Comparison of Four Diagnostic Guidelines for Hepatocellular Carcinoma Using Gadoxetic Acid-enhanced Liver MRI.

Background Noninvasive diagnostic guidelines for hepatocellular carcinoma (HCC) vary across different global geographic areas, especially regarding criteria about gadoxetic acid-enhanced MRI. Purpose To compare the diagnostic performance of four different international HCC diagnosis guidelines and readers' judgment in diagnosing HCC using gadoxetic acid-enhanced MRI in patients at high risk for HCC. Materials and Methods This retrospective study included patients who had not undergone treatment, were at risk for HCC, and who underwent gadoxetic acid-enhanced MRI from January 2015 to June 2018 from 11 tertiary hospitals in South Korea. Four radiologists independently reviewed focal liver lesions (FLLs) according to four guidelines: American Association for the Study of Liver Diseases (AASLD)/Liver Imaging Reporting and Data System (LI-RADS), Korean Liver Cancer Association-National Cancer Center (KLCA-NCC), European Association for the Study of the Liver (EASL), and Asian Pacific Association for the Study of the Liver (APASL). Reader judgment (HCC or not HCC) was also recorded. Malignant FLLs were confirmed at pathology, and histologic and clinical follow-up data were used for benign FLLs. The guidelines' diagnostic performance was compared using generalized estimating equations. Additionally, the diagnostic odds ratio was assessed. Results A total of 2445 FLLs (median size, 27.4 mm) were analyzed in 2237 patients (mean age, 59 years ± 11 [SD]; 1666 male patients); 69.3% (1694 of 2445) were HCCs. KLCA-NCC showed the highest accuracy (80.0%; 95% CI: 78.7, 81.2; P = .001), with high sensitivity in Eastern guidelines (APASL, 89.1% [95% CI: 87.8, 90.3]; KLCA-NCC, 78.2% [95% CI: 76.6, 79.7]) and high specificity in Western guidelines (AASLD/LI-RADS, 89.6% [95% CI: 87.8, 91.2]; EASL, 88.1% [95% CI: 86.2, 89.9]) (P = .001). The diagnostic odds ratios were 20.7 (95% CI: 17.0, 25.3) for AASLD/LI-RADS, 18.9 (95% CI: 15.8, 22.6) for KLCA-NCC, 16.8 (95% CI: 13.8, 20.4) for EASL, and 8.9 (95% CI: 7.4, 10.7) for APASL. The readers' judgment demonstrated higher accuracy than that of the guidelines (accuracy, 86.0%; 95% CI: 84.9, 86.9; P = .001). Conclusion Among four different international HCC diagnosis guidelines, Eastern guidelines demonstrated higher sensitivity, whereas Western guidelines displayed higher specificity. KLCA-NCC achieved the highest accuracy, and AASLD/LI-RADS exhibited the highest diagnostic odds ratio. © RSNA, 2024 Supplemental material is available for this article.

Effect of hepatic steatosis on native T1 mapping of 3T magnetic resonance imaging in the assessment of T1 values for patients with non-alcoholic fatty liver disease.

PURPOSE: This study investigated whether T1 values in native T1 mapping of 3T magnetic resonance imaging (MRI) of the liver were affected by the fatty component. METHODS: This prospective study involved 340 participants from a population-based cohort study between May 8, 2018 and August 8, 2019. Data obtained included: (1) hepatic stiffness according to magnetic resonance elastography (MRE); (2) T1 value according to T1 mapping; (3) fat fraction and iron concentration from multi-echo Dixon; and (4) clinical indices of hepatic steatosis including body mass index, waist circumference, history of diabetes, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transpeptidase, and triglycerides. The correlations between T1 value and fat fraction, and between T1 value and liver stiffness were assessed using Pearson's correlation coefficient. The independent two-sample t-test was used to evaluate the differences in T1 values according to the presence or absence of hepatic steatosis, and the one-way analysis of variance was used to evaluate the difference in T1 value by grading of hepatic steatosis according to MRI-based proton density fat fraction (PDFF). In addition, univariate and multivariate linear regression analyses were performed to determine whether other variables influenced the T1 value. RESULTS: T1 value showed a positive correlation with the fat fraction obtained from PDFF (r = 0.615, P < 0.001) and with the liver stiffness obtained from MRE (r = 0.370, P < 0.001). Regardless of the evaluation method, the T1 value was significantly increased in subjects with hepatic steatosis (P < 0.001). When comparing hepatic steatosis grades based on MRI-PDFF, the mean T1 values were significantly different in all grades, and the T1 value tended to increase as the grade increased (P < 0.001, P for trend <0.001). On multiple linear regression analysis, the T1 value was influenced by MRI-PDFF, calculated liver iron concentration, liver stiffness, and serum aspartate aminotransferase level. CONCLUSION: The T1 value obtained by current T1 mapping of 3T MRI was affected by the liver fat component and several other factors such as liver stiffness, iron concentration, and inflammation.

Corona enhancement can substitute enhancing capsule in the imaging diagnosis of small (≤ 3 cm) HCCs on gadoxetic acid-enhanced MRI.

OBJECTIVES: This study aimed to elucidate the relationship between gadoxetic acid-enhanced magnetic resonance imaging (MRI) features-enhancing capsule, corona enhancement or hypointense rim-observed in hepatocellular carcinomas (HCCs). METHODS: Of the HCCs surgically confirmed during a 5-year period (2013-2017), ≤ 3-cm lesions (n = 83) in 78 patients were evaluated. Presence of corona enhancement and enhancing capsule on multiphasic dynamic imaging and presence of hypointense rim on hepatobiliary phase imaging were determined retrospectively by two independent observers. The relationship among the three imaging features was statistically analysed and correlated with the presence of histologic fibrous capsules, tumour differentiation and gross morphologic type. RESULTS: There was substantial overall interobserver agreement in determining the presence of the three imaging features. Sixty (72.3%) lesions had histologic fibrous capsule positively correlated with all three imaging features (p < 0.05). Corona enhancement was the most common (66.3%) feature followed by enhancing capsule (61.4%) and hypointense rim (33.7%), and the correspondence rate of enhancing capsule to corona enhancement was 68.6% (p = 0.004). Corona enhancement was more frequently observed in moderately differentiated HCCs than other lesions (p = 0.012) and not dependent (p = 0.465) on the tumour size, while enhancing capsule was significantly dependent on tumour size, as indicated by univariate (p < 0.001) and multivariate analyses (odds ratio, 4.241; p = 0.002). CONCLUSIONS: Among the capsular features, corona enhancement might closely relate to enhancing capsule in HCCs. Corona enhancement was not dependent on tumour size and had the highest incidence of appearance on gadoxetic acid-enhanced multiphasic dynamic MRI. KEY POINTS: • Enhancing capsule has a limited role in the LI-RADS categorisation during gadoxetic acid-enhanced MRI. • Appearance of corona enhancement is closely related to enhancing capsule and is not dependent on size of HCCs. • Corona enhancement can substitute enhancing capsule in the diagnosis of HCCs during multiple arterial and portal venous phase gadoxetic acid-enhanced MRI.

Retrospective Comparison of Renal Ultrasonographic and Clinical Findings in Patients with Rhabdomyolysis.

BACKGROUND: This study evaluated the ultrasonographic and clinical findings of two groups with rhabdomyolysis, who showed abnormal or normal ultrasonographic findings of kidneys. METHODS: Two groups (n = 78) of abnormal (A) and normal (B) renal ultrasonographic findings were included. Multiple laboratory findings were assessed within 2 days before or after ultrasonography. Student's t-test or Mann-Whitney U-test was used for statistical analysis. RESULTS: The variable causes of rhabdomyolysis were intense exercise, burn, operation, shivering, and drug intoxication, etc. Group A (n = 26; M:F = 19:7) showed enlarged both kidneys, increased parenchymal thickness, and increased (n = 23, 88.5%) or decreased (n = 3, 11.5%) cortical echogenicity. Group A also showed elevated blood urea nitrogen (BUN), creatinine, potassium, and prolonged activated partial thromboplastin time (aPTT), compared with those in Group B (n = 52; M:F = 36:16), and these results were statistically significant (P < 0.01). The myoglobin in serum and urine, creatine kinase, prothrombin time, dark urine, and microscopic hematuria were not statistically different between the two groups. CONCLUSION: Patients with elevated BUN, creatinine, potassium, and prolonged aPTT showed the ultrasonographic findings of acute kidney injury, but other parameters were not statistically different between the two groups.

Texture Analysis of Hepatocellular Carcinoma on Magnetic Resonance Imaging: Assessment for Performance in Predicting Histopathologic Grade.

OBJECTIVE: The aim of the study was to evaluate the performance of texture analysis for discriminating the histopathological grade of hepatocellular carcinoma (HCC) on magnetic resonance imaging. METHODS: Preoperative magnetic resonance imaging data from 101 patients with HCC, including T2-weighted imaging, arterial phase, and apparent diffusion coefficient mapping, were analyzed using texture analysis software (TexRAD). Differences among the histological groups were analyzed using the Mann-Whitney U test. The performance of texture features was evaluated using receiver operating characteristic analysis. RESULTS: Entropy was the most significantly relevant texture feature for distinguishing each histological grade group of HCC (P < 0.05). In ROC analysis, entropy with spatial scale filter 3 (area under curve the receiver operating characteristic curve [AUC], 0.778), mean with coarse filter (spatial scale filter 5; AUC, 0.670), and skewness without filtration (AUC, 0.760) had the highest AUC value on T2-weighted imaging, arterial phase, and apparent diffusion coefficient maps, respectively. CONCLUSIONS: Magnetic resonance imaging texture analysis demonstrated potential for predicting the histopathological grade of HCCs.

Sclerotic changes of cavernous hemangioma in the cirrhotic liver: long-term follow-up using dynamic contrast-enhanced computed tomography.

PURPOSE: To determine the intra- and extralesional factors that predict sclerotic degeneration of hepatic hemangiomas in the cirrhotic liver on long-term follow-up computed tomography (CT) examinations. MATERIALS AND METHODS: Fifty-seven hepatic hemangiomas (> 5 mm in diameter) in 41 cirrhotic patients, recruited over a 5-year period (January 2005-December 2009), were subjected to CT to determine which factors predict sclerotic contraction or degeneration in hemangiomas. Prior and follow-up CT examinations (from 2000 to 2018) were included to observe time-related changes. The patients' gender, age, cause of cirrhosis, progression of background liver cirrhosis, lesion size/location/contrast enhancement pattern, and serum aspartate transaminase to platelet ratio index were correlated with sclerotic changes of each lesion. RESULTS: According to the dynamic CT features, 36 of 57 (63%) hemangiomas were determined to have sclerotic changes during the follow-up period (1.1-14.4 years, median: 7.8 years), including 28 lesions (49%) reduced by ≥ 20% in diameter. In univariate analysis, age (p = 0.047) and morphological progression of background cirrhosis (p = 0.013) were significantly related to sclerotic change of hemangiomas. In the logistic regression analysis, only morphological progression of background liver cirrhosis independently predicted sclerotic change (odds ratio: 4.88, p = 0.007). With the exception of exophytic location free from size reduction (p = 0.023 in multivariate analysis), no other analyzed factors were significantly correlated with sclerotic changes. CONCLUSION: Overall, sclerotic changes of hepatic cavernous hemangioma followed the morphological progression of background liver cirrhosis, while exophytic lesions tended to be free of size reduction.

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.

Efficacy of a paclitaxel-eluting biliary metal stent with sodium caprate in malignant biliary obstruction: a prospective randomized comparative study.

BACKGROUNDS: The placement of a self-expandable metal stent (SEMS) is widely used in patients with unresectable malignant biliary obstructions, but SEMSs are susceptible to occlusion by tumor ingrowth or overgrowth. The efficacy and safety of a novel paclitaxel-eluting biliary metal stent incorporating sodium caprate (MSCPM-III) were compared prospectively with those of a covered metal stent (CMS) in patients with malignant biliary obstructions. METHODS: Patients with unresectable distal malignant biliary obstructions (n = 106) were prospectively enrolled in this study at multiple treatment centers. Stents were placed endoscopically: MSCPM-III in 54 patients and CMS in 51 patients. The patients received systemic chemotherapy regimens according to their disease characteristics. RESULTS: The two groups did not differ significantly in basic characteristics or mean follow-up period. Stent occlusion occurred in 14 patients who received MSCPM-III and in 11 patients who received CMS. Time to recurrent biliary obstruction (RBO) and survival time did not differ significantly between the two groups (P  = 0.84 and P = 0.29, respectively). However, tumor size at 2 months after stent insertion was significantly decreased in patients in the MSCPM-III group with bile duct cancers or those who experienced stent migration compared with the CMS group. Complications, including cholangitis and pancreatitis, were found to be acceptable in both groups. CONCLUSIONS: Although compared with a CMS the MSCPM-III did not significantly influence time to RBO or survival duration in patients with malignant biliary obstructions, MSCPM-III reduced tumor volume and was used safely in humans.

Three cases of pancreatic pseudocysts associated with dorsal pancreatic agenesis.

Agenesis of the dorsal pancreas (ADP) is an extremely rare congenital anomaly. Human pancreas is formed by ventral and dorsal endodermal buds of the foregut endoderm. The dorsal bud forms the upper part of the head, neck, body, and tail of the pancreas and the ventral bud generates most of the head and uncinate process. ADP is derived from the embryologic failure of the dorsal pancreatic bud to form the pancreatic body and tail. ADP can be related to some diseases and conditions such as pancreatitis, hypoglycemia, and rarely pancreatic tumors. The association between cystic lesions with ADP has previously been reported. Three cases of cystic lesions of the pancreas with ADP were diagnosed clinically based on the imaging features and without any past history of pancreatitis. However, the pathologic diagnosis of resected lesions confirmed pseudocysts without pathologic evidence of tumor. We report 3 cases of pancreatic pseudocysts associated with ADP.

Apparent diffusion coefficient of hepatocellular carcinoma on diffusion-weighted imaging: Histopathologic tumor grade versus arterial vascularity during dynamic magnetic resonance imaging.

OBJECTIVES: Apparent diffusion coefficient (ADC) has been suggested to reflect the tumor grades of hepatocellular carcinomas (HCCs); i.e., it can be used as a biomarker to predict the patients' prognosis. To verify its feasibility as a biomarker, the present study sought to determine how the ADC values of HCC are affected by a tumor's histopathologic grade and arterial vascularity. MATERIALS AND METHODS: From 131 consecutive patients, 141 surgically resected HCCs (16 well-differentiated [wd-HCCs], 83 moderately-differentiated [md-HCCs], and 42 poorly-differentiated HCCs [pd-HCCs]) were subjected to a comparison of the tumors' arterial vascularity (non-, slightly-, or markedly-hypervascular) determined on dynamic magnetic resonance imaging (MRI) and the ADC was measured retrospectively. RESULTS: The pd-HCCs (1.05±0.16 × 10-3 mm2/s) had a significantly lower ADC than md-HCCs (1.16±0.21 × 10-3 mm2/s; p = 0.010), but there was no significant difference compared to wd-HCCs (1.11±0.18 × 10-3 mm2/s; p = 0.968). The mean ADC was significantly higher in markedly hypervascular lesions (1.20±0.20 × 10-3 mm2/s) than in nonhypervascular lesions (0.95±0.14 × 10-3mm2/s; p<0.001) or slightly hypervascular lesions (1.04±0.15 × 10-3mm2/s; p<0.001). The ADC values and arterial vascularity were significantly correlated in wd-HCCs (p = 0.005) and md-HCCs (p<0.001). The mean ADC of pd-HCCs was significantly lower than those of other lesions, even in the markedly hypervascular lesion subgroup (p = 0.020). CONCLUSION: Although pd-HCC constantly shows low ADCs regardless of arterial vascularities, ADCs cannot stably stratify histopathologic tumor grades due to the variable features of wd-HCCs; and the ADC should be used with caution as a tumor biomarker of HCC.

Serous Cystic Neoplasms of the Pancreas: Endoscopic Ultrasonographic Versus Computed Tomography and Magnetic Resonance Imaging Features of Surgically Removed Masses.

Our purpose was to assess the endoscopic ultrasonography (EUS) features of serous cystic neoplasms (SCNs) of the pancreas in determining the surgical removal compared with computed tomography (CT) and magnetic resonance imaging (MRI) features. For 33 consecutive patients with 34 surgically confirmed SCNs over the past 11 years, preoperative EUS features were compared with those of CT and MRI (CT&MRI). Besides the lesion size and location, a retrospective analysis of the various imaging features was performed by 2 observers to understand the characteristics that determine the need for surgical intervention in terms of multiplicity of locules, calcification, mural thickening, mural nodules, ductal communication, and main pancreatic duct dilatation in addition to the gross morphologic type: microcystic, macrocystic (>1 cm), mixed, or solid. The most common gross morphologic type was mixed lesions, which consisted of microcystic and macrocystic components (15/34; 44%), followed by microcystic (38%), macrocystic (15%), and solid (3%) lesions. A minority (5/34; 18%) of the lesions showed main pancreatic duct dilatation (upstream, n = 3; downstream, n = 0; diffuse, n = 2). Mural nodules or solid components were more frequently noted in EUS (67%) than in CT&MRI (25%; P = 0.001), whereas other findings showed no remarkable difference between EUS and CT&MRI (P > 0.05). In determining the surgical treatment of multiloculated cystic lesions, interpretation of EUS features for the presence of solid component or mural nodules should be more carefully determined, especially in the patients with suggestive features of SCN on CT or MRI to avoid unnecessary surgery.

Hepatic cavernous hemangiomas: long-term (> 5 years) follow-up changes on contrast-enhanced dynamic computed tomography or magnetic resonance imaging and determinant factors of the size change.

PURPOSE: To investigate the very long-term (> 5 years) follow-up changes of hepatic cavernous hemangiomas and to evaluate possible determinant factors for the changes. MATERIALS AND METHODS: Among 1115 consecutive patients suspected of having hepatic hemangiomas based on imaging features, 101 patients with comparable computed tomography or magnetic resonance imaging data during a 5-year follow-up interval in the Picture Archiving and Communication System were analyzed. Two radiologists independently determined the largest dimension of each lesion on axial images. In addition to background liver fibrosis or steatosis on imaging, histories of use of chemotherapeutic agents were checked from the patients' records. The final size change of the hemangioma was categorized into three groups compared with the initial diameter (increased, > 120%; no change, 80-120%; decreased, < 80%). RESULTS: Among the 101 hemangiomas, 32 lesions (31.7%) were enlarged and 21 lesions (20.8%) were shrunken during intervals of 60-157 (median, 81) months. Younger patients showed a higher prevalence of lesion enlargement (mean age: enlarged, 47.3 years; no change, 52.8 years; shrunken, 57.1 years; p = 0.003). In 15 patients with cirrhosis, the lesions (shrunken, n = 7; enlarged, n = 1) showed a higher tendency of size decrease (p = 0.009), whereas other factors did not show statistical significance (p > 0.05). Only a minor proportion (1%, n = 1) of the lesions showed size fluctuation during follow-up. CONCLUSION: During the long-term (5-13 years) follow-up, about 50% of the hepatic hemangiomas were enlarged or shrunken to > 20% of the initial diameter. Aside from the cirrhosis and aging factors, the size changes seemed sporadic.

Factors affecting survival after concurrent chemoradiation therapy for advanced hepatocellular carcinoma: a retrospective study.

BACKGROUND: Concurrent chemoradiation therapy (CCRT) followed by hepatic arterial infusional chemotherapy (HAIC) was reported to be effective for advanced hepatocellular carcinoma (HCC) with portal vein thrombosis. However, transarterial chemoembolization (TACE) is not preferred in this setting. The aim of this study was to assess the factors affecting survival after CCRT, including additional TACE during repeated HAIC. METHODS: Thirty-eight patients who underwent CCRT as the initial treatment for Barcelona Clinic Liver Cancer stage C HCC with vascular invasion between 2009 and 2016 were reviewed retrospectively. During CCRT, 5-fluorouracil (5-FU) was infused via chemoport during the first and last five days of five weeks of external beam radiation therapy. After CCRT, repeated HAIC with cisplatin and 5-FU was performed monthly. Nineteen patients (50%) underwent additional TACE between repeated HAICs. Factors related to overall survival and progression free survival (PFS) were analyzed. RESULTS: The mean age of patients was 55 years (male:female, 33:5). Underlying liver diseases were hepatitis B, hepatitis C and non-B/C in 29, 1 and 8 patients, respectively. The median radiation dose was 4500 cGy. The objective response (OR) rate at one months after CCRT was 36.8%. The median PFS was 7.4 (range, 1.8 - 32.1) months. The median overall survival was 11.6 (range 2.8-65.7) months. Achieving an OR after CCRT (hazard ratio [HR], 0.028; P < 0.001), additional TACE (HR, 0.134, P < 0.001), and further rounds of HAIC (HR, 0.742, P = 0.001) were independent significant factors related to overall survival. The overall survival duration of patients with an OR after CCRT (median 44.2 vs. 6.6 months, P < 0.001) and additional TACE (median 19.8 vs. 9.1 months, P = 0.001) were significantly greater than those without an OR after CCRT or additional TACE. CONCLUSION: Patients who achieved an OR after CCRT, underwent additional TACE, and were subjected to repeated rounds of HAIC following CCRT showed better survival after CCRT for advanced stage of HCC with vascular invasion. A further prospective study is needed to confirm the positive effect of additional TACE after CCRT.

Optimization of Split-Bolus CT Urography: Effect of Differences in Allocation of Contrast Medium and Prolongation of Imaging Delay.

OBJECTIVE: The purpose of this study was to find the optimal allocation ratio of contrast medium (CM) in split-bolus CT urography (CTU) and to investigate the effect of increased imaging delays for synchronous nephrographic-excretory phase imaging. SUBJECTS AND METHODS: One hundred ninety-two patients were randomly assigned to one of three protocols with different allocation ratios of CM: group A, 30% of CM at first bolus and 70% of CM at second bolus; group B, 70% and 30%; or group C, 50% and 50%. Saline (250 mL) was administered after the first CM bolus. Patients were subdivided by different imaging delay times (8, 10, 12, and 14 minutes). The attenuation values of the renal cortex and medulla were measured, and the opacification and maximal caliber of each segment of the ureter were evaluated. RESULTS: Renal cortical enhancement was significantly higher in group A (mean ± SD, 145.9 ± 17.5 HU) than group B (120.6 ± 106.3 HU). No significant difference in renal parenchymal enhancement was found with increased imaging delay times. The opacification and maximal caliber of each ureter segment showed no significant difference with different allocation ratios of CM or increased imaging delay times. CONCLUSION: A split-bolus CTU protocol with a larger CM volume administered at the second injection and an 8-minute imaging delay was the optimal protocol with regard to opacification of the ureter, renal parenchymal enhancement, and shorter examination time.