Presence Of Washout Research Articles

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 <15; 15-25 or >25yrs since Fontan surgery, respectively (p<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<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 >20mm and/or presence of wash-out into portal-hepatocellular phase or into LR ≥3 classes).

Analysis of contrast-enhanced ultrasound features of hepatocellular adenoma according to different pathological molecular classifications.

To explore the specific contrast-enhanced ultrasound (CEUS) features of hepatocellular adenomas (HCA) according to their pathological molecular classifications. In this retrospective study, fifty-three histopathologically proved HCA lesions (mean size, 39.7±24.9 mm) were included. Final histopathological diagnosis of HCA lesions were identified by surgical resection (n = 51) or biopsy (n = 2) specimens. CEUS imaging features were compared among four subgroups according to World Health Organization (WHO) 2019 pathological molecular classifications standards. Analysis of variance (ANOVA) were used for statistical analysis of continuous variables. Fisher's exact test were used for categorical variables. The sensitivity (SE), specificity (SP), and accuracy of CEUS feature in diagnosis of each HCA subtype were calculated and compared. Final histopathological diagnosis included HNF-1α inactivated HCAs (H-HCA, n = 12), β-catenin activated HCAs (B-HCA, n = 8), inflammatory HCAs (I-HCA, n = 31), and unclassified HCAs (U-HCA, n = 2). During arterial phase of CEUS, all HCAs were hyper-enhanced, 66.6% (8/12) of H-HCAs and 50% (4/8) of B-HCAs displayed complete hyperenhancement, whereas 58.0% (18/31) of I-HCAs showed centripetal filling hyperenhancement pattern (P = 0.016). Hyper-enhanced subcapsular arteries could be detected in 64.5% (20/31) I-HCAs during early arterial phase. During portal venous and late phase, sustained hyper- or iso-enhancement were observed in 91.7% (11/12) of H-HCAs, while most of I-HCAs (61.3%, 19/31) and B-HCAs (7/8, 87.5%) were hypo-enhanced (P = 0.000). Central unenhanced areas were most commonly observed in I-HCAs (29.0%, 9/31) (P = 0.034). Depending on its unique imaging features including enhancement filling pattern, hyper-enhanced subcapsular artery and presence of washout, CEUS might provide helpful diagnostic information for preoperative prediction of various HCA molecular subtypes.

Subtraction Images From Portal Venous Phase Gadoxetic Acid-Enhanced MRI for Observing Washout and Enhancing Capsule Features in LI-RADS Version 2018.

OBJECTIVE. The purpose of this study is to validate the use of subtraction images derived from gadoxetic acid-enhanced MRI for observation of washout and enhancing capsule in the diagnosis of hepatocellular carcinoma (HCC). MATERIALS AND METHODS. For 120 histologically verified HCCs in 115 high-risk patients, the presence of washout and enhancing capsule in the portal venous phase (PVP) on conventional MR images with and without corresponding subtraction images was determined by two independent observers. The incremental value of subtraction imaging in upgrading the categories outlined in the Liver Imaging Reporting and Data System (LI-RADS) version 2018 for the diagnosis of HCC was analyzed for different subgroups of patients classified on the basis of lesion size (< 10 mm, 10-19 mm, ≥ 20 mm), unenhanced T1-weighted signal intensity, and arterial phase hyperenhancement (APHE) of the lesions. RESULTS. When conventional PVP images were compared with the combination of conventional and subtraction PVP images, only T1-weighted isointensity or hyperintensity significantly increased the detection of washout (eight vs 15 of 18 lesions; p = 0.0233). Detection of enhancing capsule was significantly increased (p < 0.05) regardless of various factors, except for a lesion size of less than 2 cm (five vs nine of 36 lesions; p = 0.1336). Two lesions (one LI-RADS category 3 lesion and one LI-RADS category 4 lesion) with APHE were upgraded to category 5 on the basis of a review of PVP subtraction images. CONCLUSION. PVP subtraction imaging during gadoxetic acid-enhanced MRI can upgrade LI-RADS categories for the diagnosis of HCC because of its superior ability in depicting enhancing capsule and the incremental benefit of showing washout.

Diffusion tensor imaging for characterizing tumor microstructure and improving diagnostic performance on breast MRI: a prospective observational study

BackgroundDiffusion-weighted imaging (DWI) can increase breast MRI diagnostic specificity due to the tendency of malignancies to restrict diffusion. Diffusion tensor imaging (DTI) provides further information over conventional DWI regarding diffusion directionality and anisotropy. Our study evaluates DTI features of suspicious breast lesions detected on MRI to determine the added diagnostic value of DTI for breast imaging.MethodsWith IRB approval, we prospectively enrolled patients over a 3-year period who had suspicious (BI-RADS category 4 or 5) MRI-detected breast lesions with histopathological results. Patients underwent multiparametric 3 T MRI with dynamic contrast-enhanced (DCE) and DTI sequences. Clinical factors (age, menopausal status, breast density, clinical indication, background parenchymal enhancement) and DCE-MRI lesion parameters (size, type, presence of washout, BI-RADS category) were recorded prospectively by interpreting radiologists. DTI parameters (apparent diffusion coefficient [ADC], fractional anisotropy [FA], axial diffusivity [λ1], radial diffusivity [(λ2 + λ3)/2], and empirical difference [λ1 − λ3]) were measured retrospectively. Generalized estimating equations (GEE) and least absolute shrinkage and selection operator (LASSO) methods were used for univariate and multivariate logistic regression, respectively. Diagnostic performance was internally validated using the area under the curve (AUC) with bootstrap adjustment.ResultsThe study included 238 suspicious breast lesions (95 malignant, 143 benign) in 194 women. In univariate analysis, lower ADC, axial diffusivity, and radial diffusivity were associated with malignancy (OR = 0.37–0.42 per 1-SD increase, p < 0.001 for each), as was higher FA (OR = 1.45, p = 0.007). In multivariate analysis, LASSO selected only ADC (OR = 0.41) as a predictor for a DTI-only model, while both ADC (OR = 0.41) and FA (OR = 0.88) were selected for a model combining clinical and imaging parameters. Post-hoc analysis revealed varying association of FA with malignancy depending on the lesion type. The combined model (AUC = 0.81) had a significantly better performance than Clinical/DCE-MRI-only (AUC = 0.76, p < 0.001) and DTI-only (AUC = 0.75, p = 0.002) models.ConclusionsDTI significantly improves diagnostic performance in multivariate modeling. ADC is the most important diffusion parameter for distinguishing benign and malignant breast lesions, while anisotropy measures may help further characterize tumor microstructure and microenvironment.

Conventional, diffusion, and permeability MR findings in ocular medulloepithelioma.

To describe the neuroradiological features of intraocular medulloepithelioma. We retrospectively analyzed the clinical, histopathological, and MRI data of five children with medulloepithelioma. In addition to conventional images, DWI was performed in four patients and mean ADC was calculated; this was limited to the technique of this cohort of patients. DCE was performed in all patients. This is the first paper that presents diffusion and perfusion characteristics of medulloepithelioma. Four tumors were malignant teratoid variants, two non-teratoid variants. Tumors were hyperintense on T1-weighted images and hypointense on T2-weighted images. Calcifications were detectable in two out of five tumors. Cavities were detectable in three out of five tumors. All tumors showed some degree of enhancement. The mean ADC of all four patients was 1.156 ± 242.75 × 10-3mm2/s. Mean ktrans, Ve, Kep, TME, AUC, SER, and peak enhancement were 0.082 ± 0.054, 0.19 ± 0.076, 0.31 ± 0.084, 0.97 ± 0.0784, 1.22 ± 0.81, 67.34 ± 31.7, and 14.84 ± 7.34 respectively. TICs showed a very high ratio of slow increase, > 50% persistence and some degree of wash out. Teratoid variants showed higher K-trans, AUC, VE, TME, and persistent TIC pattern than non-teratoid ones, while plateau pattern ratio was lower. Conventional MR findings were similar to previously reported cases. Mean ADCs were moderately high. TICs showed slow increase and presence of wash out. K-trans, AUC, VE, and TME were higher in teratoid variants. Permeability parameters in differential diagnosis with lesions mimicking medulloepithelioma need further investigations.

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

BackgroundCombined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver tumor, which has overlapping imaging features with mass forming intra-hepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC). Previous studies reported imaging features more closely resemble ICC and the aim of our study was to examine the differential MRI features of cHCC-CC and ICC with emphasis on enhancement pattern observations of gadolinium enhanced MRI.MethodsInstitutional review board approval with consent waiver was obtained for this retrospective bi-centric study. Thirty-three patients with pathologically proven cHCC-CC and thirty-eight patients with pathologically proven ICC, who had pre-operative MRI, were identified. MRI images were analyzed for tumor location and size, T1 and T2 signal characteristics, the presence/absence of: cirrhosis, intra-lesional fat, hemorrhage/hemosiderin, scar, capsular retraction, tumor thrombus, biliary dilatation, degree of arterial enhancement, enhancement pattern, pseudocapsule and washout. Associations between MRI features and tumor type were examined using the Fisher’s exact and chi-square tests.ResultsStrong arterial phase enhancement and the presence of: washout, washout and progression, intra-lesional fat and hemorrhage were all strongly associated with cHCC-CC (P < 0.001). While cHCC-CC had a varied enhancement pattern, the two most common enhancement patterns were peripheral persistent (n = 6) and heterogeneous hyperenhancement with washout (n = 6), compared to ICC where the most common enhancement patterns were peripheral hypoenhancement with progression (n = 18) followed by heterogeneous hypoenhancement with progression (n = 14) (P < 0.001).ConclusionThe cHCC-CC enhancement pattern seems to more closely resemble HCC with the degree of arterial hyperenhancement and the presence of washout being valuable in differentiating cHCC-CC from ICC. However the presence of washout and progression, in the same lesion or a predominantly peripheral /rim hyperenhancing mass were also seen as important features that should alert the radiologist to the possibility of a cHCC-CC.

CEUS LI-RADS: algorithm, implementation, and key differences from CT/MRI.

Contrast-enhanced ultrasound (CEUS) is a specialized form of ultrasound (US) performed with an intravenous injection of microbubble contrast agents. It has been successfully used for a variety of applications including characterization of liver tumors. In April 2014, the American College of Radiology (ACR) convened a working group of international experts to develop ACR CEUS Liver Imaging Reporting and Data System (CEUS LI-RADS). An initial version of CEUS LI-RADS was published in August 2016. Although the CEUS LI-RADS concept and principles for liver lesion characterization, using dynamic contrast enhancement features, are similar to those for CT or MRI, there are significant differences between CT/MRI and CEUS LI-RADS. Therefore, CEUS LI-RADS has different diagnostic features and a unique characterization algorithm. The size of a lesion, the type and degree of arterial phase enhancement, the presence of washout, and the timing and degree of washout are the major features used for categorization. This paper describes key differences between CT/MRI and CEUS, and provides a diagnostic algorithm of CEUS LI-RADS with detailed, step-by-step instructions and imaging examples of CEUS LI-RADS categories.

Multidetector Computed Tomography Triphasic Evaluation of the Liver Before Transplantation

We aim to identify the sensitivity and positive predictive value (PPV) of arterial phase imaging in detecting hepatocellular carcinoma (HCC) and determine the added value of portal venous and equilibrium phase imaging and lesion morphology characterization. We reviewed all patients who underwent liver transplantation at our institution that had a triphasic multidetector computed tomography examination within 6 months of transplantation. Forty-seven hypervascular lesions were identified in 24 patients. Imaging findings were correlated with explant pathologic correlation. Hypervascularity in the arterial phase resulted in sensitivity of 87.5% and PPV of 29.8%. The presence of washout in the equilibrium phase increased the PPV to 92.9% with a slight decrease in sensitivity (81.3%). The negative predictive value of hypervascular lesions without washout in the equilibrium phase was 97.1%. There was significant correlation between larger lesions and HCC and between round lesions and HCC. The presence of washout in the equilibrium phase is a better indicator of malignancy.

Vascular invasion in hepatocellular carcinoma: is there a correlation with MRI?

Hepatocellular carcinoma (HCC) is one of the commonest malignancies worldwide. Prognosis is predicted by size at diagnosis, vascular invasion and tumour proliferation markers. This study investigates if MRI features of histologically proven HCCs correlate with vascular invasion. Between 2006 and 2008, 18 consecutive patients, with a total of 27 HCCs, had comprehensive MRI studies performed at our institution within a median of 36 days of histology sampling. Each lesion was evaluated independently on MRI by 3 radiologists (blinded to both the radiology and histopathology reports) using a 5-point confidence scale for 23 specific imaging features. The mean of the rating scores across readers was calculated to determine interobserver consistency. The most consistent features were then used to examine the value of features in predicting vascular invasion, using a χ(2 )test for trend, having eliminated those features without sufficient variability. 22 of the 23 imaging features showed sufficient variability across lesions. None of these significantly correlated with the presence of vascular invasion, although a trend was identified with the presence of washout in the portal venous phase on MRI and the median size of lesions, which was greater with vascular invasion. This study suggests that no single MRI feature accurately predicts the presence of vascular invasion in HCCs, although a trend was seen with the presence of washout in the portal venous phase post gadolinium. Larger prospective studies are required to investigate this further.