008 and December 2019. Three independent readers evaluated the LI-RADS version 2018 categories and features. Histopathologic features including World Health Organization tumor grade, microvascular and macrovascular invasion, satellite nodules, and tumor capsule were recorded. Overall survival and disease-free survival were assessed with Cox regression models. Marginal effects of nontargetoid features on survival were estimated using propensity score matching. Results A total of 360 patients (median age, 64 years [IQR, 56-70 years]; 280 male patients) were included. At CT and MRI, the LI-RADS LR-M category was associated with increased risk of recurrence (CT: hazard ratio [HR] = 1.83 [95% CI: 1.26, 2.66], P = .001; MRI: HR = 2.22 [95% CI: 1.56, 3.16], P < .001) and death (CT: HR = 2.47 [95% CI: 1.72, 3.55], P < .001; MRI: HR = 1.80 [95% CI: 1.32, 2.46], P < .001) independently of histopathologic features. The presence of at least one nontargetoid feature was associated with an increased risk of recurrence (CT: HR = 1.80 [95% CI: 1.36, 2.38], P < .001; MRI: HR = 1.93 [95% CI: 1.81, 2.06], P < .001) and death (CT: HR = 1.51 [95% CI: 1.10, 2.07], P < .010) independently of histopathologic features. In matched samples, recurrence was associated with the presence of at least one nontargetoid feature at CT (HR = 2.06 [95% CI: 1.15, 3.66]; P = .02) or MRI (HR = 1.79 [95% CI: 1.01, 3.20]; P = .048). Conclusion In patients with solitary resected HCC, LR-M category and nontargetoid features were negatively associated with survival independently of histopathologic characteristics. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Kartalis and Grigoriadis in this issue.

LI-RADS CT and MRI Ancillary Feature Association with Hepatocellular Carcinoma and Malignancy: An Individual Participant Data Meta-Analysis.

Background The independent contribution of each Liver Imaging Reporting and Data System (LI-RADS) CT or MRI ancillary feature (AF) has not been established. Purpose To evaluate the association of LI-RADS AFs with hepatocellular carcinoma (HCC) and malignancy while adjusting for LI-RADS major features through an individual participant data (IPD) meta-analysis. Materials and Methods Medline, Embase, Cochrane Central Register of Controlled Trials, and Scopus were searched from January 2014 to January 2022 for studies evaluating the diagnostic accuracy of CT and MRI for HCC using LI-RADS version 2014, 2017, or 2018. Using a one-step approach, IPD across studies were pooled. Adjusted odds ratios (ORs) and 95% CIs were derived from multivariable logistic regression models of each AF combined with major features except threshold growth (excluded because of infrequent reporting). Liver observation clustering was addressed at the study and participant levels through random intercepts. Risk of bias was assessed using a composite reference standard and Quality Assessment of Diagnostic Accuracy Studies 2. Results Twenty studies comprising 3091 observations (2456 adult participants; mean age, 59 years ± 11 [SD]; 1849 [75.3%] men) were included. In total, 89% (eight of nine) of AFs favoring malignancy were associated with malignancy and/or HCC, 80% (four of five) of AFs favoring HCC were associated with HCC, and 57% (four of seven) of AFs favoring benignity were negatively associated with HCC and/or malignancy. Nonenhancing capsule (OR = 3.50 [95% CI: 1.53, 8.01]) had the strongest association with HCC. Diffusion restriction (OR = 14.45 [95% CI: 9.82, 21.27]) and mild-moderate T2 hyperintensity (OR = 10.18 [95% CI: 7.17, 14.44]) had the strongest association with malignancy. The strongest negative associations with HCC were parallels blood pool enhancement (OR = 0.07 [95% CI: 0.01, 0.49]) and marked T2 hyperintensity (OR = 0.18 [95% CI: 0.07, 0.45]). Seventeen studies (85%) had a high risk of bias. Conclusion Most LI-RADS AFs were independently associated with HCC, malignancy, or benignity as intended when adjusting for major features. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Crivellaro in this issue.

Systematic training of LI-RADS CT v2018 improves interobserver agreements and performances in LR categorization for focal liver lesions.

To retrospectively explored whether systematic training in the use of Liver Imaging Reporting and Data System (LI-RADS) v2018 on computed tomography (CT) can improve the interobserver agreements and performances in LR categorization for focal liver lesions (FLLs) among different radiologists. A total of 18 visiting radiologists and the liver multiphase CT images of 70 hepatic observations in 63 patients at high risk of HCC were included in this study. The LI-RADS v2018 training procedure included three thematic lectures, with an interval of 1 month. After each seminar, the radiologists had 1 month to adopt the algorithm into their daily work. The interobserver agreements and performances in LR categorization for FLLs among the radiologists before and after training were compared. After training, the interobserver agreements in classifying the LR categories for all radiologists were significantly increased for most LR categories (P < 0.001), except for LR-1 (P = 0.053). After systematic training, the areas under the curve (AUCs) for LR categorization performance for all participants were significantly increased for most LR categories (P < 0.001), except for LR-1 (P = 0.062). Systematic training in the use of the LI-RADS can improve the interobserver agreements and performances in LR categorization for FLLs among radiologists with different levels of experience.

Assessing Adherence to US LI-RADS Follow-up Recommendations in Vulnerable Patients Undergoing Hepatocellular Carcinoma Surveillance.

Purpose To assess adherence to the US Liver Imaging Reporting and Data System (LI-RADS) recommendations for hepatocellular carcinoma (HCC) surveillance and associated patient-level factors in a vulnerable, diverse patient sample. Materials and Methods The radiology report database was queried retrospectively for patients who underwent US LI-RADS-based surveillance examinations at a single institution between June 1, 2020, and February 28, 2021. Initial US and follow-up liver imaging were included. Sociodemographic and clinical data were captured from electronic medical records. Adherence to radiologist recommendation was defined as imaging (US, CT, or MRI) follow-up in 5-7 months for US-1, imaging follow-up in 3-6 months for US-2, and CT or MRI follow-up in 2 months for US-3. Descriptive analysis and multivariable modeling that adjusted for age, sex, race, and time since COVID-19 pandemic onset were performed. Results Among 936 patients, the mean age was 59.1 years; 531 patients (56.7%) were male and 544 (58.1%) were Asian or Pacific Islander, 91 (9.7%) were Black, 129 (13.8%) were Hispanic, 147 (15.7%) were White, and 25 (2.7%) self-reported as other race. The overall adherence rate was 38.8% (95% CI: 35.7, 41.9). The most common liver disease etiology was hepatitis B (60.6% [657 of 936 patients]); 19.7% of patients (183 of 936) had current or past substance use disorder, and 44.8% (416 of 936) smoked. At adjusted multivariable analysis, older age (odds ratio [OR], 1.20; P = .02), male sex (OR, 1.62; P = .003), hepatology clinic attendance (OR, 3.81; P < .001), and recent prior US examination (OR, 2.44; P < .001) were associated with full adherence, while current smoking (OR, 0.39; P < .001) was negatively associated. Conclusion Adherence to HCC imaging surveillance was suboptimal, despite US LI-RADS implementation. Keywords: Liver, Ultrasound, Screening, Abdomen/GI, Cirrhosis, Metabolic Disorders, Socioeconomic Issues Supplemental material is available for this article. © RSNA, 2024.

Comparison of the Ability of Gadobenate Dimeglumine and Gadolinium Ethoxybenzyl Dimeglumine to Display the major Features for Noninvasively Diagnosing Hepatocellular Carcinoma According to the LI-RADS 2018v.

To compare the ability of gadolinium ethoxybenzyl dimeglumine (Gd-EOB-DTPA) and gadobenate dimeglumine (Gd-BOPTA) to display the 3 major features recommended by the Liver Imaging Reporting and Data System (LI-RADS 2018v) for diagnosing hepatocellular carcinoma (HCC). In this retrospective study, we included 98 HCC lesions that were scanned with either Gd-EOB-DTPA-MR or Gd-BOPTA-M.For each lesion, we collected multiple variables, including size and enhancement pattern in the arterial phase (AP), portal venous phase (PVP), transitional phase (TP), delayed phase (DP), and hepatobiliary phase (HBP). The lesion-to-liver contrast (LLC) was measured and calculated for each phase and then compared between the 2 contrast agents. A P value < .05 was considered statistically significant. The display efficiency of the LLC between Gd-BOPTA and Gd-EOB-DTPA for HCC features was evaluated by receiver operating characteristic (ROC) curve analysis. Between Gd-BOPTA and Gd-EOB-DTPA, significant differences were observed regarding the display efficiency for capsule enhancement and the LLC in the AP/PVP/DP (P < .05), but there was no significant difference regarding the LLC in the TP/HBP. Both Gd-BOPTA and Gd-EOB-DTPA had good display efficiency in each phase (AUCmin > 0.750). When conducting a total evaluation of the combined data across the 5 phases, the display efficiency was excellent (AUC > 0.950). Gd-BOPTA and Gd-EOB-DTPA are liver-specific contrast agents widely used in clinical practice. They have their own characteristics in displaying the 3 main signs of HCC. For accurate noninvasive diagnosis, the choice of agent should be made according to the specific situation.

ChatGPT yields low accuracy in determining LI-RADS scores based on free-text and structured radiology reports in German language.

To investigate the feasibility of the large language model (LLM) ChatGPT for classifying liver lesions according to the Liver Imaging Reporting and Data System (LI-RADS) based on MRI reports, and to compare classification performance on structured vs. unstructured reports. LI-RADS classifiable liver lesions were included from German written structured and unstructured MRIreports with report of size, location, and arterial phase contrast enhancement as minimum inclusion requirements. The findings sections of the reports were propagated to ChatGPT (GPT-3.5), which was instructed to determine LI-RADS scores for each classifiable liver lesion. Ground truth was established by two radiologists in consensus. Agreement between ground truth and ChatGPT was assessed with Cohen's kappa. Test-retest reliability was assessed by passing a subset of n = 50 lesions five times to ChatGPT, using the intraclass correlation coefficient (ICC). 205 MRIs from 150 patients were included. The accuracy of ChatGPT at determining LI-RADS categories was poor (53% and 44% on unstructured and structured reports). The agreement to the ground truth was higher (k = 0.51 and k = 0.44), the mean absolute error in LI-RADS scores was lower (0.5 ± 0.5 vs. 0.6 ± 0.7, p < 0.05), and the test-retest reliability was higher (ICC = 0.81 vs. 0.50), in free-text compared to structured reports, respectively, although structured reports comprised the minimum required imaging features significantly more frequently (Chi-square test, p < 0.05). ChatGPT attained only low accuracy when asked to determine LI-RADS scores from liver imaging reports. The superior accuracy and consistency throughout free-text reports might relate to ChatGPT's training process. Our study indicates both the necessity of optimization of LLMs for structured clinical data input and the potential of LLMs for creating machine-readable labels based on large free-text radiological databases.

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.

Comparison of CT and gadoxetic acid–enhanced MRI with liver imaging reporting and data system to assess liver tumors before resection

Background/purposeHepatocellular carcinoma (HCC) can be noninvasively diagnosed through dynamic computed tomography (CT) and magnetic resonance imaging (MRI). We compared the diagnostic performance of CT and gadoxetic acid–enhanced MRI (EOB-MRI) in categorizing tumors by using the 2018 version of the Liver Imaging Reporting And Data System (LI-RADS v2018) and assessing liver tumors before resection. MethodsData from a prospective cohort from October 2011 to March 2019 on 106 hepatic tumors in 96 patients with suspected malignancy were included in this study. We performed preoperative CT and EOB-MRI, and reviewed these images retrospectively. Ninety-seven tumors from 87 patients were pathologically diagnosed as HCC, and nine tumors were non-HCC. The clinical data, imaging characteristics, diagnostic performance, and outcomes of CT and EOB-MRI were analyzed and compared. ResultsEOB-MRI had more favorable diagnostic performance (area under curve: 0.920 vs. 0.868) and significantly higher sensitivity (86.87% vs. 69.70%, p = 0.005) than did CT. However, the specificity of EOB-MRI did not differ from that of CT (88.89% vs. 88.89%, p > 0.999). Fourteen (14.5%) patients with pathologically verified HCC had lesions categorized as LI-RADS 4 through CT and as LI-RADS 5 through EOB-MRI. Patients with EOB-MRI-categorized but not CT-categorized LI-RADS 5 lesions had significantly longer overall survival than did those with LI-RADS 4 lesions (p < 0.001). ConclusionEOB-MRI had higher sensitivity than did CT in diagnosing HCC. Patients with EOB-MRI-categorized LI-RADS 5 lesions had more favorable outcomes than did those with LI-RADS 4 lesions after liver resection.

Per-patient Negative Predictive Value of the CT and MRI Liver Imaging Reporting and Data System Version 2018 Treatment Response Algorithm for Hepatocellular Carcinoma.

Background The Liver Imaging Reporting and Data System version 2018 (LI-RADS) treatment response algorithm (TRA) is a high-specificity, lower-sensitivity grading system to diagnose hepatocellular carcinoma (HCC) and recurrence after local-regional therapy. However, the emphasis on specificity can result in disease understaging, potentially leading to poorer posttransplant outcomes. Purpose To determine the negative predictive value (NPV) of pretransplant CT and MRI assessment for viable HCC on a per-patient basis using the LI-RADS TRA, considering explant pathology as the reference standard. Materials and Methods Patient records from 218 consecutive adult patients from a single institution with HCC who underwent liver transplant from January 2011 to November 2017 were retrospectively reviewed. Two readers blinded to the original report reviewed immediate (within 90 days) pretransplant imaging and characterized observations according to the LI-RADS TRA. Based on this, patients with LR-4, LR-5, or LR-TR (treatment response) viable tumors were designated as viable tumor; patients with solely LR-3 or LR-TR equivocal tumors were designated as equivocal; and patients with only LR-TR nonviable lesions were designated as no viable disease. Patients were designated as within or outside the Milan criteria. These per-patient designations were compared with the presence of viable disease at explant pathology. Fisher exact test was used to compare the differences between CT and MRI. Weighted κ values were used to calculate interreader reliability. Results Final study sample consisted of 206 patients (median age, 61 years [IQR, 57-65 years]; 157 male patients and 49 female patients). Per-patient LI-RADS TRA assessment of pretransplant imaging had an NPV of 32% (95% CI: 27, 38) and 26% (95% CI: 20, 33) (readers 1 and 2, respectively) for predicting viable disease. Seventy-five percent (reader 1) and 77% (reader 2) of patients deemed equivocal had residual tumors at explant pathology. Weighted interreader reliability was substantial (κ = 0.62). Conclusion Patient-based stratification of viable, equivocal, and nonviable disease at pretransplant CT or MRI, based on LI-RADS TRA, demonstrated low negative predictive value in excluding HCC at explant pathology. © RSNA, 2023 See also the editorial by Tamir and Tau in this issue.

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.

Role Of Ultrasound Liver Imaging Reporting And Data System In Categorization Of Cirrhotic Patients

Role Of Ultrasound Liver Imaging Reporting And Data System In Categorization Of Cirrhotic Patients

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.

Does threshold growth benefit imaging criteria when used as a major diagnostic imaging feature for hepatocellular carcinoma?

PurposeTo evaluate the added value of threshold growth (TG) for imaging criteria for diagnosing hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced MRI. MethodsPatients who underwent preoperative gadoxetic acid-enhanced MRI because of absence of ‘definite HCC’ (Liver Imaging Reporting and Data System category 5) on prior CT or MRI between January 2016 and December 2020 were retrospectively analyzed. The sensitivity and specificity for ‘definite HCC’ according to the criteria of the European Association for the Study of the Liver [EASL], Asian Pacific Association for the Study of the Liver [APASL], and Korean Liver Cancer Association-National Cancer Center [KLCA-NCC] were separately calculated with and without TG as a major imaging feature. The results were compared using generalized estimating equations. ResultsOf 202 nodules in 154 patients, 19 % showed TG. When TG was used as a major imaging feature, the sensitivity of EASL were significantly higher than when it was not used (59.2 % vs. 51.4 %, p = 0.001), whereas the sensitivities of APASL and KLCA-NCC did not significantly differ. No significant difference was found in the specificities of the three imaging criteria when TG was used or not (p ≥ 0.16). Of 11 HCCs additionally detected when TG was added to EASL criteria, 9 showed transitional-phase or hepatobiliary-phase hypointensity without portal venous-phase washout. ConclusionTG had added value for improving the sensitivity of EASL criteria for gadoxetic acid-enhanced MRI without extending washout to transitional-phase or hepatobiliary-phase images.

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.

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.