Additional value of SPIO-enhanced MR imaging for the noninvasive imaging diagnosis of hepatocellular carcinoma in cirrhotic liver. Invest Radiol. 2009;44:800-807. [PMID: 19838119 DOI: 10.1097/rli.0b013e3181bc271d]

Overall diagnostic accuracy of different MR imaging sequences for detection of dysplastic nodules: a systematic review and meta-analysis

OBJECTIVE

To assess the overall diagnostic accuracy of different MR imaging sequences in the detection of the dysplastic nodule (DN).

METHODS

PubMed, Cochrane Library, and Web of Science were systematically searched. Study selection and data extraction were conducted by two authors independently. Quality assessment of diagnostic accuracy studies (QUADAS) 2 in RevMan software was used to score the included studies and assess their methodological quality. A random-effects model was used for statistical pooling by Meta-Disc. Subgroup analysis and sensitivity analysis were used to explore potential sources of heterogeneity.

RESULTS

Fourteen studies (335 DN lesions in total) were included in our meta-analysis. The area under the curve (AUC) of summary receiver operating characteristic (SROC) of T₂WI was 0.87. Pooled sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of DWI were 0.81 (95%CI, 0.73-0.87), 0.90 (95%CI, 0.86-0.93), 7.04 (95%CI, 4.49-11.04), and 0.24 (95%CI, 0.17-0.33) respectively. In the arterial phase, pooled sensitivity, specificity, PLR, and NLR were 0.89 (0.84-0.93), 0.75 (0.72-0.79), 3.72 (2.51-5.51), and 0.17 (0.12-0.25), respectively. Pooled sensitivity, specificity, PLR, and NLR of the delayed phase were 0.78 (0.72-0.83), 0.60 (0.55-0.65), 2.19 (1.55-3.10), and 0.36 (0.23-0.55) separately. Pooled sensitivity, specificity, PLR, and NLR of the hepatobiliary phase were 0.77 (0.71-0.82), 0.92 (0.89-0.94), 8.74 (5.91-12.92), and 0.24 (0.14-0.41) respectively. Pooled sensitivity, specificity, and PLR were higher on DWI and hepatobiliary phase in diagnosing LGDN than HGDN.

CONCLUSION

MR sequences, particularly DWI, arterial phase, and hepatobiliary phase imaging demonstrate high diagnostic accuracy for DN.

KEY POINTS

• MRI has dramatically improved the detection and accurate diagnosis of DNs and their differentiation from hepatocellular carcinoma. • Overall diagnostic accuracy of different MRI sequences in the detection of DN has not been studied before. • Our meta-analysis demonstrates that MRI achieves a high diagnostic value for DN, especially when using DWI, arterial phase imaging, and hepatobiliary phase imaging.

Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients

The Liver Imaging Reporting and Data System (LI-RADS) is composed of four individual algorithms intended to standardize the lexicon, as well as reporting and care, in patients with or at risk for hepatocellular carcinoma in the context of surveillance with US; diagnosis with CT, MRI, or contrast material-enhanced US; and assessment of treatment response with CT or MRI. This report provides a broad overview of LI-RADS, including its historic development, relationship to other imaging guidelines, composition, aims, and future directions. In addition, readers will understand the motivation for and key components of the 2018 update.

Diagnostic value of imaging examinations in patients with primary hepatocellular carcinoma

Primary hepatocellular carcinoma (PHC) includes hepatocellular carcinoma, intrahepatic cholangiocarcinoma and other pathological types and is characterized by rapid progression. Most of the clinical diagnoses are made at late stage or when distant metastasis occurs, increasing the difficulty of treatment and resulting in a poor prognosis. Therefore, the early diagnosis of PHC plays an important role in timely treatment and the improvement of prognosis. The gold standard for the diagnosis of primary liver cancer is liver biopsy, but it has limitations as an invasive examination. Presently, imaging has become the first choice for the diagnosis of liver cancer. We here summarize the new methods and techniques of imaging in diagnosis and evaluation of primary liver cancer in recent years, including ultrasonography, computed tomography perfusion imaging, diffusion-weighted imaging technology-voxel incoherent motion, diffusion tensor imaging, iterative decomposition of water and fat with echo asymmetry and least squares estimation-iron quantification, dynamic enhanced magnetic resonance imaging and hepatocyte-specific contrast medium imaging. Imaging diagnosis can not only evaluate the degree of differentiation, blood supply and perfusion, and invasiveness of the lesion, but also predict the prognosis, evaluate liver function, and provide references for clinical diagnosis and treatment.

Evidence Supporting LI-RADS Major Features for CT- and MR Imaging-based Diagnosis of Hepatocellular Carcinoma: A Systematic Review

The Liver Imaging Reporting and Data System (LI-RADS) standardizes the interpretation, reporting, and data collection for imaging examinations in patients at risk for hepatocellular carcinoma (HCC). It assigns category codes reflecting relative probability of HCC to imaging-detected liver observations based on major and ancillary imaging features. LI-RADS also includes imaging features suggesting malignancy other than HCC. Supported and endorsed by the American College of Radiology (ACR), the system has been developed by a committee of radiologists, hepatologists, pathologists, surgeons, lexicon experts, and ACR staff, with input from the American Association for the Study of Liver Diseases and the Organ Procurement Transplantation Network/United Network for Organ Sharing. Development of LI-RADS has been based on literature review, expert opinion, rounds of testing and iteration, and feedback from users. This article summarizes and assesses the quality of evidence supporting each LI-RADS major feature for diagnosis of HCC, as well as of the LI-RADS imaging features suggesting malignancy other than HCC. Based on the evidence, recommendations are provided for or against their continued inclusion in LI-RADS. © RSNA, 2017 Online supplemental material is available for this article.

The Diagnostic Performance of Dynamic Contrast-enhanced MR Imaging for Detection of Small Hepatocellular Carcinoma Measuring Up to 2 cm: A Meta-Analysis

PURPOSE

To determine the performance of dynamic contrast material-enhanced magnetic resonance (MR) imaging in the diagnosis of small (≤2-cm) hepatocellular carcinoma (HCC) and to identify factors that influence this performance.

MATERIALS AND METHODS

Medline and Embase databases were searched for studies performed from January 2000 to March 2014 in which the performance of MR imaging was reported for the detection of HCC up to 2 cm on either a lesion- or patient-based level, with sufficient data to construct 2 × 2 contingency tables. Diagnostic performance was quantitatively pooled for all studies by using a bivariate random-effects model with exploration involving subgroup analysis, meta-regression, and determination of study heterogeneity.

RESULTS

Twenty-two studies with 1387 small HCC lesions in 1908 patients met inclusion criteria. Heterogeneity was higher for sensitivity (range, 30%-99%) than specificity (range, 61%-100%). Overall sensitivity was 78% (95% confidence interval [CI]: 68%, 85%; I(2) = 89%), and overall specificity was 92% (95% CI: 88%, 95%; I(2) = 69%). The primary potential source of bias was use of explant as the reference standard in only 13% of studies, although lower sensitivity in such studies was not significant (59% vs 80%, P = .165). Sensitivities were significantly higher for studies that originated from Asia compared with those that originated elsewhere (89% vs 71%, P = .028), those performed with hepatobiliary phase imaging compared with those without (87% vs 65%, respectively; P = .004), and those in which gadoxetate disodium was used versus an extracellular agent (92% vs 67%, P ≤ .001). Specificity was not significantly different between subgroups (P ≥ .122). At pairwise meta-regression analysis with either study origin from Asia or performance of hepatobiliary phase imaging, only gadoxetate disodium contrast agent showed significant independent association with higher sensitivity (P = .002-.007).

CONCLUSION

Results of this meta-analysis suggest that dynamic contrast-enhanced MR imaging has moderate sensitivity and excellent specificity in the detection of HCC up to 2 cm. Gadoxetate disodium contrast agent showed the strongest association with increased sensitivity.

Superparamagnetic iron oxide-enhanced magnetic resonance imaging for focal hepatic lesions: systematic review and meta-analysis

AIM

To evaluate the performance of superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) in the detection and characterization of focal hepatic lesions (FHLs).

METHODS

This meta-analysis compared relevant studies that were identified by searching PubMed, EMBASE, and the Cochrane Library databases for articles published between January 1988 and September 2014 and that met the following criteria: (1) SPIO-enhanced MRI was conducted to identify FHLs and data were sufficient for pooled analysis using Meta-DiSc 1.4; (2) hepatocellular carcinomas (HCCs) were differentiated from other FHLs; (3) well-differentiated HCCs (WD-HCCs) were contradistinguished from dysplastic nodules; and (4) WD-HCCs were compared with moderately and poorly differentiated HCCs (MD- and PD-HCCs, respectively).

RESULTS

The data obtained from 15 eligible studies yielded a sensitivity of 85% and a specificity of 78% for differentiating between HCCs and other FHLs. The sensitivity was unchanged and the specificity was increased to 87% when non-HCC malignancies were excluded. Comparative analyses between WD-HCCs and MD- and PD-HCCs from seven studies showed a sensitivity of 98% and a specificity of 50% for the diagnosis of MD- and PD-HCCs, and the area under the summary receiver operating characteristics (sROC) curve was 0.97. A comparison between WD-HCCs and dysplastic nodules revealed a sensitivity of 50% and a specificity of 92% for the diagnosis of WD-HCCs and the area under the sROC curve was 0.80.

CONCLUSION

SPIO-enhanced MRI is useful in differentiating between HCCs and other FHLs.

CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features

Computed tomography (CT) and magnetic resonance (MR) imaging play critical roles in the diagnosis and staging of hepatocellular carcinoma (HCC). The second article of this two-part review discusses basic concepts of diagnosis and staging, reviews the diagnostic performance of CT and MR imaging with extracellular contrast agents and of MR imaging with hepatobiliary contrast agents, and examines in depth the major and ancillary imaging features used in the diagnosis and characterization of HCC.

Imaging of hepatocellular carcinoma: diagnosis, staging and treatment monitoring

Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Imaging is important for establishing a diagnosis of HCC. Several imaging modalities including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and angiography are used in evaluating patients with chronic liver disease and suspected HCC. CT, MRI and contrast-enhanced US have replaced biopsy for diagnosis of HCC. Dynamic multiphase contrast-enhanced CT or MRI is the current standard for imaging diagnosis of HCC. Functional imaging techniques such as perfusion CT and diffusion-weighted MRI provide additional information about tumor angiogenesis that may be useful for treatment. Techniques evaluating tissue mechanical properties such as magnetic resonance elastography, and acoustic radiation force impulse imaging are being explored for characterizing liver lesions. The role of PET in the evaluation of HCC is evolving with promise seen especially with the use of a hepatocyte-specific PET tracer. Imaging is also critical for assessment of treatment response and detection of recurrence following locoregional treatment. Knowledge of the post-treatment appearance of HCC is essential for correct interpretation. This review article provides an overview of the role of imaging in the diagnosis, staging and post-treatment follow-up of HCC.

Diagnosis of hepatocellular carcinoma: newer radiological tools

With the recent dramatic advances in diagnostic modalities, the diagnosis of hepatocellular carcinoma (HCC) is primarily based on imaging. Ultrasound (US) plays a crucial role in HCC surveillance. Dynamic multiphasic multidetector-row CT (MDCT) and magnetic resonance imaging (MRI) are the standard diagnostic methods for the noninvasive diagnosis of HCC, which can be made based on hemodynamic features (arterial enhancement and delayed washout). The technical development of MDCT and MRI has made possible the fast scanning with better image quality and resolution, which enables an accurate CT hemodynamic evaluation of hepatocellular tumor, as well as the application of perfusion CT and MRI in clinical practice. Perfusion CT and MRI can measure perfusion parameters of tumor quantitatively and can be used for treatment response assessment to anti-vascular agents. Besides assessing the hemodynamic or perfusion features of HCC, new advances in MRI can provide a cellular information of HCC. Liver-specific hepatobiliary contrast agents, such as gadoxetic acid, give information regarding hepatocellular function or defect of the lesion, which improves lesion detection and characterization. Diffusion-weighted imaging (DWI) of the liver provides cellular information of HCC and also has broadened its role in lesion detection, lesion characterization, and treatment response assessment to chemotherapeutic agents. In this article, we provide an overview of the state-of-the art imaging techniques of the liver and their clinical role in management of HCC.

Negatively charged superparamagnetic iron oxide nanoparticles: a new blood-pooling magnetic resonance contrast agent

PURPOSE

Our purpose was to investigate the utility of superparamagnetic iron-oxide nanoparticles (SPIO) as a blood-pooling contrast agent at magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We studied four contrast agents: carboxymethyl-diethylaminoethyl dextran magnetite SPIO (CMEADM-S, diameter 54 nm), negatively charged CMEADM ultrasmall SPIO (CMEADM-U, 32 nm), alkali-treated dextran magnetite SPIO (ATDM-S, 55 nm), and ATDM ultrasmall SPIO (ATDM-U, 28 nm) carrying a neutral charge. Each contrast agent (80 μmol/kg) was injected intraperitoneally into apolipoprotein E (apoE) mice and the tissue iron concentration was measured 30-, 60-, 180-, and 300-min later by nuclear MR. For MR angiographic (MRA) evaluation, we injected the agents into the auricular vein of four groups of 15 rabbits. Immediately and 30-, 60-, 180-, and 300-min later, three rabbits from each group were subjected to MRI. The organ/background signal ratio (SR) was calculated. Statistical analyses were performed with Tukey's honestly significant difference (HSD) test.

RESULTS

At 60 and 180 min, blood-iron concentration of CMEADM-U was significantly different from other contrast agents. In the abdominal aorta and inferior vena cava, SR of CMEADM-U was higher at 180 and 300 min than of the other contrast agents. In the thoracic aorta, there was no difference in SR at 300 min between CMEADM-U and CMEADM-S.

CONCLUSION

Negatively charged SPIO nanoparticles may be useful as a blood-pooling contrast agent.

New paradigm for management of hepatocellular carcinoma by imaging

Based on recent clinical practice guidelines, imaging is largely replacing pathology as the preferred diagnostic method for determination of hepatocellular carcinoma (HCC). A variety of imaging modalities, including ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and angiography, are currently used to examine patients with chronic liver disease and suspected HCC. Advancements in imaging techniques such as perfusion imaging, diffusion imaging, and elastography along with the development of new contrast media will further improve the ability to detect and characterize HCC. Early diagnosis of HCC is essential for prompt treatment, which may in turn improve prognosis. Considering the process of hepatocarcinogenesis, it is important to evaluate sequential changes via imaging which would help to differentiate HCC from premalignant or benign lesions. Recent innovations including multiphasic examinations, high-resolution imaging, and the increased functional capabilities available with contrast-enhanced US, multidetector row CT, and MRI have raised the standards for HCC diagnosis. Although hemodynamic features of nodules in the cirrhotic liver remain the main diagnostic criterion, newly developed cellspecific contrast agents have shown great possibilities for improved HCC diagnosis and may overcome the diagnostic dilemma associated with small or borderline hepatocellular lesions. In the 20th century paradigm of medical imaging, radiological diagnosis was based on morphological characteristics, but in the 21st century, a paradigm shift to include biomedical, physiological, functional, and genetic imaging is needed. A multidisciplinary team approach is necessary to foster an integrated approach to HCC imaging. By developing and combining new imaging modalities, all phases of HCC patient care, including screening, diagnosis, treatment, and therapy, can be dramatically improved.

Imaging study of early hepatocellular carcinoma: usefulness of gadoxetic acid-enhanced MR imaging

PURPOSE

To describe imaging findings of early hepatocellular carcinoma (HCC) at gadoxetic acid-enhanced magnetic resonance (MR) imaging, dynamic contrast material-enhanced computed tomography (CT), CT during arterial portography (CTAP), and CT during hepatic arteriography (CTHA) and to compare the diagnostic performance of each modality for small (≤ 2 cm) HCC.

MATERIALS AND METHODS

The institute ethics committee deemed study approval unnecessary. One hundred eight resected small lesions in 64 patients were diagnosed as a dysplastic nodule (DN) (n = 12), progressed HCC (n = 66), or early HCC (n = 30). All but two patients underwent all imaging examinations. The imaging characteristics of the lesions with each modality were determined. To evaluate the diagnostic performance of the modalities, two radiologists graded the presence of HCC with use of a five-point confidence scale. The area under the receiver operating characteristic curve (A(z)), sensitivity, and specificity of each modality were compared.

RESULTS

The imaging features that are statistically significant for differentiating an early HCC from a DN include fat-containing lesions at dual-echo T1-weighted MR imaging (seen in 16 of the 30 early HCCs and none of the DNs), low attenuation at unenhanced CT (seen in 13 of the 30 early HCCs and none of the DNs), low attenuation at CTAP (seen in 11 of the 30 early HCCs and none of the DNs), and low signal intensity at hepatocyte phase gadoxetic acid-enhanced MR imaging (seen in 29 of the 30 early HCCs and none of the DNs). The diagnostic performance of gadoxetic acid-enhanced MR imaging (A(z), 0.98 and 0.99) was significantly greater than that of contrast-enhanced CT (A(z), 0.87) and CTHA-CTAP (A(z), 0.85 and 0.86) owing to its significantly higher sensitivity (P < .001).

CONCLUSION

Gadoxetic acid-enhanced MR imaging is the most useful imaging technique for evaluating small HCC, including early HCC.

APASL and AASLD Consensus Guidelines on Imaging Diagnosis of Hepatocellular Carcinoma: A Review

Consensus guidelines for radiological diagnosis of hepatocellular carcinoma (HCC) have been drafted by several large international working groups. This article reviews the similarities and differences between the most recent guidelines proposed by the American Association for Study of Liver Diseases and the Asian Pacific Association for the Study of the Liver. Current evidence for the various imaging modalities for diagnosis of HCC and their relevance to the consensus guidelines are reviewed.

Association of exogenous insulin or sulphonylurea treatment with an increased incidence of hepatoma in patients with hepatitis C virus infection

BACKGROUND

Diabetes mellitus is frequently seen in hepatitis C patients and is often treated with antidiabetic agents that increase serum insulin levels. Because insulin is a growth-promoting hormone, antidiabetic agents could pose a risk for hepatocellular carcinoma (HCC).

AIM

The aim of this study was to investigate an association between antidiabetic therapies and the incidence of HCC in hepatitis C patients with diabetes mellitus.

METHODS

A nested case-control study was conducted. Participants were recruited from a cohort study, in which patients with hepatitis C were consecutively registered. Participants were assigned to an HCC group (n=138) or a non-HCC group (n=103). To identify independent factors, variables including use of antidiabetic agents were analysed by logistic regression analysis.

RESULTS

Besides ageing, being male, cirrhosis and hypoalbuminaemia, use of exogenous insulin and a second-generation sulphonylurea were significant independent factors associated with an incidence of HCC [odds ratio (OR) 2.969, 95% confidence interval (CI) 1.293-6.819, P<0.0103 and OR 6.831, 95% CI 1.954-23.881, P<0.0026 respectively). In stratified analyses, the impact of these antidiabetic agents was more evident in patients who were non-cirrhotic than in those who were cirrhotic.

CONCLUSIONS

Exogenous insulin and a second-generation sulphonylurea were independent variables associated with an incidence of HCC in hepatitis C patients with diabetes mellitus. This association was evident in patients who were non-cirrhotic. To verify a causal relationship between these antidiabetic agents and the development of HCC, a prospective cohort study is required.