Multidetector helical CT plus superparamagnetic iron oxide-enhanced MR imaging for focal hepatic lesions in cirrhotic liver: a comparison with multi-phase CT during hepatic arteriography

Added value of contrast enhancement boost images in routine multiphasic contrast-enhanced CT for the diagnosis of small (<20 mm) hypervascular hepatocellular carcinoma

PURPOSE

To investigate the added value of contrast enhancement boost (CE-boost) images in multiphasic contrast-enhanced CT (CE-CT) for diagnosing small (<20 mm) hypervascular hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This retrospective study included 69 patients (age, 74 ± 8 years; 52 men) with 70 hypervascular HCCs (<20 mm) who underwent multiphasic CE-CT (pre-contrast, late arterial phase [LAP], portal venous phase [PVP], and equilibrium phase). Two types of CE-boost images were generated by subtracting PVP from LAP (LA-PV) images and LAP from PVP (PV-LA) images to enhance the contrast effect of hepatic arterial and portal venous perfusion more selectively. Tumor-to-liver contrast-to-noise ratios (CNRs) in CE-boost images were compared with those in CE-CT images using the Wilcoxon signed-rank test. Two independent readers reviewed the imaging datasets: CE-CT alone and CE-CT with CE-boost images. The diagnostic performance of each dataset was compared using jackknife alternative free-response receiver operating characteristics (JAFROC-1).

RESULTS

The tumor-to-liver CNRs in the LA-PV (6.4 ± 3.0) and PV-LA (-3.3 ± 2.1) images were greater than those in the LAP (3.2 ± 1.7) and PVP images (-1.1 ± 1.4) (p <.001 for both). The reader-averaged figures of merit were 0.751 for CE-CT alone and 0.807 for CE-CT with CE-boost images (p <.001). Sensitivities increased by adding CE-boost images for both readers (p <.001 and = 0.03), while positive predictive values were equivalent (p >.99).

CONCLUSION

Adding CE-boost images to multiphasic CE-CT can improve the diagnostic accuracy and sensitivity for small hypervascular HCC by increasing the tumor-to-liver CNR.

Computed tomography for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and fourth in terms of cancer deaths. In clinical practice, computed tomography (CT) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-foetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study CT or magnetic resonance imaging (MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is valid to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma is, therefore, missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of CT may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CT in people with chronic liver disease, who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma.

OBJECTIVES

Primary: to assess the diagnostic accuracy of multidetector, multiphasic contrast-enhanced CT for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of CT for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Trials Register, Cochrane Hepato-Biliary Diagnostic-Test-Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science until 4 May 2021. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of CT for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 21 studies, with a total of 3101 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Regarding applicability in the patient selection domain, we judged 14% (3/21) of studies to be at low concern and 86% (18/21) of studies to be at high concern owing to characteristics of the participants who were on waiting lists for orthotopic liver transplantation. CT for hepatocellular carcinoma of any size and stage: sensitivity 77.5% (95% CI 70.9% to 82.9%) and specificity 91.3% (95% CI 86.5% to 94.5%) (21 studies, 3101 participants; low-certainty evidence). CT for resectable hepatocellular carcinoma: sensitivity 71.4% (95% CI 60.3% to 80.4%) and specificity 92.0% (95% CI 86.3% to 95.5%) (10 studies, 1854 participants; low-certainty evidence). In the three studies at low concern for applicability (861 participants), we found sensitivity 76.9% (95% CI 50.8% to 91.5%) and specificity 89.2% (95% CI 57.0% to 98.1%). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results.

AUTHORS' CONCLUSIONS

In the clinical pathway for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, CT has roles as a confirmatory test for hepatocellular carcinoma lesions, and for staging assessment. We found that using CT in detecting hepatocellular carcinoma of any size and stage, 22.5% of people with hepatocellular carcinoma would be missed, and 8.7% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 28.6% of people with resectable hepatocellular carcinoma would improperly not be resected, while 8% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.

Imaging Techniques for the Diagnosis of Hepatocellular Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

Several imaging modalities are available for diagnosis of hepatocellular carcinoma (HCC).

PURPOSE

To evaluate the test performance of imaging modalities for HCC.

DATA SOURCES

MEDLINE (1998 to December 2014), the Cochrane Library Database, Scopus, and reference lists.

STUDY SELECTION

Studies on test performance of ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI).

DATA EXTRACTION

One investigator abstracted data, and a second investigator confirmed them; 2 investigators independently assessed study quality and strength of evidence.

DATA SYNTHESIS

Few studies have evaluated imaging for HCC in surveillance settings. In nonsurveillance settings, sensitivity for detection of HCC lesions was lower for ultrasonography without contrast than for CT or MRI (pooled difference based on direct comparisons, 0.11 to 0.22), and MRI was associated with higher sensitivity than CT (pooled difference, 0.09 [95% CI, 0.07 to 12]). For evaluation of focal liver lesions, there were no clear differences in sensitivity among ultrasonography with contrast, CT, and MRI. Specificity was generally 0.85 or higher across imaging modalities, but this item was not reported in many studies. Factors associated with lower sensitivity included use of an explanted liver reference standard, and smaller or more well-differentiated HCC lesions. For MRI, sensitivity was slightly higher for hepatic-specific than nonspecific contrast agents.

LIMITATIONS

Only English-language articles were included, there was statistical heterogeneity in pooled analyses, and costs were not assessed. Most studies were conducted in Asia and had methodological limitations.

CONCLUSION

CT and MRI are associated with higher sensitivity than ultrasonography without contrast for detection of HCC; sensitivity was higher for MRI than CT. For evaluation of focal liver lesions, the sensitivities of ultrasonography with contrast, CT, and MRI for HCC are similar.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (

PROSPERO

CRD42014007016).

Performance of gadoxetic acid-enhanced MRI for detecting hepatocellular carcinoma in recipients of living-related-liver-transplantation: comparison with dynamic multidetector row computed tomography and angiography-assisted computed tomography

PURPOSE

To clarify the diagnostic performance of gadoxetic acid-enhanced MRI for the detection of hepatocellular carcinoma (HCC) in recipients of living related-liver transplantation (LRLT).

MATERIALS AND METHODS

This retrospective study group consisted of 15 patients with 61 HCCs who each underwent multidetector row computed tomography (MDCT), gadoxetic acid-enhanced MRI, and angiography-assisted computed tomography (CT) before LRLT. The three modalities were compared for their ability to detect HCC. Two blinded readers independently reviewed the images obtained by each modality for the presence of HCC on a segment-by-segment basis using a 5-point confidence scale. The diagnostic performance of the modalities was evaluated in a receiver operating characteristic (ROC) analysis. The area under the ROC curve (Az), sensitivity, specificity, and accuracy were compared for the three modalities.

RESULTS

No significant difference in Az, sensitivity, specificity, or accuracy was obtained among gadoxetic acid-enhanced MRI, MDCT, and angiography-assisted CT for both readers. For reader 1, the sensitivity (55.6%) and the accuracy (84.7%) of angiography-assisted CT were significantly higher than those of MDCT (33.3% and 78.0%) (P < 0.05).

CONCLUSION

Gadoxetic acid-enhanced MRI has a relatively high diagnostic ability to detect HCC even in recipients of LRLT, equivalent to the abilities of MDCT and angiography-assisted CT.

Gadoxetic acid-enhanced MRI compared with CT during angiography in the diagnosis of hepatocellular carcinoma

PURPOSE

To assess the value of gadoxetic acid-enhanced magnetic resonance imaging (MRI) for the pre-therapeutic detection of hepatocellular carcinoma (HCC) using receiver operating characteristic (ROC) analysis with the combination of computed tomography (CT) arterial portography and CT hepatic arteriography (CTAP/CTHA).

MATERIALS AND METHODS

A total of 54 consecutive patients with 87 nodular HCCs were retrospectively analyzed. All HCC nodules were confirmed pathologically. Three blinded readers independently reviewed 432 hepatic segments, including 78 segments with 87 HCCs. Each reader read two sets of images: Set 1, CTAP/CTHA; Set 2, gadoxetic acid-enhanced MRI including a gradient dual-echo sequence and diffusion-weighted imaging (DWI). The ROC method was used to analyze the results. The sensitivity, specificity, positive predictive value, negative predictive value and sensitivity according to tumor size were evaluated.

RESULTS

For each reader, the area under the curve was significantly higher for Set 2 than for Set 1. The mean area under the curve was also significantly greater for Set 2 than for Set 1 (area under the curve, 0.98 vs. 0.93; P=.0009). The sensitivity was significantly higher for Set 2 than for Set 1 for all three readers (P=.012, .013 and .039, respectively). The difference in the specificity, positive predictive values and negative predictive values of the two modalities for each reader was not significant (P>.05).

CONCLUSION

Gadoxetic acid-enhanced MRI including a gradient dual-echo sequence and DWI is recommended for the pre-therapeutic evaluation of patients with HCC.

C-arm CT during hepatic arteriography tumour-to-liver contrast: intraindividual comparison of three different contrast media application protocols

OBJECTIVE

To compare tumour-to-liver contrast (TLC) of C-arm CT during hepatic arteriography (CACTHA) acquired using three protocols in patients with HCC.

METHODS

This prospective study was IRB approved and informed consent was obtained from each patient. Twenty-nine patients (mean age, 68 ± 7 years; 27 men) with 55 HCCs (mean diameter, 2.6 ± 1.5 cm) underwent three different CACTHA protocols in random order before chemoembolisation. Contrast medium (100 mg iodine/ml) was injected into the common hepatic artery (flow rate 4 ml/s). The imaging delay for the start of the CACTHA examination was 4 s (protocol A), 8 s (protocol B) and 12 s (protocol C) (total amount of injected contrast medium: 48 ml, 64 ml, 80 ml). TLC was measured by placing regions of interest (ROIs) in the HCC and liver parenchyma. Mixed model ANOVAs and Bonferroni corrected post hoc tests were used for statistical analysis.

RESULTS

Mean values for TLC were 132 ± 3.3 HU, 186 ± 5.8 HU and 168 ± 2.8 HU for protocols A, B and C. Protocol B provided significantly higher TLC than protocols A and C (p < 0.001).

CONCLUSION

TLC was significantly higher using an imaging delay of 8 s compared with a delay of 4 or 12 s.

Ultrasonography, computed tomography and magnetic resonance imaging of hepatocellular carcinoma: toward improved treatment decisions

Detection, characterization, staging, and treatment monitoring are major roles in imaging diagnosis in liver cancers. Contrast-enhanced ultrasonography (CEUS) using microbubble contrast agents has expanded the role of US in the detection and diagnosis of liver nodules in patients at high risk of hepatocellular carcinoma (HCC). CEUS provides an accurate differentiation between benign and malignant liver nodules, which is critical for adequate management of HCC and is also useful for guidance of percutaneous local therapy of HCC and postprocedure monitoring of the therapeutic response. The technology of multidetector-row computed tomography (MDCT) has increased spatial and temporal resolutions of computed tomography (CT). It has made possible a more precise evaluation of the hemodynamics of liver tumor, and the diagnostic accuracy of dynamic MDCT has improved. Perfusion CT can measure tissue perfusion parameters quantitatively and can assess segmental hepatic function. Dynamic MDCT with high spatial and temporal resolution enables us to reconstruct 3- and 4-dimensional imaging, which is very useful for pretreatment evaluation. Dual-energy CT makes possible the differentiation of materials and tissues in images obtained based on the differences in iodine and water densities. Monochromatic images, which can be reconstructed by dual-energy CT data, provide some improvement in contrast and show a higher contrast-to-noise ratio for hypervascular HCCs. Dynamic magnetic resonance imaging with fast imaging sequence of 3-dimensional Fourier transformation T(1)-weighted gradient echo and nonspecific contrast medium can show high detection sensitivity of hypervascular HCC. However, the hepatic tissue-specific contrast medium, gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid, has become an essential contrast medium for liver imaging because of its higher diagnostic ability. It may replace CT during hepatic arteriography and during arterioportography.

Hepatocellular carcinoma with marginal superparamagnetic iron oxide uptake on T2*-weighted magnetic resonance imaging: histopathologic correlation

PURPOSE

To evaluate the characteristics of hepatocellular carcinomas (HCCs) with marginal superparamagnetic iron oxide (SPIO) uptake on T2*-weighted MRI.

MATERIALS AND METHODS

The study group consisted of 73 patients with 83 surgically resected HCCs. Preoperative SPIO-enhanced MRI studies were retrospectively reviewed. Marginal SPIO uptake was considered positive if a rim-like or band-like low intensity area was present on SPIO-enhanced T2*-weighted images. The prevalence of marginal SPIO uptake was evaluated. Pathological specimens with hematoxylin and eosin staining and immunohistochemical staining of CD68 were reviewed in HCCs with marginal SPIO uptake and 33 HCCs without marginal SPIO uptake (control group).

RESULTS

Ten of 83 (12%) HCCs showed marginal SPIO uptake. All HCCs were hypervascular, and only one nodule showed a nodule-in-nodule appearance on imaging findings. The pathology specimens suggested possible causes of marginal SPIO uptake, including marginal macrophage infiltration in moderately or poorly differentiated HCC (n=4), residual normal hepatic tissue at the marginal area of confluent multinodular or single nodular with extranodular growth type HCC (n=3), and a well-differentiated HCC component in nodule-in-nodule type HCC (n=3). Marginal macrophage infiltration was not seen in the control group.

CONCLUSION

SPIO-enhanced MRI may be able to demonstrate marginal macrophage infiltration in HCC.

The impact of vascular and nonvascular findings on the noninvasive diagnosis of small hepatocellular carcinoma based on the EASL and AASLD criteria

OBJECTIVES

Noninvasive criteria for the diagnosis of hepatocellular carcinoma (HCC) in cirrhosis, recommended by the European Association for the Study of Liver (EASL) in 2001 and by the American Association for the Study of Liver Diseases (AASLD) in 2005, have left a number of small liver neoplastic nodules undefined. We designed this prospective study in 2003 with the aims of assessing the diagnostic contribution of vascular contrast-enhanced techniques and investigating the possible additional contribution of superparamagnetic iron oxide magnetic resonance (SPIO-MR) in this setting.

METHODS

Between 2003 and 2005, 75 consecutive small (10-30 mm) liver nodules detected at ultrasonography in 60 patients with cirrhosis were prospectively submitted to contrast-enhanced ultrasound (CEUS), helical-computed tomography (helical-CT), and gadolinium magnetic resonance (gad-MR), each blinded to the other. A total of 68 nodules were also studied with SPIO-MR at the same time as gad-MR.

RESULTS

Using the EASL noninvasive criteria, the diagnosis of HCC was established in 44 of 55 (80%) nodules with a final diagnosis of HCC. Gad-MR was the most sensitive technique for detecting the typical vascular pattern. SPIO-MR showed a pattern consistent with HCC in 5 of 10 HCCs, not satisfying the EASL noninvasive criteria, and was negative in 17 of 18 (94.4%) nonmalignant nodules. The review of the present case series according to the AASLD criteria for the noninvasive diagnosis of HCC yielded a sensitivity rate of 81.8%.

DISCUSSION

This study shows that both EASL and AASLD noninvasive recall strategies for nodules of 10-30 mm in the cirrhotic liver, based on the vascular pattern of nodules, have a false-negative rate of approximately 20%. SPIO-MR may increase the diagnostic potential of noninvasive techniques, contributing to the diagnosis of HCC lacking a typical vascular pattern.

Hypervascular hepatocellular carcinoma: Combined dynamic MDCT and SPIO-enhanced MRI versus combined CTHA and CTAP

AIM

Recently, many diagnostic modalities have been developed for the detection of hepatocellular carcinoma (HCC). Of these, a less invasive and more accurate diagnostic procedure is desirable. This study was undertaken to compare combined dynamic multidetector row helical computerized tomography (MDCT) and superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) with combined CT hepatic arteriography (CTHA) and CT during arterial portography (CTAP) for the detection of hypervascular HCC.

METHODS

Forty-eight patients with 56 pathologically proved hypervascular HCCs (less than 5.0 cm in diameter) underwent dynamic MDCT and SPIO-enhanced MRI, as well as CTHA and CTAP. The images were reviewed by four independent and blinded readers on a tumor-by-tumor basis.

RESULTS

The mean areas under alternative-free response receiver operating characteristic curve (Az) for combined dynamic MDCT and SPIO-enhanced MRI (IV set) and combinedCTHA and CTAP (IA set) were comparable (0.948 and 0.969, respectively, P > 0.05), although the Az value of the IV set was significantly lower than that of the IA set in HCCs smaller than or equal to 1.5 cm (0.867 and 0.937, respectively, P = 0.033). The mean sensitivity and positive predictive value of the IV set were similar to those of the IA set.

CONCLUSIONS

Combined dynamic MDCT and SPIO-enhanced MRI showed a diagnostic accuracy comparable to intra-arterial contrast-enhanced CT (CTHA and CTAP) for hypervascular HCC, and may be a useful diagnostic option prior to curative treatments of hypervascular HCC, although a limitation exists in detecting HCCs smaller than or equal to 1.5 cm.

Abdominal MRI advances in the detection of liver tumours and characterisation

With recent technical advances in hardware, software, and intravenous contrast agents, MRI has evolved into a clinically useful procedure to detect and characterise liver tumours. The combination of MRI systems with larger gradients, improved surface coils, and parallel imaging techniques have produced substantial improvements in MRI quality and speed of image acquisition. Images that previously needed several minutes to acquire can now be obtained in several seconds. The notably faster imaging capabilities of new MRI scanners are ideally suited for dynamic contrast-enhanced liver imaging in which early arterial-phase imaging is best for detecting hepatocellular carcinomas and hypervascular liver metastases. The inherent excellent soft-tissue contrast of MRI can be further improved by non-specific extracellular contrast agents and by liver-specific contrast agents. These contrast agents are now routinely used for liver imaging and improve the sensitivity and specificity of hepatobiliary MRI.