LI-RADS to categorize liver nodules in patients at risk of HCC: tool or a gadget in daily practice?

PURPOSE: To determine the effectiveness of liver reporting and data system (LI-RADS) to diagnose hepatocellular carcinoma (HCC) and to retrospectively evaluate its impact on the adopted therapeutic strategy. MATERIALS AND METHODS: Preoperative imaging of 40 of 350 patients (median age 66, 31 M/9 F) submitted to liver resection for suspected HCC, between January 2008 and August 2019, has been retrospectively analyzed by two radiologists with different expertise, according to CT/MRI LI-RADS® v2018, both blinded to clinical and pathological results and untrained to using aforementioned scoring system. RESULTS: The perfect agreement between the readers was about 62.5% (25/40) (Cohen k: 0.41), better for LR-5 category (16/25) and higher in magnetic resonance imaging (MRI) investigations (68%; 13/19), which has been demonstrated the modality of choice for diagnosis of high probable and certain HCC, with arterial phase hyperenhancement as the most sensitive and accurate major feature. Compared to final histology, LR4 and LR5 scores assigned by senior radiologist reached sensitivity, specificity, positive and negative predictive values (PPV, PNV) and diagnostic accuracy of 90,9%, 29,0%, 93,8%, 62,5% and 87,5%, respectively, slightly higher than junior's ones. Misdiagnosis of HCC was done by both radiologists in the same two patients: 1 primary hepatic lymphoma (PHL) and 1 regenerative liver nodule (RLN). If LI-RADS would have been applied at the time of pre-surgical imaging, treatment planning would be modified in 10% of patients (4/40); the patient scheduled as LR-3 and finally resulted a focal nodular hyperplasia would have avoided liver resection. CONCLUSIONS: Application of LI-RADS, especially on MRI, may provide a more accurate evaluation of suspected HCC. PHL and RLN are the Achille's heels according to our experience.

Artificial intelligence for the detection of COVID-19 pneumonia on chest CT using multinational datasets.

Chest CT is emerging as a valuable diagnostic tool for clinical management of COVID-19 associated lung disease. Artificial intelligence (AI) has the potential to aid in rapid evaluation of CT scans for differentiation of COVID-19 findings from other clinical entities. Here we show that a series of deep learning algorithms, trained in a diverse multinational cohort of 1280 patients to localize parietal pleura/lung parenchyma followed by classification of COVID-19 pneumonia, can achieve up to 90.8% accuracy, with 84% sensitivity and 93% specificity, as evaluated in an independent test set (not included in training and validation) of 1337 patients. Normal controls included chest CTs from oncology, emergency, and pneumonia-related indications. The false positive rate in 140 patients with laboratory confirmed other (non COVID-19) pneumonias was 10%. AI-based algorithms can readily identify CT scans with COVID-19 associated pneumonia, as well as distinguish non-COVID related pneumonias with high specificity in diverse patient populations.

Quantification of heterogeneity to classify benign parotid tumors: a feasibility study on most frequent histotypes.

Aim: To differentiate Warthin tumors (WTs) and pleomorphic adenomas (PAs) measuring heterogeneity of intravoxel incoherent motion (IVIM) and dynamic-contrast enhanced-magnetic resonance imaging biomarkers. Methods: Volumes of interest were traced on 18 WT and 18 PA in 25 patients. For each IVIM and dynamic-contrast enhanced biomarker, histogram parameters were calculated and then compared using the Wilcoxon-signed-rank test. Receiver operating characteristic curves and multivariate analysis were employed to identify the parameters and their pairs with the best accuracy. Results: Most of the biomarkers exhibited significant difference (p < 0.05) between PA and WT for histogram parameters. Time to peak median and skewness, and D* median and entropy showed the highest area under the curve. No meaningful improvement of accuracy was obtained using two features. Conclusion: IVIM and dynamic-contrast enhanced histogram descriptors may help in the classification of WT and PA.

DEB-TACE: a standard review.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a relative new endovascular treatment based on the use of microspheres to release chemotherapeutic agents within a target lesion with controlled pharmacokinetics. This aspect justifies the immediate success of DEB-TACE, that nowadays represents one of the most used treatments for unresectable hepatocellular carcinoma. However, there is no consensus about the choice of the best embolotherapy technique. In this review, we describe the available microspheres and report the results of the main comparative studies, to clarify the role of DEB-TACE in the hepatocellular carcinoma management. We underline that there is no evidence about the superiority of DEB-TACE over conventional TACE in terms of efficacy, but there may be some benefits with respect to safety especially with the improvement of new technologies.

CT-MRI LI-RADS v2017: A Comprehensive Guide for Beginners.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second leading cause of cancer-related deceases worldwide. Early diagnosis is essential for correct management and improvement of prognosis. Proposed for the first time in 2011 and updated for the last time in 2017, the Liver Imaging-Reporting and Data System (LI-RADS) is a comprehensive system for standardized interpretation and reporting of computed tomography (CT) and magnetic resonance imaging (MRI) liver examinations, endorsed by the American College of Radiology to achieve congruence with HCC diagnostic criteria in at-risk populations. Understanding its algorithm is fundamental to correctly apply LI-RADS in clinical practice. In this pictorial review, we provide a guide for beginners, explaining LI-RADS indications, describing major and ancillary features and eventually elucidating the diagnostic algorithm with the use of some clinical examples.

The role of interventional radiology in the treatment of epiphora.

Epiphora is a relatively common ophthalmologic affection representing almost 5% of clinical consultations in ophthalmology and it consists in the complete or partial obstruction of nasolacrimal duct, leading to insufficient drainage of tears. The traditional treatment is represented by surgery namely, external dacryocystorhinostomy (DCR). Despite the high success rate DCR has many disadvantages and limitations since it requires general anesthesia, it may arise in a permanent facial scar and it is often affected by the reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity. Fluoroscopically guided interventional procedures are a therapeutic alternative to surgery for lacrimal duct system obstructions that can consist either in balloon dacryocystoplasty or in nasolacrimal stent placement. In both cases, a pre-operative imaging characterization of the occlusion is needed for a correct treatment planning. In this review, we propose to highlight the role of interventional radiology in the treatment of epiphora and the role of computed tomography dacryocystography (CTD) in depiction and the pre-interventional planning.

A multiparametric analysis combining DCE-MRI- and IVIM -derived parameters to improve differentiation of parotid tumors: a pilot study.

AIM: To evaluate dynamic contrast-enhanced (DCE)-MRI and diffusion weighted (DW)-MRI diagnostic value to differentiate Warthin tumors (WT) by pleomorphic adenomas (PA). MATERIALS & METHODS: Seven WT and seven PA were examined. DCE- and  DW-MRI parameters were extracted from volumes of interest; volume of interest-based averages and standard deviations were calculated. Statistical analysis included: linear discriminant analysis, receiver operating characteristic curves, sensitivity and specificity. RESULTS: No single feature was able to differentiate WT by PA (p > 0.05); linear discriminant analysis analysis showed that a combination of all features or combinations of feature pairs (namely: Ktrans(std) & f(std), Ktrans(std) & D(std), kep(std) & D(std), MRE(av) & TTP(av)) might achieve sensitivity (SENS), specificity (SPEC) = 100%, with a slight reduction after cross-validation analysis (SENS = 0.875; SPEC = 1). CONCLUSION: Although preliminary and not conclusive, our results suggest that differentiation between WT and PA is possible through a multiparametric approach based on combination of DCE- and DW-MRI parameters.

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study.

BACKGROUND: When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm). METHODS: We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival. RESULTS: Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival. CONCLUSION: Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Intravoxel Incoherent Motion (IVIM) Diffusion Weighted Imaging (DWI) in the Periferic Prostate Cancer Detection and Stratification.

The aim of this study was to compare the Intravoxel Incoherent Motion (IVIM) parameters between healthy Peripheral Zone (PZ), Benign Prostatic Hyperplasia (BPH) and Prostate Cancer (PCa) and compare them to assess whether there was correlation with Gleason Score (GS) grading system. Thirty-one patients with suspect of PCa underwent 1.5T Multi-Parametric Magnetic Resonance Imaging (MP-MRI) with endorectal coil with a protocol including T2WI, DWI using 10 b values (0, 10, 20, 30, 50, 80, 100, 200, 400, 1000 s/mm2) and DCE. Monoexponential and IVIM model fits were used to calculate both apparent diffusion coefficient (ADC) and the following IVIM parameters: molecular diffusion coefficient (D), perfusion-related diffusion coefficient (D*) and perfusion fraction (f). The ADC and D values were significantly lower in the PCa (0.70 ± 0.16 × 10-3 mm2/s and 0.88 ± 0.31 × 10-3 mm2/s) compared to those found in the PZ (1.22 ± 0.20 × 10-3 mm2/s and 1.78 ± 0.34 × 10-3 mm2/s) and in the BPH (1.53 ± 0.23 × 10-3 mm2/s and 1.11 ± 0.28 × 10-3 mm2/s). The D* parameter was significantly increased in the PCa (5.35 ± 5.12 × 10-3 mm2/s) compare to the healthy PZ (3.02 ± 2.86 × 10-3 mm2/s), instead there was not significantly difference in the PCa compare to the BPH (5.61 ± 6.77 × 10-3 mm2/s). The f was statistically lower in the PCa (9.01 ± 5.20%) compared to PZ (10.57 ± 9.30%), but not significantly different between PCa and BPH (9.29 ± 7.29%). The specificity, sensitivity and accuracy of T2WI associated with DWI and IVIM were higher (100, 98 and 99%, respectively) than for T2WI/DWI and IVIM alone (89, 92 and 90%, respectively). Only for ADC was found a statistical difference between low- and intermediate-/high-grade tumors. Adding IVIM to the MP-MRI could increase the diagnostic performance to detect clinically relevant PCa. ADC values have been found to have a rule to discriminate PCa reliably from normal areas and differed significantly in low- and intermediate-/high-grade PCa. In contrast, IVIM parameters were unable to distinguish between the different GS.

The role of interventional radiology in the treatment of intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. Complete surgical resection remains the only potentially curative option for patients with ICC. However, until now, early diagnosis with potential surgical intervention has been the exception rather than the rule with only 30% of patients qualifying for attempted surgical cure. Many patients are unresectable because of disease stage, anatomic conditions, medical comorbidities, and small future remnant liver. Interventional radiology procedures are available for these types of patients with intra-arterial therapies and/or ablative treatments both for curative and for palliative treatment. The goals of interventional therapy are to control local tumor growth, to relieve symptoms, and to improve and preserve quality of life. The choice of treatment depends largely on tumor extent and patient performance. No randomized studies exist to compare treatments. The present review describes the current evidence of the interventional treatments in the management of the ICC. Moreover, interventional procedures available to increase the future liver reserve before surgery were analyzed.

Role of magnetic resonance imaging in evaluation of the activity of perianal Crohn's disease.

AIM: To evaluate the diagnostic ability of contrast-enhanced Magnetic Resonance Imaging (MRI) in assessment of the activity of perianal fistulas in Crohn's disease (CD) patients, compared to clinical data. MATERIALS AND METHODS: Fifty CD patients (25 men; mean[SD] age: 40.4[12.6] years) with known or suspected perianal fistulas underwent perianal space MRI. Radiological activity of disease was measured as the percentage increase (PI) of ROI values of fistulas in relation to ROI values of healthy local fat, after contrast administration. Clinical activity of disease was defined according to Perianal Disease Activity Index (PDAI) and Fistula Drainage Assessment (FDA). RESULTS: Forty-two patients presented perianal disease at MRI (55 fistulas identified). An association between both fistula's PI and PDAI (Pearson's coefficient 0.512, p<0.0001) and between PI and FDA (p=0.003) was demonstrated. Areas under ROC curves of PI values in relation to PDAI and FDA were respectively 0.876 [95%CI=(0.743-1.00), p<0.001] and 0.784 [95%CI=(0.588-0.980), p=0.003]. A cut-off value of PI, calculated on these preliminary data, correctly classified more than 90% of fistulas. CONCLUSIONS: Contrast-enhanced MRI with PI calculation offered practical information about activity of perianal fistulas and might be helpful in providing a comprehensive evaluation of CD perianal disease.

Unknown internal carotid artery atherosclerotic stenoses detected with biphasic multidetector computed tomography for head and neck cancer.

The possibility of detecting unknown internal carotid artery stenoses in patients undergoing biphasic multidetector computed tomography (MDCT) for current or previous head and neck cancer was investigated in 52 patients who underwent four-row MDCT (4 mm x 1.25 mm collimation, pitch 3, kVp 120, mAs 140; 90-100 ml of non-ionic contrast agent at 2 ml/s, early and late phases). Vessel stenoses were classed as severe (70-99%), moderate (30-69%), or mild (<30%). Internal carotid arteries (ICAs) with vessel stenosis was found in 37 patients (age 67.0+/-9.8 years, median 69 years) and 67 ICAs. Four patients (age 65.5+/-9.7 years) had severe stenosis, all of them associated with contralateral moderate stenosis. Seventeen patients (age 70.35+/-9.78 years) had moderate stenosis, bilateral (n=7), associated with contralateral mild stenosis (n=8), unilateral (n=2). Sixteen patients (age 64.8+/-9.8 years) had mild stenosis, bilateral (n=10) or unilateral (n=6). Of the four patients with unknown MDCT-detected severe stenosis, three had a change of therapy: one endarterectomy before tumor surgery, one combined vascular and tumor surgery, and one patient with a previously treated hypopharyngeal cancer had carotid stenting. In conclusion, of 52 patients, four (7.7 %) had unknown severe ICA stenoses, three of them with relevant impact on therapy. ICAs should be carefully evaluated for atherosclerotic disease using biphasic MDCT for head and neck cancer.