Liver Imaging Reporting and Data System Version 2018: What Radiologists Need to Know. J Comput Assist Tomogr. 2020;44:168-177. [PMID: 32195795 DOI: 10.1097/rct.0000000000000995]

Inter-observer reliability and predictive values of triphasic computed tomography for microvascular invasion in hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is the most frequent primary liver tumor globally and a leading cause of mortality in cirrhotic patients. Our study aimed to estimate the diagnostic performance of triphasic CT and inter-observer reliability in the preoperative detection of microvascular invasion (MVI) in HCC. Two independent radiologists accomplished a retrospective analysis for 99 patients with HCC to assess the CT features for MVI in each lesion. Postoperative histopathology was considered the gold standard.

Results

Multivariate regression analysis revealed that incomplete or absent tumor capsules, presence of TTPV, and absence of hypodense halo were statistically significant independent predictors of MVI. There was excellent agreement among observers in evaluating peritumoral enhancement, identifying intratumoral arteries, hypodense halo, TTPV, and macrovascular invasion. Also, our results revealed moderate agreement in assessing the tumor margin and tumor capsule.

Conclusion

Triphasic CT features of MVI are reliable imaging predictors that may be helpful for standard preoperative interpretation of HCC.

Two-dimensional perfusion angiography permits direct visualization of redistribution of flow in hepatocellular carcinoma during b-TACE

OBJECTIVES

To demonstrate in vivo redistribution of the blood flow towards HCC's lesions by utilizing two-dimensional perfusion angiography in b-TACE procedures.

MATERIAL AND METHODS

In total, 30 patients with 35 HCC nodules treated in the period between January 2019 and November 2021. For each patient, a post-processing software leading to a two-dimensional perfusion angiography was applied on each angiography performed via balloon microcatheter, before and after inflation. On the colour map obtained, reflecting the evolution of contrast intensity change over time, five regions of interests (ROIs) were assessed: one on the tumour (ROI-t), two in the immediate peritumoural healthy liver parenchyma (ROI-ihl) and two in the peripheral healthy liver parenchyma (ROI-phl). The results have been interpreted with a novel in silico model that simulates the hemodynamics of the hepatic arterial system.

RESULTS

Among the ROIs drawn inside the same segment of target lesion, the time-to-peak of the ROI-t and of the ROI-ihl have a significantly higher mean value when the balloon was inflated compared with the ROIs obtained with deflated balloon (10.33 ± 3.66 s vs 8.87 ± 2.60 s (p = 0.015) for ROI-t; 10.50 ± 3.65 s vs 9.23 ± 2.70 s (p = 0.047) for ROI-ihl). The in silico model prediction time-to-peak delays when balloon was inflated, match with those observed in vivo. The numerical flow analysis shows how time-to-peak delays are caused by the obstruction of the balloon-occluded artery and the opening of intra-hepatic collateral.

CONCLUSION

The measurements identify predictively the flow redistribution in the hepatic arteries during b-TACE, supporting a proper positioning of the balloon microcatheter.

Utility of diffusion tensor imaging in differentiating benign from malignant hepatic focal lesions

OBJECTIVES

To assess the diagnostic accuracy of diffusion tensor imaging (DTI) in the characterization of hepatic focal lesions (HFLs) and compare it to diffusion-weighted imaging (DWI).

METHODS

Prospective analysis was done for 49 patients (23 male and 26 female) with 74 HFLs who underwent dynamic MRI, DWI, and DTI. Apparent diffusion coefficient (ADC) values from DWI, fractional anisotropy (FA) values, and mean diffusivity (MD) values from DTI were measured by two independent radiologists. HFLs were classified into benign and malignant HFLs; the latter were subdivided into HCC and non-HCC lesions. Binary logistic regression was performed to analyze the associations between the DTI parameters and the distinction of malignant lesions.

RESULTS

The ADC, MD, and FA at cutoff values of ≤ 1.17 × 10^-3 mm²/s, ≤ 1.71 × 10^-3 mm²/s, and > 0.29, respectively, are excellent discriminators for differentiating malignant and benign HFLs. The mean ADC and MD values of hemangiomas were significantly higher than HCC and non-HCC malignant lesions. In contrast, the mean FA values of hemangiomas were significantly lower than those of non-HCC malignant lesions and HCCs. The ADC and MD were very good discriminators at cutoff values of > 1.03 × 10^-3 mm²/s and > 1.12 × 10^-3 mm²/s, respectively. The FA at a cutoff value > 0.38 is an excellent discriminator for HCC versus non-HCC malignant lesions. Only FA value > 0.38 was a statistically significant independent predictor of HCC versus non-HCC lesions among the three parameters. There was an excellent inter-observer agreement with ICC > 0.9.

CONCLUSION

MD and FA of DTI are non-invasive, very good, and excellent discriminators superior to ADC measured by DWI for the differentiation of HFLs.

KEY POINTS

• The ADC, MD, and FA at cutoff values of ≤ 1.17 × 10^-3 mm²/s, ≤ 1.71 × 10^-3 mm²/s, and > 0.29, respectively, are excellent discriminators for differentiating malignant and benign HFLs. • The mean ADC and MD values of hemangiomas were significantly higher than those of HCC and non-HCC malignant lesions. In contrast, the mean FA values of hemangiomas were significantly lower than those of non-HCC malignant lesions and HCCs, respectively. • Multivariate regression analysis revealed that only FA value > 0.38 was a statistically significant independent predictor of HCC vs. non-HCC lesions. A lesion with FA > 0.38 has 34 times higher odds of being HCC rather than non-HCC lesions.

Giant Hepatic Regenerative Nodule in a Patient With Hepatitis B Virus-related Cirrhosis

Hepatic regenerative nodules are reactive hepatocellular proliferations that develop in response to liver injury. Giant hepatic regenerative nodules of 10 cm or more are extremely rare and have only been reported in patients with biliary atresia or Alagille syndrome. A 50-year-old man presented with a pathologically confirmed giant 11.3×9.4×11.2 cm hepatic regenerative nodule and hepatitis B virus-related cirrhosis. Imaging of intrahepatic nodule included mild hyperenhancement in the portal phase of contrast-enhanced CT and the hepatobiliary phase in the gadoxetic acid-enhanced MRI scan, as well as the portal vein crossing through sign in the setting of liver cirrhosis. This case highlights the imaging characteristics of giant hepatic regenerative nodules in hepatitis cirrhosis.

Combined Hepatocellular-Cholangiocarcinoma: An Update on Pathology and Diagnostic Approach

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare primary liver carcinoma displaying both hepatocytic and cholangiocytic differentiation within the same tumor. Relative to classic hepatocellular carcinoma (HCC), cHCC-CCA has more aggressive behavior and a poorer prognosis. Though recent advances have improved our understanding of the biology underlying cHCC-CCAs, they remain diagnostically challenging for pathologists because of their morphologic and phenotypic diversity. Accurate diagnosis of cHCC-CCA is important for patient management and prognostication. Herein, we review recent updates on cHCC-CCA, focusing on tumor classification, pathology, and diagnostic approach.

Development and validation of a management system and dataset quality assessment tool for the Radiology Common Data Model (R_CDM): A case study in liver disease

BACKGROUND

The Observational Medical Outcomes Partnership-Common Data Model (OMOP-CDM), a distributed research network, has low clinical data coverage. Radiological data are valuable, but imaging metadata are often incomplete, and a standardized recording format in the OMOP-CDM is lacking. We developed a web-based management system and data quality assessment (RQA) tool for a radiology_CDM (R_CDM) and evaluated the feasibility of clinically applying this dataset.

METHODS

We designed an R_CDM with Radiology_Occurrence and Radiology_Image tables. This was seamlessly linked to the OMOP-CDM clinical data. We adopted the standardized terminology using the RadLex playbook and mapped 5,753 radiology protocol terms to the OMOP vocabulary. An extract, transform, and load (ETL) process was developed to extract detailed information that was difficult to extract from metadata and to compensate for missing values. Image-based quantification was performed to measure liver surface nodularity (LSN), using customized Wonkwang abdomen and liver total solution (WALTS) software.

RESULTS

On a PACS, 368,333,676 DICOM files (1,001,797 cases) were converted to R_CDM chronic liver disease (CLD) data (316,596 MR images, 228 cases; 926,753 CT images, 782 cases) and uploaded to a web-based management system. Acquisition date and resolution were extracted accurately, but other information, such as "contrast administration status" and "photography direction", could not be extracted from the metadata. Using WALTS, 9,609 pre-contrast axial-plane abdominal MR images (197 CLD cases) were assigned LSN scores by METAVIR fibrosis grades, which differed significantly by ANOVA (p < 0.001). The mean RQA score (83.5) indicated good quality.

CONCLUSION

This study developed a web-based system for management of the R_CDM dataset, RQA tool, and constructed a CLD R_CDM dataset, with good quality for clinical application. Our management system and R_CDM CLD dataset would be useful for multicentric and image-based quantification researches.

OPA Interacting Protein 5 Antisense RNA 1 Expedites Cell Migration and Invasion Through FOXM1/ Wnt/β-Catenin Pathway in Pancreatic Cancer

BACKGROUND

Pancreatic cancer (PC) is a digestive tract malignancy with poor prognosis. Long noncoding RNA (lncRNA) OPA interacting protein 5 antisense RNA 1 (OIP5-AS1) was regarded to be correlated with human malignancy, working as tumor suppressor or promoter on the basis of tumor types. However, the function of OIP5-AS1 in PC remained unclear.

AIMS

The study focused on the function and regulatory mechanism of OIP5-AS1 in PC.

METHODS

OIP5-AS1 expression was assessed by the quantitative reverse transcription PCR (RT-qPCR) in tumor tissues and PC cell lines. 5-ethynyl-2'-deoxyuridine (EdU) incorporation and cell counting kit-8 (CCK-8) assays were applied to detect cell proliferation ability. Through wound healing and transwell assays, cell migration and invasion capacities were estimated. Flow cytometry analysis was performed to examine apoptosis capability of PC cells.

RESULTS

OIP5-AS1 downregulating inhibited cell proliferation, migration, and invasion capacities, while promoting cell apoptosis rates. As a competing endogenous RNA (ceRNA), OIP5-AS1 competed with Forkhead Box M1 (FOXM1) for the binding sites on microRNA-320b (miR-320b). OIP5-AS1 was able to upregulate FOXM1 expression via silencing miR-320b. Furthermore, FOXM1 served as an activator of Wnt/β-catenin pathway and mediated the effect of OIP5-AS1 on Wnt/β-catenin pathway.

CONCLUSION

OIP5-AS1 expedites the proliferative, migrated, and invasive capability of PC cells, while repressing cell apoptosis through regulating miRNA-320b/FOXM1 axis and FOXM1/Wnt/β-catenin pathway in PC. OIP5-AS1 regulation on FOXM1/Wnt/β-catenin pathway may offer novel efficient markers for PC treatments.

A validation study of combined resection and ablation therapy for multiple hepatocellular carcinoma

AIM

To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report.

MATERIALS AND METHODS

A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed.

RESULTS

There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761).

CONCLUSIONS

The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

Predicting early necrosis of colorectal liver metastases using volumetric enhancement on baseline MRI and oil deposition on post-cTACE unenhanced CT

PURPOSE

To predict tumor necrosis after conventional TACE (cTACE) in patients with colorectal liver metastasis (CRLM) based on volumetric oil deposition on CT one day after treatment.

METHODS

Thirty-four lesions in 20 men and 6 women were included in this IRB-approved HIPAA-compliant, retrospective lesion-by-lesion-based study. Semiautomatic volumetric segmentation of target lesions was performed on baseline MRI and post-treatment CT. Predicted percentage of tumor necrosis was defined as 100%-(%baseline MRI enhancement-%CT oil deposition). Necrosis on post-TACE MRI was measured after volumetric segmentation to assess the accuracy of predicting tumor necrosis. The relationship between predicted necrosis percent and post-cTACE measured necrosis percent on MRI was compared using Pearson correlation analysis. Inter-reader agreement was calculated by intraclass correlation coefficient (ICC) after using the same method.

RESULTS

Patients in this cohort had a mean age of 64 ± 14 years. Mean percentage of the viable tumor on pre-cTACE venous phase MRI was 58.5% ± 23.9%. Mean oil deposition was 19.8% ± 14.6%. Mean percentage of calculated necrosis one month after cTACE was 59.2% ± 22.7% on venous phase MRI, which had a significant correlation with predicted necrotic percentage of 61.3% ± 19.3% (r = 0.89, p < 0.0001). ICC for enhancement percentage on pre-cTACE and post-cTACE venous phase MRIs were 0.93 (95% CI 0.83, 0.97) and 0.86 (95% CI 0.66, 0.94), respectively. ICC for oil deposition was 0.92 (95% CI 0.81, 0.96).

CONCLUSION

Measuring oil deposition of the whole tumor on CT one day after cTACE can assist to predict post-cTACE tumor necrosis.

A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat?

PURPOSE

To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT.

METHODS

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method.

RESULTS

A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case-control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01-6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14-0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20-1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02-1.32).

CONCLUSIONS

In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT.

Coronary artery disease imaging reporting and data system (CAD-RADS): what radiologists need to know?

The aim of this work is to review Coronary Artery Disease Imaging Reporting and Data System (CAD-RADS) that was designed to standardize reporting language and improve the communication of data among radiologists and clinicians. Stenotic lesions are graded into 5 grades ranging from 0 (no stenosis) to 5 (total occlusion), where the highest grade represents the final score. The expert consensus platform has added 4 special modifiers (non-diagnostic, stent, graft, and vulnerability) to aid patient management through linking these scores with decision algorithm and treatment plan. Adherence to standard imaging protocol; knowledge of normal, variant, and anomalous anatomy; and skillful evaluation of stenosis are important for proper utilization of this reporting system. Lastly, radiologists should be aware of the inherited benefits, limitations, and common pitfalls of this classification system.

Change in hepatic volume profile in potential live liver donors after lifestyle modification for reduction of hepatic steatosis

PURPOSE

We aimed to evaluate changes in hepatic volume and hemiliver volume percentage in potential liver donors after hepatic steatosis (HS) reduction through lifestyle modification.

METHODS

Fifty liver donor candidates with HS (macrovesicular fat [MaF] ≥ 20%) underwent abdominal computed tomography (CT) and liver biopsy before (baseline) and after (follow-up) lifestyle modification. According to the change in MaF, subjects were classified as group A (MaF reduction ≥ 20%, n = 25), and group B (MaF reduction < 20%, n = 25). The hepatic volume and hemiliver volume percentage were measured using CT volumetric analysis.

RESULTS

Volume percentage of the left hemiliver + S1 (over the whole liver) significantly increased at follow-up in group A (P < 0.001) but not in group B (P = 0.598). The absolute volume change of the right hemiliver and its percentage change from the baseline were significantly greater than those of the left hemiliver + S1 in group A (P < 0.007). There were no significant differences in these values in group B (P = 0.064 and 0.507, respectively). The percentage of subjects that earned the benefit of becoming suitable donors from the change in hepatic volume distribution caused by HS improvement was 52.0% (13/25) and 40.0% (10/25) in group A and group B, respectively. Regarding posthepatectomy liver failure, none was identified in group A after donation, whereas 12% (3/25) was identified in group B.

CONCLUSION

Hepatic volume profile may change considerably in potential liver donors with HS (MaF ≥ 20%) after HS reduction through lifestyle modification. Reevaluation of the hepatic volume is required before liver procurement after lifestyle modification in these subjects.

Increasing incidence of non-HBV- and non-HCV-related hepatocellular carcinoma: single-institution 20-year study

Background

We previously reported on the trends in the etiologies of hepatocellular carcinoma (HCC) diagnosed in patients between 1995 and 2009. The aims of our updated study were to evaluate the incidence, nonhepatitis B and nonhepatitis C viral (NBNC) etiologies, and clinical characteristics of HCCs occurring in patients between 1992 and 2018.

Methods

The study enrolled 2171 consecutive patients with HCC between 1992 and 2018. Their medical records were reviewed. The patients were divided into two groups, patients with early diagnoses from 1992 to 2009 and those with late diagnoses from 2010 to 2018.

Results

NBNC-HCC occurred in 514 patients (23.6%). The percentage of patients with HCC who had NBNC-HCC increased from 26.5% in 2009 to 46.3% in 2018. Patients with NBNC-HCC were older (median ages from 67 to 73 years). Type 2 diabetes mellitus (48.5–60.3%: P = 0.008), hypertension (48.5–57.4%: P = 0.047), and hyperlipidemia (39.2–53.8%: P = 0.001) increased significantly in recent years. The median FIB-4 index decreased (4.37–3.61: P = 0.026) and the median platelet count increased (15.1–17.9 × 10⁴/μL: P = 0.013). Among the 514 patients with NBNC-HCC, 194 underwent hepatic resection for nonalcoholic steatohepatitis (NASH) (15%), alcoholic liver disease (ALD) (29%), and cryptogenic hepatitis (56%). Cirrhosis was detected in 72%, 39%, and 16% of patients with NASH, ALD, and cryptogenic hepatitis, respectively. The prevalence of cirrhosis in patients with NASH was significantly higher than the prevalence of cirrhosis in the other groups (P < 0.001). Overall, 70% of the non-malignant liver tissue of patients with NBNC-HCC was not involved with cirrhosis. On the other hand, the median FIB-4 index in patients with cryptogenic HCC was 2.56, which was a significantly lower value than those values in the other groups of patients. The FIB-4 index considered as one of useful screening of HCC.

Conclusions

The prevalence of NBNC-HCC has increased rapidly even in a regional university hospital. Metabolic syndrome may be an important risk factor for HCC. HCC was also found in patients with non-cirrhotic livers. The FIB-4 index may be a useful screening method for HCC in patients with NBNC.

Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case-control study

BACKGROUND AND AIMS

The association between prognosis of variceal bleeding and portal vein thrombosis (PVT) is unclear. In this multicentre study, we determined the effect of PVT on rebleeding and mortality in patients with acute variceal bleeding (AVB) after oesophageal variceal band ligation (EVL).

METHODS

Cirrhotic patients with AVB who had undergone EVL were included. The patients were allocated to either the PVT group or the control cirrhotic group (CCG) based on the presence or absence of PVT. One-year rebleeding episodes and mortality after EVL were recorded.

RESULTS

A total of 218 cirrhotic patients with AVB from 3 centres were included. Patients with PVT had a higher rate of 14-day and 6-week rebleeding than those without PVT (14-day: 8.26% vs. 1.83%, p = 0.03; 6-week: 11.92% vs. 1.83%, p = 0.003). The rates of 5-day failure (3.67% vs. 0.92%, p = 0.175), 1-year rebleeding (21.10% vs. 20.18%, p = 0.867), and 14-day, 6-week, and 1-year mortality were similar between the groups (14-day: 3.67% vs. 0.92%, p = 0.175; 6-week: 3.67% vs. 0.92%, p = 0.175; 1-year: 3.67% vs. 1.83%, p = 0.408). The Child-Pugh class [p = 0.022, hazard ratio (HR): 1.453; 95% confidence interval (CI) 1.056-1.998], PVT (p = 0.050, HR: 4.622, 95% CI 0.999-21.395), albumin < 30 g/L (p = 0.023, HR: 5.886, 95% CI 1.272-27.245), and number of bands (p = 0.010, HR: 1.207, 95% CI 1.046-1.393) were identified as the predictors for 14-day rebleeding; the multivariate analysis revealed only the number of bands (p = 0.009, HR: 1.247, 95% CI 1.056-1.473) as the independent factor. PVT (p = 0.012, HR: 6.732, 95% CI 1.519-29.835) and albumin < 30 g/L (p = 0.027, HR: 3.643, 95% CI 1.160-11.441) were identified as predictors for 6-week rebleeding; however, only PVT (p = 0.015, HR: 6.380, 95% CI 1.427-28.515) was found to be the independent factor in the multivariate analysis. Further analysis showed that superior mesenteric vein (SMV) thrombosis is the only risk factor predicting 6-week rebleeding in patients with PVT (p = 0.032, HR: 3.405, 95% CI 1.112-10.429).

CONCLUSIONS

PVT was associated with high 14-day and 6-week rebleeding in patients after EVL. SMV thrombosis was the only risk factor for 6-week rebleeding in patients with PVT. High albumin levels may serve as a protective factor for the 14-day and 6-week rebleeding risk. PVT was not responsible for mortality after EVL during 1-year follow-up.

A novel computer-aided diagnostic system for accurate detection and grading of liver tumors

Liver cancer is a major cause of morbidity and mortality in the world. The primary goals of this manuscript are the identification of novel imaging markers (morphological, functional, and anatomical/textural), and development of a computer-aided diagnostic (CAD) system to accurately detect and grade liver tumors non-invasively. A total of 95 patients with liver tumors (M = 65, F = 30, age range = 34–82 years) were enrolled in the study after consents were obtained. 38 patients had benign tumors (LR1 = 19 and LR2 = 19), 19 patients had intermediate tumors (LR3), and 38 patients had hepatocellular carcinoma (HCC) malignant tumors (LR4 = 19 and LR5 = 19). A multi-phase contrast-enhanced magnetic resonance imaging (CE-MRI) was collected to extract the imaging markers. A comprehensive CAD system was developed, which includes the following main steps: i) estimation of morphological markers using a new parametric spherical harmonic model, ii) estimation of textural markers using a novel rotation invariant gray-level co-occurrence matrix (GLCM) and gray-level run-length matrix (GLRLM) models, and iii) calculation of the functional markers by estimating the wash-in/wash-out slopes, which enable quantification of the enhancement characteristics across different CE-MR phases. These markers were subsequently processed using a two-stages random forest-based classifier to classify the liver tumor as benign, intermediate, or malignant and determine the corresponding grade (LR1, LR2, LR3, LR4, or LR5). The overall CAD system using all the identified imaging markers achieved a sensitivity of 91.8%±0.9%, specificity of 91.2%±1.9%, and F\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$_{1}$$\end{document}1 score of 0.91±0.01, using the leave-one-subject-out (LOSO) cross-validation approach. Importantly, the CAD system achieved overall accuracies of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$88\%\pm 5\%$$\end{document}88%±5%, 85%±2%, 78%±3%, 83%±4%, and 79%±3% in grading liver tumors into LR1, LR2, LR3, LR4, and LR5, respectively. In addition to LOSO, the developed CAD system was tested using randomly stratified 10-fold and 5-fold cross-validation approaches. Alternative classification algorithms, including support vector machine, naive Bayes classifier, k-nearest neighbors, and linear discriminant analysis all produced inferior results compared to the proposed two stage random forest classification model. These experiments demonstrate the feasibility of the proposed CAD system as a novel tool to objectively assess liver tumors based on the new comprehensive imaging markers. The identified imaging markers and CAD system can be used as a non-invasive diagnostic tool for early and accurate detection and grading of liver cancer.

Prostate Imaging Reporting and Data System (PI-RADS): What the radiologists need to know?

We aim to review the new modifications in MR imaging technique, image interpretation, lexicon, and scoring system of the last version of Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1) in a simple and practical way. This last version of PI-RADS v2.1 describes the new technical modifications in the protocol of Multiparametric MRI (MpMRI) including T2, diffusion-weighted imaging (DWI), and dynamic contrast enhancement (DCE) parameters. It includes also; new guidelines in the image interpretation specifications in new locations (lesions located in the central zone and anterior fibromuscular stroma), clarification of T2 scoring of lesions of the transition zone, the distinction between DWI score 2 and 3 lesions in the transition zone and peripheral zone, as well as between positive and negative enhancement in DCE. Biparametric MRI (BpMRI) along with simplified PI-RADS is gaining more acceptances in the assessment of clinically significant prostatic cancer.

Evaluation of two different transarterial chemoembolization protocols using Lipiodol and degradable starch microspheres in therapy of hepatocellular carcinoma: a prospective trial

BACKGROUND

This prospective randomized trial is designed to compare the performance of conventional transarterial chemoembolization (cTACE) using Lipiodol-only with additional use of degradable starch microspheres (DSM) for hepatocellular carcinoma (HCC) in BCLC-stage-B based on metric tumor response.

METHODS

Sixty-one patients (44 men; 17 women; range 44-85) with HCC were evaluated in this IRB-approved HIPPA compliant study. The treatment protocol included three TACE-sessions in 4-week intervals, in all cases with Mitomycin C as a chemotherapeutic agent. Multiparametric magnetic resonance imaging (MRI) was performed prior to the first and 4 weeks after the last TACE. Two treatment groups were determined using a randomization sheet: In 30 patients, TACE was performed using Lipiodol only (group 1). In 31 cases Lipiodol was combined with DSMs (group 2). Response according to tumor volume, diameter, mRECIST criteria, and the development of necrotic areas were analyzed and compared using the Mann-Whitney-U, Kruskal-Wallis-H-test, and Spearman-Rho. Survival data were analyzed using the Kaplan-Meier estimator.

RESULTS

A mean overall tumor volume reduction of 21.45% (± 62.34%) was observed with an average tumor volume reduction of 19.95% in group 1 vs. 22.95% in group 2 (p = 0.653). Mean diameter reduction was measured with 6.26% (± 34.75%), for group 1 with 11.86% vs. 4.06% in group 2 (p = 0.678). Regarding mRECIST criteria, group 1 versus group 2 showed complete response in 0 versus 3 cases, partial response in 2 versus 7 cases, stable disease in 21 versus 17 cases, and progressive disease in 3 versus 1 cases (p = 0.010). Estimated overall survival was in mean 33.4 months (95% CI 25.5-41.4) for cTACE with Lipiosol plus DSM, and 32.5 months (95% CI 26.6-38.4), for cTACE with Lipiodol-only (p = 0.844), respectively.

CONCLUSIONS

The additional application of DSM during cTACE showed a significant benefit in tumor response according to mRECIST compared to cTACE with Lipiodol-only. No benefit in survival time was observed.

The value of MRI in identifying pancreatic neuroendocrine tumour G3 and carcinoma G3

AIM

To explore the magnetic resonance imaging (MRI) differences between pancreatic neuroendocrine tumour grade 3 (pNET-G3) and pancreatic neuroendocrine carcinoma grade 3 (pNEC-G3).

MATERIALS AND METHODS

Between 2009 and 2019, 31 patients underwent pNEN-G3 resection with preoperative MRI in two local hospitals in China. The 31 patients were assigned to a pNET-G3 group (n=13) or a pNEC-G3 group (n=18). The MRI findings between the groups were compared.

RESULTS

There was no statistically significant difference between the two groups in lesion size, clinical characteristics, or laboratory indexes. The lesions showed high or slightly higher signal on diffusion-weighted imaging and decreased apparent diffusion coefficient (ADC) values, which differed between the two groups (p=0.013). The difference between the groups regarding positive enhancement integral, arterial phase and portal phase signal enhancement ratio were statistically significant; however, the delayed phase signal enhancement ratio was not significantly different.

CONCLUSIONS

pNET-G3 and pNEC-G3 showed different characteristics on MRI. In particular, the ADC value and dynamic enhanced imaging could have an important role in distinguishing between the two.

Efficacy of the association liver partition and portal vein ligation for staged hepatectomy for the treatment of solitary huge hepatocellular carcinoma: a retrospective single-center study

BACKGROUND

The feasibility of association liver partition and portal vein ligation for staged hepatectomy (ALPPS) for solitary huge hepatocellular carcinoma (HCC, maximal diameter ≥ 10 cm) remains uncertain. This study aims to evaluate the safety and the efficacy of ALPPS for patients with solitary huge HCC.

METHODS

Twenty patients with solitary huge HCC who received ALPPS during January 2017 and December 2019 were retrospectively analyzed. The oncological characteristics of contemporaneous patients who underwent one-stage resection and transcatheter arterial chemoembolization (TACE) were compared using propensity score matching (PSM).

RESULTS

All patients underwent complete two-staged ALPPS. The median future liver remnant from the ALPPS-I stage to the ALPPS-II stage increased by 64.5% (range = 22.3-221.9%) with a median interval of 18 days (range = 10-54 days). The 90-day mortality rate after the ALPPS-II stage was 5%. The 1- and 3-year overall survival (OS) rates were 70.0% and 57.4%, respectively, whereas the 1- and 3-year progression-free survival (PFS) rates were 60.0% and 43.0%, respectively. In the one-to-one PSM analysis, the long-term survival of patients who received ALPPS was significantly better than those who received TACE (OS, P = 0.007; PFS, P = 0.011) but comparable with those who underwent one-stage resection (OS, P = 0.463; PFS, P = 0.786).

CONCLUSION

The surgical outcomes of ALPPS were superior to those of TACE and similar to those of one-stage resection. ALPPS is a safe and effective treatment strategy for patients with unresectable solitary huge HCC.

Balloon occluded TACE (B-TACE) vs DEM-TACE for HCC: a single center retrospective case control study

BACKGROUND

To compare oncological results and safety profile of balloon micro-catheter trans-arterial chemoembolization (b-TACE) and drug-eluting-microsphere (DEM-TACE) in patients with hepatocellular-carcinoma (HCC).

METHODS

This is a case-control, retrospective, single-center study. Between January-2015/March-2019, 149 patients (131 males [87.9%]) with 226 HCC were treated, 22 patients (35 HCC; 19 [86.4%] males) with b-TACE and 127 with DEM-TACE (191 HCC, 112 [88.2%] males). Embolization protocol was standardized (sequential 100 ± 25 and 200 ± 25 μm microspheres). Results were evaluated by modified-response-evaluation-criteria-in-solid-tumor [mRECIST] at 1, 3-6 and 9-12 months and time to recurrence after complete response [TTR] at 1 years. Cox's regression weighted with tumor dimensions was performed. Adverse events (AEs) were recorded.

RESULTS

mRECIST oncological response at all time points (1, 3-6 and 9-12 months) for both treatments were similar, with the exception of Objective response rate at 9-12 months. Objective response at 1 and 3-6 months between b-TACE vs DEM-TACE [23/35 (65.7%) vs 119/191 (62.3%), 21/29 (72.4%) vs 78/136 (57.4%) (p > 0.05), respectively]. On the contrary, at 9-12 months, it was significantly higher in b-TACE subgroup than DEM-TACE (15/19 [78.9%] vs 48/89 [53.9%], p = 0.05). TTR for complete response at 1 year had a better trend for b-TACE vs DEM-TACE (278.0 days [196.0-342.0] vs 219.0 days [161.0-238.0], OR 0.68 [0.4-1.0], p = 0.10). The use of balloon micro-catheter reduced the relative risk of the event of recurrence by 0.63 [CI95% 0.38-1.04]; p = 0.07). No significant differences were found in AEs rate.

CONCLUSION

b-TACE showed a trend of better oncological response over DEM-TACE with and longer TTR with a similar adverse events rate, in patients presenting with larger tumors.

Clinical outcomes of patients with a high alpha-fetoprotein level but without evident recurrence on CT or MRI in surveillance after curative-intent treatment for hepatocellular carcinoma

PURPOSE

Multiphasic CT or MRI and serum alpha-fetoprotein (AFP) are widely used for posttreatment surveillance of hepatocellular carcinoma (HCC). This study aimed to investigate the clinical outcomes of patients with high posttreatment AFP but without evident recurrence on CT or MRI after curative-intent treatment of HCC.

METHODS

We retrospectively analyzed 121 patients presenting with high posttreatment AFP (> 20 ng/mL) without evident recurrence on multiphasic CT or MRI during surveillance after curative-intent surgical resection or radiofrequency ablation (RFA) for HCC. The time interval from the first event of high posttreatment AFP to imaging-evident recurrence (Time_{AFP-Imaging recurrence}) was estimated using the Kaplan-Meier method. Cox regression analyses were performed to assess the associated factors with Time_{AFP-Imaging recurrence}.

RESULTS

The median Time_{AFP-Imaging recurrence} was 20.0 months (95% CI 13.0-28.0 months), and the estimated 6-month and 1-year cumulative incidences of imaging-evident recurrence were 24.4% and 40.1%, respectively. In multivariate Cox analyses, late onset of AFP elevation (> 3 months after treatment) was an independent predictor of shorter Time_{AFP-Imaging recurrence} (HR 2.11, P = 0.015) if using variables available at the first event of AFP elevation, while non-normalization of AFP at the next follow-up was an independent predictor of shorter Time_{AFP-Imaging recurrence} (HR 3.65, P < 0.001) if using variables including the follow-up data.

CONCLUSION

In the surveillance setting after curative-intent treatment of HCC, patients presenting with high posttreatment AFP without evident recurrence on CT or MRI may frequently progress to imaging-evident recurrence. In high-risk patients, an extensive diagnostic workup or close monitoring is needed to detect HCC recurrence earlier.

Dual-Energy Computed Tomography of the Liver: Uses in Clinical Practices and Applications

Dual-energy computed tomography (DECT) is an imaging technique based on data acquisition at two different energy settings. Recent advances in CT have allowed data acquisitions and simultaneous analyses of X-rays at two energy levels, and have resulted in novel developments in the field of abdominal imaging. The use of low and high X-ray tube voltages in DECT provide fused images that improve the detection of liver tumors owing to the higher contrast-to-noise ratio (CNR) of the tumor compared with the liver. The use of contrast agents in CT scanning improves image quality by enhancing the CNR and signal-to-noise ratio while reducing beam-hardening artifacts. DECT can improve detection and characterization of hepatic abnormalities, including mass lesions. The technique can also be used for the diagnosis of steatosis and iron overload. This article reviews and illustrates the different applications of DECT in liver imaging.

LI-RADS 4 or 5 categorization may not be clinically relevant for decision-making processes: A prospective cohort study

INTRODUCTION AND OBJECTIVES

The liver imaging reporting data system (LI-RADS) for hepatocellular carcinoma (HCC) was proposed to standardize and enhance consensus of reporting. However, clinical utility of LI-RADS has not been evaluated in Latin America. We therefore sought to compare LI-RADS categories with histopathology findings in liver transplant (LT) explants in a regional center.

MATERIALS AND METHODS

Prospective cohort study conducted between 2012 and 2018 in a single center from Argentina including patients with HCC listed for LT. LI-RADS definitions were applied to magnetic resonance images (MRI) or computed tomography (CT) abdominal scans at time of listing and at final pre-LT reassessment and compared to explant pathology findings; specifically, major nodule (NOD1).

RESULTS

Of 130 patients with HCC listed for LT (96.1% with cirrhosis and 35.6% with hepatitis C virus infection), 72 underwent LT. Overall, 65% had imaging HCC diagnosis based on MRI (n = 84), 26% with CT (n = 34) and 9% (n = 12) with both methods. Among LT patients with pre-transplant imaging at our institution (n = 42/72), 69% of the NOD1 were LR-5, 21% LR-4 and 10% LR-3. Definite HCC diagnosis was 50% in LR-3 NOD1 (CI 18-90); none presented microvascular invasion. In LR-4 NOD1, HCC was confirmed in 89% (CI 59-98), of which 11% showed microvascular invasion; whereas in LR-5 NOD1 77% (CI 64-87) had confirmed HCC, 17% with microvascular invasion.

CONCLUSIONS

LI-RADS was useful to standardize reports; however, no significant differences were observed between LR-4 and LR-5 HCC probability when compared to explant pathology.

A Contemporary Approach to Diagnosis and Treatment of Combined Hepatocellular-Cholangiocarcinoma

Purpose of review

To provide updates on terminology, epidemiology, diagnosis, and treatment of combined hepatocellular-cholangiocarcinoma (cHCC-CCA).

Recent findings

cHCC-CCAs are tumors that in the same nodule contain a variable degree of HCC and CCA components with a transition zone. cHCC-CCAs develop in cirrhotic and non-cirrhotic livers like and is associated with poor outcomes. Mutations in TP53, TERT promoter, and ARID1A are the most common genetic aberrations in cHCC-CCA. Fusion gene PTMS-AP1G1 is unique for cHCC-CCA. A biopsy is required for diagnosis. Surgical resection remains treatment of choice, while liver transplantation for early cHCC-CCA is associated with favorable outcomes. Gemcitabine-based therapy shows benefits for advanced cHCC-CCA.

Summary

cHCC-CCAs are a heterogeneous group of primary liver cancers with unique biological behavior. Multicenter studies are required for a molecular analysis to inform novel therapeutic approaches, and understand epidemiology and benefits of liver transplantation, liver-directed and targeted therapies for this rare aggressive cancer.

Radiolabelled PSMA PET/CT or PET/MRI in hepatocellular carcinoma (HCC): a systematic review

Introduction

Radiolabelled prostate-specific membrane antigen PSMA-based PET/CT or PET/MRI is a whole-body imaging technique usually performed for the detection of prostate cancer lesions. PSMA has been also demonstrated to be expressed by the neovasculature of many other solid tumors. The aim of this review is to evaluate the possible diagnostic role of radiolabelled PSMA PET/CT or PET/MRI in patients with hepatocellular carcinoma, by summarizing the available literature data.

Methods

A wide literature search of the PubMed/MEDLINE, Scopus, Embase and Cochrane library databases was made to find relevant published articles about the diagnostic performance of radiolabelled PSMA binding agents in PET/CT or PET/MRI imaging of patients with hepatocellular carcinoma.

Results

Ten case reports and three studies showed that hepatocellular carcinoma is PSMA-avid.

Conclusion

Radiolabelled PSMA imaging seems to be useful in analyzing hepatocellular carcinoma. Further studies enrolling a wider population are needed to clarify the real clinical and diagnostic role of radiolabelled PSMA in this setting.

A hypocaloric high-protein diet supplemented with β-cryptoxanthin improves non-alcoholic fatty liver disease: a randomized controlled trial

Background

Despite promising animal data, there is no randomized controlled trial (RCT) on the effects of high protein (HP)-diet and/or β-cryptoxanthin in non-alcoholic fatty liver disease (NAFLD). Aims: Safety and efficacy assessment of a hypocaloric HP-diet supplemented with β-cryptoxanthin in NAFLD.

Methods

Ninety-two Iranian NAFLD outpatients were recruited for this 12-week, single-center, parallel-group, double-blind RCT and randomized into 4 arms (n = 23): HP-diet and β-cryptoxanthin (hypocaloric HP-diet + β-cryptoxanthin), HP-diet (hypocaloric HP-diet + placebo), β-cryptoxanthin (standard hypocaloric diet + β-cryptoxanthin), and control (standard hypocaloric diet + placebo). Serum levels of liver enzymes and grade of hepatic steatosis were assessed at baseline and study endpoint as outcome measures.

Results

In the intention-to-treat population (N = 92), HP-diet and β-cryptoxanthin group experienced greater 12-week reductions in serum levels of liver enzymes than control group (mean difference for alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase: − 27.2, − 7.2, − 39.2, and − 16.3 IU/L, respectively; all p < 0.010). Clinical remission rate (achieving grade 0 hepatic steatosis) in HP-diet and β-cryptoxanthin group (82.6%) was also higher than other groups (13.0%, 17.4%, and 0.0% in HP-diet, β-cryptoxanthin, and control groups, respectively; p < 0.001). Sixteen patients reported minor adverse events.

Conclusion

A hypocaloric HP-diet supplemented with β-cryptoxanthin safely and efficaciously improves NAFLD.

Trial registration number

This trial was registered at https://www.irct.ir as IRCT2017060210181N10.

Interstitial Lung Fibrosis Imaging Reporting and Data System: What Radiologist Wants to Know?

The aim of this work is to review interstitial lung fibrosis Imaging Reporting and Data System (ILF-RADS) that was designed for reporting of interstitial lung fibrosis (ILF). Findings include pulmonary and extrapulmonary findings and is subsequently designed into 4 categories. Pulmonary findings included lung volume, reticulations, traction bronchiectasis, honeycomb, nodules, cysts, ground glass, consolidation, mosaic attenuation and emphysema, and distribution of pulmonary lesions; axial (central, peripheral and diffuse), and zonal distribution (upper, middle, and lower zones). Complications in the form of acute infection, acute exacerbation, and malignancy were also assessed. Extrapulmonary findings included mediastinal, pleural, tracheal, and bone or soft tissue lesions. The lexicon of usual interstitial pneumonia (UIP) was classified into 4 categories designated as belonging in 1 of 4 categories. Lexicon of ILF-RADS-1 (typical UIP), ILF-RADS-2 (possible UIP), ILF-RADS-3 (indeterminate for UIP), and ILF-RADS-4 (inconsistent with UIP).

Prognostic value of pretreatment contrast-enhanced computed tomography in esophageal neuroendocrine carcinoma: A multi-center follow-up study

BACKGROUND

The rare incidence of esophageal neuroendocrine carcinoma (NEC) and limited treatment experience result in insufficient clinical observations and unsuitable guidelines for its management.

AIM

To investigate the prognostic value of pretreatment contrast-enhanced computed tomography (CT) characteristics in patients with esophageal NEC.

METHODS

Seventy-seven esophageal NEC patients who received contrast-enhanced CT at two hospitals were enrolled in this study from June 2014 to December 2019. The clinical features and image characteristics were recorded accordingly. Univariate survival analysis was performed using the Kaplan-Meier method and log-rank test, and multivariate analysis was carried out with a Cox proportional hazards model.

RESULTS

The multivariate analysis performed using the Cox proportional hazards model showed that N stage, adjuvant chemotherapy, and degree of enhancement were independent prognostic factors for overall survival (OS). Meanwhile, adjuvant chemotherapy was an independent prognostic factor for progression-free survival (PFS). The hazard ratios (HRs) of N stage, adjuvant chemotherapy, and degree of enhancement (mild vs moderate/marked) for OS were 0.426 (P = 0.024), 3.862 (P = 0.006), and 2.169/0.809 (P = 0.037), respectively. The HR of adjuvant chemotherapy for PFS was 6.432 (P < 0.001). Adjuvant chemotherapy was significantly associated with degree of enhancement (P = 0.018).

CONCLUSION

Adjuvant chemotherapy is an independent prognostic factor for OS and PFS. Additionally, N stage and degree of enhancement are prognostic factors for OS in patients with esophageal NEC.

Congenital and hereditary cystic diseases of the abdomen

Congenital and hereditary cystic lesions of the abdomen are relatively rare. Correct diagnosis is critical as they may simulate several other benign and malignant acquired diseases of the abdomen. With the correct and appropriate use of imaging, diagnosis may be relatively straightforward and clinical management may be implemented appropriately. The purpose of this article is to describe imaging findings of common and uncommon congenital and hereditary cystic disease of the abdominal organs.