Radiological detectability of minute hepatic venous invasion in hepatocellular carcinoma

Multiparametric assessment of microvascular invasion in hepatocellular carcinoma using gadoxetic acid-enhanced MRI

PURPOSE

To elucidate how precisely microvascular invasion (MVI) in hepatocellular carcinoma (HCC) can be predicted using multiparametric assessment of gadoxetic acid-enhanced MRI.

METHODS

In this retrospective single-center study, patients who underwent liver resection or transplantation of HCC were evaluated. Data obtained in patients who underwent liver resection were used as the training set. Nine kinds of MR findings for predicting MVI were compared between HCCs with and without MVI by univariate analysis, followed by multiple logistic regression analysis. Using significant findings, a predictive formula for diagnosing MVI was obtained. The diagnostic performance of the formula was investigated in patients who underwent liver resection (validation set 1) and in patients who underwent liver transplantation (validation set 2) using a receiver operating characteristic curve analysis. The area under the curves (AUCs) of these three groups were compared.

RESULTS

A total of 345 patients with 356 HCCs were selected for analysis. Tumor diameter (D) (P = 0.021), tumor washout (TW) (P < 0.01), and peritumoral hypointensity in the hepatobiliary phase (PHH) (P < 0.01) were significantly associated with MVI after multivariate analysis. The AUCs for predicting MVI of the predictive formula were as follows: training set, 0.88 (95% confidence interval (CI) 0.82,0.93); validation set 1, 0.81 (95% CI 0.73,0.87); validation set 2, 0.67 (95% CI 0.51,0.80). The AUCs were not significantly different among three groups (training set vs validation set 1; P = 0.15, training set vs validation set 2; P = 0.09, validation set 1 vs validation set 2; P = 0.29, respectively).

CONCLUSION

Our multiparametric assessment of gadoxetic acid-enhanced MRI performed quite precisely and with good reproducibility for predicting MVI.

Can MRI features predict clinically relevant hepatocellular carcinoma genetic subtypes?

PURPOSE

Recent studies in cancer genomics have revealed core drivers for hepatocellular carcinoma (HCC) pathogenesis. We aim to study whether MRI features can serve as non-invasive markers for the prediction of common genetic subtypes of HCC.

METHODS

Sequencing of 447 cancer-implicated genes was performed on 43 pathology proven HCC from 42 patients, who underwent contrast-enhanced MRI followed by biopsy or resection. MRI features were retrospectively evaluated including tumor size, infiltrative tumor margin, diffusion restriction, arterial phase hyperenhancement, non-peripheral washout, enhancing capsule, peritumoral enhancement, tumor in vein, fat in mass, blood products in mass, cirrhosis and tumor heterogeneity. Fisher's exact test was used to correlate genetic subtypes with imaging features. Prediction performance using correlated MRI features for genetic subtype and inter-reader agreement were assessed.

RESULTS

The two most prevalent genetic mutations were TP53 (13/43, 30%) and CTNNB1 (17/43, 40%). Tumors with TP53 mutation more often demonstrated an infiltrative tumor margin on MRI (p = 0.01); inter-reader agreement was almost perfect (kappa = 0.95). The CTNNB1 mutation was associated with peritumoral enhancement on MRI (p = 0.04), inter-reader agreement was substantial (kappa = 0.74). The MRI feature of an infiltrative tumor margin correlated with the TP53 mutation with accuracy, sensitivity, and specificity of 74.4%, 61.5% and 80.0%, respectively. Peritumoral enhancement correlated with the CTNNB1 mutation with accuracy, sensitivity, and specificity of 69.8%, 47.0% and 84.6%, respectively.

CONCLUSION

An infiltrative tumor margin on MRI correlated with TP53 mutation and peritumoral enhancement correlated with CTNNB1 mutation in HCC. Absence of these MRI features are potential negative predictors of the respective HCC genetic subtypes that have implications for prognosis and treatment response.

A gadoxetic acid-enhanced MRI-based multivariable model using LI-RADS v2018 and other imaging features for preoperative prediction of macrotrabecular-massive hepatocellular carcinoma

PURPOSE

To identify imaging features of macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) using LI-RADS v2018 and other imaging features and to develop a gadoxetic acid-enhanced MRI (EOB-MRI)-based model for pretreatment prediction of MTM-HCC.

MATERIALS AND METHODS

A total of 93 patients with pathologically proven HCC (39 MTM-HCC and 54 non-MTM-HCC) were retrospectively evaluated with EOB-MRI at 3 T. Imaging analysis according to LI-RADS v2018 was evaluated by two readers. Univariate and multivariate analyses were performed to determine independent predictors for MTM-HCC. Different logistic regression models were built based on MRI features, including model A (enhancing capsule, blood products in mass and ascites), model B (enhancing capsule and ascites), model C (blood products in mass and ascites), and model D (blood products in mass and enhancing capsule). Diagnostic performance was assessed by receiver operating characteristic (ROC) curves.

RESULTS

After multivariate analysis, absence of enhancing capsule (odds ratio = 0.102, p = 0.010), absence of blood products in mass (odds ratio = 0.073, p = 0.030), and with ascites (odds ratio = 55.677, p = 0.028) were identified as independent differential factors for the presence of MTM-HCC. Model A yielded a sensitivity, specificity, and AUC of 35.90% (21.20,52.80), 94.44% (84.60, 98.80), and 0.731 (0.629, 0.818). Model A achieved a comparable AUC than model D (0.731 vs. 0.699, p = 0.333), but a higher AUC than model B (0.731 vs. 0.644, p = 0.048) and model C (0.731 vs. 0.650, p = 0.005).

CONCLUSION

The EOB-MRI-based model is promising for noninvasively predicting MTM-HCC and may assist clinicians in pretreatment decisions.

Hemodynamic Alteration in the Liver in Acute Hepatitis: A Quantitative Evaluation Using Computed Tomographic Perfusion

BACKGROUND/AIM

We aimed to elucidate the hemodynamic alterations in the liver of patients with acute hepatitis (AH) using computed tomography perfusion imaging.

PATIENTS AND METHODS

For 14 patients with AH and nine patients with no disease (ND group), we compared the mean arterial blood flow (AF), portal blood flow (PF) and perfusion index (%) [PI=AF/(AF+PF) ×100] of the right and left liver lobes and investigated their relationship with clinical factors.

RESULTS

The mean PI of the right lobe in the AH group (30.5±10.0%) was significantly higher than that in the ND group (20.8±9.7%) (p=0.031). For all patients of the AH and ND groups, the PI of the right lobe was increased as the prothrombin time decreased (R=-0.56, p=0.006) and as the prothrombin time-international normalized ratio increased (R=0.48, p=0.02).

CONCLUSION

The PI of the right liver lobe may increase in AH and may be a predictive parameter for the severity of hepatic failure.

Liver Imaging and Data System (LI-RADS) Version 2018 and Other Imaging Features in Intrahepatic Cholangiocarcinoma in Chinese Adults with vs. without Chronic Hepatitis B Viral Infection

PURPOSE

To describe liver imaging reporting and data system (LI-RADS) version 2018 and other MRI imaging features in intrahepatic mass-forming cholangiocarcinoma (iCCA) in Chinese adults with vs. without chronic hepatitis B viral (HBV) infection.

METHODS

We retrospectively enrolled 89 patients with pathologically proven iCCA after multiphase imaging performed between 2004 and 2017 at a tertiary medical center in southern China. Based on whether patients had chronic HBV, iCCA was divided into two subgroups: HBV-positive (n = 50 patients, including 9 with cirrhosis) vs. HBV-negative (n = 39 patients, including 14 with hepatolithiasis and 25 with no identifiable risk factor for iCCA; none had cirrhosis). Two independent abdominal radiologists in consensus reviewed the largest mass in each patient to assign LI-RADS v2018 features; they also scored each observation's shape and location. Imaging features were compared using chi-square or Fisher's exact tests.

RESULTS

Most iCCAs in HBV-positive (88% (44/50)) and HBV-negative (97% (38/39)) patients had at least one LR-M feature. Compared to iCCAs in HBV-negative patients, iCCAs in HBV-positive patients were more likely to have at least one major feature of HCC (46% (23/50) vs. 8% (3/39), P < 0.001) and more likely to be smooth (42% (21/50) vs. 10% (4/39), P = 0.001). Six of 50 (12%) iCCAs in HBV-positive patients and 1/39 (3%) iCCAs in HBV-negative patients had at least one major feature of HCC without any LR-M feature.

CONCLUSIONS

In this retrospective single-center study in Chinese adults, iCCAs in HBV-positive patients were more likely to resemble HCCs than iCCAs in HBV-negative patients.

Peritumoral tissue on preoperative imaging reveals microvascular invasion in hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Histologic microvascular invasion (MVI) substantially worsens the prognosis of patients with hepatocellular carcinoma, and can only be diagnosed postoperatively. Preoperative assessment of MVI by imaging has been focused on tumor-related features, while peritumoral imaging features have been indicated elsewhere to be more accurate. The aim of the present study is to evaluate the association between peritumoral imaging features and MVI.

METHODS

Literature search was performed using the PubMed, Embase, and Cochrane Library databases. Summary results of the association between peritumoral imaging features and MVI were presented as the odds ratio (OR) and the 95% confidence interval. Meta-regression and subgroup analyses were performed when heterogeneity was detected. Diagnostic accuracy analysis was also conducted for identified features.

RESULTS

Ten studies were included in the analysis. Moderate and low heterogeneities were found among the seven studies on peritumoral enhancement and four studies on peritumoral hypointensity on HBP, respectively. Summary results revealed a significant association between MVI and peritumoral enhancement (OR 4.04 [2.23, 7.32], p < 0.05), and peritumoral hypointensity on HBP (OR 10.62 [5.31, 21.26], p < 0.05). Diagnostic accuracy analysis revealed high specificity (0.90-0.94) but low sensitivity (0.29-0.40) for both features to assess MVI.

CONCLUSION

The two peritumoral imaging features are significantly associated with MVI. The two features highly suggest MVI only when present with a high false negative rate. Promotion of their diagnostic efficiency can be a worthwhile task for future research.

Clinical implications for imaging of vascular invasion in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second largest cause of cancer mortality in the world, with vascular invasion being one of the most important prognostic factors. HCC with tumor thrombus was traditionally considered to have very limited treatment options. However, multiple promising treatment strategies have emerged in recent years, with diagnostic and interventional radiologists playing a major role in patient management. We provide a comprehensive update on the diagnosis and management of HCC with vascular invasion and the role of the radiologist in this condition.

Corona Enhancement and Mosaic Architecture for Prognosis and Selection Between of Liver Resection Versus Transcatheter Arterial Chemoembolization in Single Hepatocellular Carcinomas >5 cm Without Extrahepatic Metastases: An Imaging-Based Retrospective Study

Corona enhancement and mosaic architecture are 2 radiologic features of hepatocellular carcinoma (HCC). However, neither their prognostic values nor their impacts on the selection of liver resection (LR) versus transcatheter arterial chemoembolization (TACE) as treatment modalities have been established.We retrospectively analyzed 275 patients with a single HCC lesion >5 cm without extrahepatic metastasis treated with LR or TACE. In LR patients, the overall survival (OS) and time to progression (TTP) were compared between corona enhancement negative (corona-) versus positive (corona+) and mosaic architecture negative (mosaic-) versus positive (mosaic+) patients. Furthermore, by the combination of corona and mosaic, LR patients were divided into negative for both corona and mosaic patterns (LR-/-), positive for only 1 feature (LR+/-), and positive for both (LR+/+); their OS and TTP were compared to those of the TACE group. Cox regression was performed to identify independent factors for OS.In the survival plots for LR, corona- had better OS and TTP than corona+, and mosaic- had better OS than mosaic+. There was no significant difference in TTP between the subgroups. On Cox regression analysis, corona enhancement, but not mosaic architecture, was a significant factor for OS, whereas neither were a significant factor for TTP. In TACE patients, neither corona nor mosaic patterns had significant correlations with OS or TTP. In the whole population, LR-/ and LR+/- subgroups had similar OS, which was better than the LR+/+ and TACE groups. Moreover, LR-/- and LR+/- patients had better TTP than TACE patients, but there were no differences between the LR-/- versus LR+/-, LR-/ versus LR+/+, LR+/- versus LR+/+, and LR+/+ versus TACE groups. On Cox regression analysis, the presence of corona/mosaic patterns was an independent prognostic factor for OS.Our results showed that, for patients with a single HCC >5 cm without extrahepatic metastasis, corona and mosaic patterns are indicators of limited LR efficacy. When both of the features are present, TACE can be used instead of LR with no negative influence on survival.

Clinicopathological significance of the peritumoral decreased uptake area of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid in hepatocellular carcinoma

BACKGROUND AND AIM

A faint hypointensity in the noncancerous tissue around hepatocellular carcinoma (HCC) in the hepatobiliary phase of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) is encountered. The goal is to elucidate the significance of this type of pseudolesion designated as the peritumoral decreased uptake area of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) (PDUAE).

METHODS

This study group consisted of 61 patients with 61 surgically resected HCCs who underwent preoperative Gd-EOB-DTPA-enhanced MRI. The presence of a faint and hypointense area around the tumor in the hepatobiliary phase was defined as PDUAE. The frequency with which PDUAE was seen was compared between pairs of groups determined by clinical and pathological parameters using a Fisher's exact probability test. The parameters showing significant differences in this test were further tested by multiple logistic regression analysis.

RESULTS

PDUAE was observed in 25 cases. In univariate analysis, the values of alpha-fetoprotein and protein-induced by vitamin K absence or antagonist-II, maximal diameter, the presence of a capsule, and vascular invasion were significantly correlated with the frequency with which PDUAE was seen. In multivariate analysis, only maximal diameter and vascular invasion were significantly correlated. When the presence of PDUAE was used as an indicator of vascular invasion, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 72%, 80.6%, 77%, 72%, and 80.6%, respectively.

CONCLUSIONS

By using this indicator, "microscopic" vascular invasion of HCC can be easily predicted with Gd-EOB-DTPA-enhanced MRI.

Preoperative prediction of the microvascular invasion of hepatocellular carcinoma with diffusion-weighted imaging

The aim of this study was to investigate whether diffusion-weighted imaging (DWI) could be useful in predicting the microvascular invasion (MVI) of hepatocellular carcinoma (HCC). Sixty-seven surgically proven HCCs from 65 patients (54 men and 11 women with an age range of 35-75 years and a mean age of 56.0 years) were retrospectively analyzed. The signal intensities (SIs) of the lesions on preoperative diffusion-weighted (DW) images were visually categorized as isointense or hyperintense in comparison with the adjacent liver. We also quantitatively measured SIs and apparent diffusion coefficients (ADCs) by drawing regions of interest in HCCs and livers on DW images with b values of 50, 400, and 800 second/mm(2) and on ADC map images. Logistic regression analyses were performed so that we could identify independent predictors of MVI among laboratory and DWI findings. A univariate analysis showed that a histological grade of 3, a larger tumor size, a higher SI ratio on DW images, and a lower ADC value were significantly associated with MVI. A multiple logistic regression analysis showed that a histological grade of 3 and the ADC value were independent predictors of MVI. With a cutoff of 1.11 × 10(-3) mm(2)/second, the ADC value provided a sensitivity of 93.5% and a specificity of 72.2% for the prediction of MVI with an odds ratio of 24.5 (95% confidence interval = 4.14-144.8, P < 0.001). In conclusion, lower ADC values (1.11 × 10(-3) mm(2)/second or less) can be a useful predictor of MVI during the preoperative evaluation of HCC.

Optimal dose of contrast medium for depiction of hypervascular HCC on dynamic MDCT

PURPOSE

The purpose of this study is to prospectively investigate the optimal dose of contrast medium for the depiction of hypervascular hepatocellular carcinoma (HCC) during the hepatic arterial phase (HAP), portal venous phase (PVP) and delayed phase (DP) of dynamic MDCT.

MATERIALS AND METHODS

The study included 128 patients, out of these patients, 36 patients were found to have 56 hypervascular HCCs. Sixty-three patients were assigned to receive a dose of 525 mgI/kg with protocol A, and 62 received a dose of 630 mgI/kg with protocol B. Measurements of the attenuation values of the abdominal aorta, portal vein, hepatic vein, hepatic parenchyma and HCC during the HAP, PVP and DP were taken. Tumor-liver contrast (TLC) was calculated from the attenuation value of the hepatic parenchyma and HCC.

RESULTS

The aortic attenuation value with protocol B (351, 166, and 132 HU) was significantly higher than that with protocol A (313, 153, and 120 HU) during all the phases, (P<0.01 for all phases). The hepatic enhancement from unenhanced baseline with protocol B (25.2, 63.6, 50.6 HU) was significantly higher than that with protocol A (20.2, 55.1 and 43.0 HU) during all the phases, (P<0.01 for all phases). The TLC with protocol B (37.4, -11.8 and -13.6 HU) was significantly higher than that with protocol A (28.0, -9.8 and -12.1 HU) during HAP (P=0.042).

CONCLUSION

The administration of 630 mgI/kg of body weight depicts hypervascular HCC more clearly during HAP and shows sufficient hepatic enhancement of 50 HU during DP.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Radiological assessment of hepatic vein invasion by hepatocellular carcinoma using combined computed tomography hepatic arteriography and computed tomography arterial portography

PURPOSE

The aim of this study was to elucidate computed tomography hepatic arteriography (CTHA) and CT arterial portography (CTAP) findings characteristic of hepatocellular carcinoma (HCC) with large hepatic venous invasion (HVI) and then to examine whether the presence of minute HVI can be diagnosed based on each finding.

MATERIALS AND METHODS

Combined CTHA and CTAP of 106 HCCs were examined. Two radiologists analyzed the radiological findings of five nodules with large HVI (group vv2). The remaining 101 nodules were classified into two groups: group vv1, positive minute HVI; group vv0, negative HVI. They examined whether each finding observed in group vv2 could be detected in groups vv1 and vv0.

RESULTS

Analysis of group vv2 identified (a) tumor thrombus, (b) early inflow of the contrast into the hepatic vein proximal to the invaded site, and (c) partially decreased portal venous flow in the peripheral parenchyma subject to the involved hepatic vein. Findings (b) and (c) were observed in 16% of group vv1. A significant difference in frequency of finding (c) was obtained between groups vv1 and vv0. The positive and negative predictive values of finding (c) were 66.7% and 77.9%, respectively.

CONCLUSION

Findings (b) and (c), especially the latter, may partly contribute to the radiological diagnosis of minute HVI.

Treatment of early hepatocellular carcinoma: How to predict and prevent recurrence

Early and very early stage hepatocellular cancers (HCC) when staged clinically, if they are coincident with histological early HCC, have the best outcome in terms of recurrence rates and survival after potential curative therapy. This is because predictors of HCC recurrence such as microscopic vascular invasion and satellite metastases, are rarely present in histological early HCC. Other predictors of HCC recurrence are size of the principal lesion, numbers of lesions, histological grade, several gene signature patterns that are promising for future clinical practice, and other less constantly predictive features such as high alpha-fetoprotein and transaminase concentrations, and cellular aneuploidia. Adjuvant and neo-adjuvant therapies have been proposed to reduce the risk of HCC recurrence after potentially curative treatments. These preventative therapies are focused on extra-tumoural therapies, such as retinoids or interferon, possibly effective in preventing late recurrence by influencing the premalignant field in cirrhosis, and on tumour related therapies, by utilising several procedures able to downstage tumours, such as neo-adjuvant and "bridge to transplant" therapies, which influence mainly early recurrence. Both strategies have been combined for example with using sorafenib which may treat both the patient's premalignant liver and malignant liver cells themselves.