Do transition and hepatobiliary phase hypointensity improve LI-RADS categorization as an alternative washout: a systematic review and meta-analysis

Modified LR-5 criteria based on gadoxetic acid can improve the sensitivity in the diagnosis of hepatocellular carcinoma

BACKGROUND

Currently, only tumors classified as LR-5 are considered definitive hepatocellular carcinoma (HCC), and no further pathologic confirmation is required to initiate therapy. Previous studies have shown that the sensitivity of LR-5 is modest, and lesions enhanced by gadoxetic acid (Gd-EOB-DTPA) may exhibit lower sensitivity than those enhanced by Gd-DTPA.

AIM

To identify malignant ancillary features (AFs) that can independently and significantly predict HCC in Liver Imaging Reporting and Data System version 2018, and to develop modified LR-5 criteria to improve diagnostic performance on Gd-EOB-DTPA - enhanced magnetic resonance imaging.

METHODS

Imaging data from patients with HCC risk factors who underwent abdominal Gd-EOB-DTPA - enhanced magnetic resonance imaging were collected. Univariate and multivariate logistic regression analyses were performed to determine AFs that could independently and significantly predict HCC. The modified LR-5 criteria involved reclassifying LR-4/LR-3 lesions based on major features combined with independently significant AFs for HCC, or by substituting threshold growth with significant AFs. McNemar's test was used to compare the diagnostic performance of the modified LR-5 criteria.

RESULTS

A total of 244 lesions from 216 patients were included. Transitional phase hypointensity, mild - moderate T2 hyperintensity, and fat in mass (more than adjacent liver) were identified as significant independent predictors of HCC. Using the modified LR-5 criteria (e.g., LR-5-M1: LR-4 + transitional phase hypointensity; LR-5-M4: LR-5 by transitional phase hypointensity instead of threshold growth; LR-5-M5: LR-5 by mild - moderate T2 hyperintensity instead of threshold growth; LR-5-M8: LR-3/LR-4 + any two features of transitional phase hypointensity/mild - moderate T2 hyperintensity/fat in mass), sensitivities were significantly increased (88.5%-89.1%) compared to the standard LR-5 (60.6%; all P values < 0.05), while specificities (84.8%-89.9%) remained largely unchanged (93.7%; all P values > 0.05). The LR-5-M8 criterion achieved the highest sensitivity.

CONCLUSION

Mild - moderate T2 hyperintensity, transitional phase hypointensity, and fat in mass are independent and significant predictors of HCC malignant AFs. The modified LR-5 criteria can improve sensitivity without significantly reducing specificity.

Optimizing predictions: improved performance of preoperative gadobenate-enhanced MRI hepatobiliary phase features in predicting vessels encapsulating tumor clusters in hepatocellular carcinoma-a multicenter study

BACKGROUND

Vessels Encapsulating Tumor Clusters (VETC) are now recognized as independent indicators of recurrence and overall survival in hepatocellular carcinoma (HCC) patients. However, there has been limited investigation into predicting the VETC pattern using hepatobiliary phase (HBP) features from preoperative gadobenate-enhanced MRI.

METHODS

This study involved 252 HCC patients with confirmed VETC status from three different hospitals (Hospital 1: training set with 142 patients; Hospital 2: test set with 64 patients; Hospital 3: validation set with 46 patients). Independent predictive factors for VETC status were determined through univariate and multivariate logistic analyses. Subsequently, these factors were used to construct two distinct VETC prediction models. Model 1 included all independent predictive factors, while Model 2 excluded HBP features. The performance of both models was assessed using the Area Under the Curve (AUC), Decision Curve Analysis, and Calibration Curve. Prediction accuracy between the two models was compared using Net Reclassification Improvement (NRI) and Integrated Discriminant Improvement (IDI).

RESULTS

CA199, IBIL, shape, peritumoral hyperintensity on HBP, and arterial peritumoral enhancement were independent predictors of VETC. Model 1 showed robust predictive performance, with AUCs of 0.836 (training), 0.811 (test), and 0.802 (validation). Model 2 exhibited moderate performance, with AUCs of 0.813, 0.773, and 0.783 in the respective sets. Calibration and decision curves for both models indicated consistent predictions between predicted and actual VETC, benefiting HCC patients. NRI showed Model 1 increased by 0.326, 0.389, and 0.478 in the training, test, and validation sets compared to Model 2. IDI indicated Model 1 increased by 0.036, 0.028, and 0.025 in the training, test, and validation sets compared to Model 2.

CONCLUSION

HBP features from preoperative gadobenate-enhanced MRI can enhance the predictive performance of VETC in HCC.

Is there added value of the hepatobiliary phase of MRI with hepatobiliary contrast agents for hepatocellular carcinoma diagnosis? A meta-analysis

Purpose

So far, there have been published several meta-analyses which focused on hepatocellular carcinoma (HCC) detection with hepatobiliary phase (HBP) contrast agents. However, only a few of them aimed at establishing whether there is any added value of the HBP itself for HCC diagnosis. To answer the question, we performed a systematic literature search with the time limit going back to 2010.

Material and methods

True positive, false positive, false negative, and true negative values with and without the HBP were extracted from the included studies. Pooled sensitivities and specificities with and without the HBP were calculated and summary receiver operating characteristics curves were drawn to assess the diagnostic performance of the studies with and without the HBP.

Results

A total of 13 studies were included involving 1184 HCC lesions. In 13 studies without the HBP, the pooled sensitivity, specificity, and area under the curve (AUC) were 0.83, 0.89 and 0.94 respectively. In 13 studies with the HBP, the pooled sensitivity, specificity and AUC were 0.91, 0.85 and 0.98 respectively.

Conclusions

We found no statistically significant differences in sensitivities between studies with and without the HBP (p = 0.1651).

Simplified liver imaging reporting and data system for the diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND

The liver imaging reporting and data system (LI-RADS) diagnostic table has 15 cells and is too complex. The diagnostic performance of LI-RADS for hepatocellular carcinoma (HCC) is not satisfactory on gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI).

AIM

To evaluate the ability of the simplified LI-RADS (sLI-RADS) to diagnose HCC on EOB-MRI.

METHODS

A total of 331 patients with 356 hepatic observations were retrospectively analysed. The diagnostic performance of sLI-RADS A-D using a single threshold was evaluated and compared with LI-RADS v2018 to determine the optimal sLI-RADS. The algorithms of sLI-RADS A-D are as follows: The single threshold for sLI-RADS A and B was 10 mm, that is, classified observations ≥ 10mm using an algorithm of 10-19 mm observations (sLI-RADS A) and ≥ 20 mm observations (sLI-RADS B) in the diagnosis table of LI-RADS v2018, respectively, while the classification algorithm remained unchanged for observations < 10 mm; the single threshold for sLI-RADS C and D was 20 mm, that is, for < 20 mm observations, the algorithms for < 10 mm observations (sLI-RADS C)and 10-19 mm observations (sLI-RADS D) were used, respectively, while the algorithm remained unchanged for observations ≥ 20 mm. With hepatobiliary phase (HBP) hypointensity as a major feature (MF), the final sLI-RADS (F-sLI-RADS) was formed according to the optimal sLI-RADS, and its diagnostic performance was evaluated. The times needed to classify the observations according to F-sLI-RADS and LI-RADS v2018 were compared.

RESULTS

The optimal sLI-RADS was sLI-RADS D (with a single threshold of 20 mm), because its sensitivity was greater than that of LI-RADS v2018 (89.8% vs 87.0%, P = 0.031), and its specificity was not lower (89.4% vs 90.1%, P > 0.999). With HBP hypointensity as an MF, the sensitivity of F-sLI-RADS was greater than that of LI-RADS v2018 (93.0% vs 87.0%, P < 0.001) and sLI-RADS D (93.0% vs 89.8%, P = 0.016), without a lower specificity (86.5% vs 90.1%, P = 0.062; 86.5% vs 89.4%, P = 0.125). Compared with that of LI-RADS v2018, the time to classify lesions according to F-sLI-RADS was shorter (51 ± 21 s vs 73 ± 24 s, P < 0.001).

CONCLUSION

The use of sLI-RADS with HBP hypointensity as an MF may improve the sensitivity of HCC diagnosis and reduce lesion classification time.

Simplified liver imaging reporting and data system for the diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND

The liver imaging reporting and data system (LI-RADS) diagnostic table has 15 cells and is too complex. The diagnostic performance of LI-RADS for hepatocellular carcinoma (HCC) is not satisfactory on gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI).

AIM

To evaluate the ability of the simplified LI-RADS (sLI-RADS) to diagnose HCC on EOB-MRI.

METHODS

A total of 331 patients with 356 hepatic observations were retrospectively analysed. The diagnostic performance of sLI-RADS A-D using a single threshold was evaluated and compared with LI-RADS v2018 to determine the optimal sLI-RADS. The algorithms of sLI-RADS A-D are as follows: The single threshold for sLI-RADS A and B was 10 mm, that is, classified observations ≥ 10mm using an algorithm of 10-19 mm observations (sLI-RADS A) and ≥ 20 mm observations (sLI-RADS B) in the diagnosis table of LI-RADS v2018, respectively, while the classification algorithm remained unchanged for observations < 10 mm; the single threshold for sLI-RADS C and D was 20 mm, that is, for < 20 mm observations, the algorithms for < 10 mm observations (sLI-RADS C)and 10-19 mm observations (sLI-RADS D) were used, respectively, while the algorithm remained unchanged for observations ≥ 20 mm. With hepatobiliary phase (HBP) hypointensity as a major feature (MF), the final sLI-RADS (F-sLI-RADS) was formed according to the optimal sLI-RADS, and its diagnostic performance was evaluated. The times needed to classify the observations according to F-sLI-RADS and LI-RADS v2018 were compared.

RESULTS

The optimal sLI-RADS was sLI-RADS D (with a single threshold of 20 mm), because its sensitivity was greater than that of LI-RADS v2018 (89.8% vs 87.0%, P = 0.031), and its specificity was not lower (89.4% vs 90.1%, P > 0.999). With HBP hypointensity as an MF, the sensitivity of F-sLI-RADS was greater than that of LI-RADS v2018 (93.0% vs 87.0%, P < 0.001) and sLI-RADS D (93.0% vs 89.8%, P = 0.016), without a lower specificity (86.5% vs 90.1%, P = 0.062; 86.5% vs 89.4%, P = 0.125). Compared with that of LI-RADS v2018, the time to classify lesions according to F-sLI-RADS was shorter (51 ± 21 s vs 73 ± 24 s, P < 0.001).

CONCLUSION

The use of sLI-RADS with HBP hypointensity as an MF may improve the sensitivity of HCC diagnosis and reduce lesion classification time.

ESR Essentials: diagnosis of hepatocellular carcinoma-practice recommendations by ESGAR

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and a leading cause of cancer related death worldwide. Current guidelines for the noninvasive diagnosis of HCC are provided by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD) which endorsed the Liver Imaging Reporting and Data System (LI-RADS) algorithm, the Korean Liver Cancer Association-National Cancer Center (KLCA-NCC), and the Asian-Pacific Association for the Study of the Liver (APASL). These allow the diagnosis of HCC in high-risk patients in the presence of typical imaging features on contrast-enhanced CT, MRI, or contrast-enhanced ultrasound. Size, non-rim arterial phase hyperenhancement, non-peripheral washout, enhancing capsule, and growth are major imaging features and they should be combined for the diagnosis of HCC. This article provides concise and relevant practice recommendations aimed at general radiologist audience, summarizing the best practice and informing on the essential imaging criteria for the diagnosis of HCC, while also discussing the high-risk population criteria, imaging modalities, and imaging features according to the current guidelines. KEY POINTS: • Noninvasive diagnosis of hepatocellular carcinoma (HCC) can be provided only in patients at high risk. • Contrast-enhanced CT or MRI are the first-line imaging exams for the diagnosis of HCC. • Major imaging features should be combined to provide the diagnosis of definitive HCC.

Liver imaging reporting and data system diagnostic performance in hepatocellular carcinoma when modifying the definition of "washout" on gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND AND STUDY AIMS

The sensitivity of the Liver Imaging Reporting and Data System (LI-RADS) in the diagnosis of hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) was suboptimal. This study evaluated the LI-RADS diagnostic performance in HCC when modifying the definition of washout using the transition phase (TP) or hepatobiliary phase (HBP) hypointensity on EOB-MRI.

PATIENTS AND METHODS

This retrospective study included patients at high risk of HCC who underwent EOB-MRI from June 2016 to June 2021. Three modified LI-RADS (mLI-RADS) algorithms were formulated according to different definitions of washout as follows: (a) portal venous phase (PVP) or TP hypointensity, (b) PVP or HBP hypointensity, and (c) PVP or TP or HBP hypointensity. Diagnostic performance, including sensitivity, specificity, and accuracy, was compared between mLI-RADS and LI-RADS v2018 using McNemar's test.

RESULTS

A total of 379 patients with 426 pathologically confirmed hepatic observations (250 HCCs, 88 nonHCC malignancies, and 88 benign lesions) were included in our study. The sensitivity rates of mLI-RADS a-c (80.0 %, 80.8 %, and 80.8 %) were all higher than that of LI-RADS v2018 (74.4 %) (all p < 0.05). The specificity rates of mLI-RADS a-c (86.9 %, 85.8 %, and 85.8 %) were all slightly lower than that of LI-RADS v2018 (88.6 %), although no statistically significant difference was noted (all p > 0.05). The accuracies of the three mLI-RADS algorithms were the same and were all higher than that of LI-RADS v2018 (82.9 % vs. 80.3 %, all p < 0.05).

CONCLUSION

When the definition of washout appearance was extended to TP or HBP hypointensity on EOB-MRI, the diagnostic sensitivity of LI-RADS for HCC improved without decreasing specificity.

Based on Gadolinium Ethoxybenzyl DTPA-Enhanced MRI: Diagnostic Performance of the Category-Modified LR-5 Criteria in Patients At Risk for Hepatocellular Carcinoma

Introduction: We aimed to modify the LR-5 strategy to improve the diagnostic sensitivity for hepatocellular carcinoma (HCC) in high-risk patients while maintaining specificity. Methods: This study retrospectively analyzed 412 patients with 445 liver observations who underwent preoperative gadolinium ethoxybenzyl DTPA (GD-EOB-DTPA)-enhanced MRI followed by surgical procedures or biopsies. All observations were classified according to LI-RADS v2018, and the classifications were adjusted by modifying major features (MF)(substituting threshold growth with a more HCC-specific ancillary features (AF): presence of blood products within the mass, arterial phase hyperenhancement (APHE) was interpreted with hypointensity on precontrast imaging- isointensity in arterial phase (AP) and extending washout to transitional phase (TP)(2 min)). The specificity, sensitivity, and positive predictive value (PPV) were assessed to compare LR-5 (definitely HCC) diagnostic efficacy between LI-RADS version 2018 and modified LI-RADS. Results: Apart from nonenhancing "capsule", the interreader agreement of MFs and HCC-specific AFs between the two readers reached substantial or excellent ranges (κ values ranging from 0.631 to 0.911). According to LI-5 v2018, the specificity, sensitivity and PPV of HCC were 90.74%, 82.35%, and 98.17%, respectively. Based on a more HCC-specific AF, signal intensity in AP and TP (2 min), the sensitivity of the three modified strategies were 86.19%, 93.09%, 96.67% (P < .05)), while maintaining high specificity and PPV rates at 88.89% and 98.25% (P > .05) Conclusion: Further investigation into the efficacy of threshold growth as a MF is warranted. By utilizing GD-EOB-DTPA-enhanced MRI, enhancing the sensitivity of the modified LR-5 category may be achieved without compromising specificity and PPV in diagnosing HCC among high-risk patients.

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.