Dynamic enhancement pattern of HCC smaller than 3 cm in diameter on gadoxetic acid-enhanced MRI: comparison with multiphasic MDCT

Preoperative MRI features for characterization of vessels encapsulating tumor clusters and microvascular invasion in hepatocellular carcinoma

PURPOSE

This study aimed to analyze imaging features based on preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the identification of vessels encapsulating tumor clusters (VETC)-microvascular invasion (MVI) in hepatocellular carcinoma (HCC), VM-HCC pattern.

METHODS

Patients who underwent hepatectomy and preoperative DCE-MRI between January 2015 and March 2021 were retrospectively analyzed. Clinical and imaging features related to VM-HCC (VETC + /MVI-, VETC-/MVI +, VETC + /MVI +) and Non-VM-HCC (VETC-/MVI-) were determined by multivariable logistic regression analyses. Early and overall recurrence were determined using the Kaplan-Meier survival curve. Indicators of early and overall recurrence were identified using the Cox proportional hazard regression model.

RESULTS

In total, 221 patients (177 men, 44 women; median age, 60 years; interquartile range, 52-66 years) were evaluated. The multivariable logistic regression analyses revealed fetoprotein > 400 ng/mL (odds ratio [OR] = 2.17, 95% confidence interval [CI] 1.07, 4.41, p = 0.033), intratumor vascularity (OR 2.15, 95% CI 1.07, 4.31, p = 0.031), and enhancement pattern (OR 2.71, 95% CI 1.17, 6.03, p = 0.019) as independent predictors of VM-HCC. In Kaplan-Meier survival analysis, intratumor vascularity was associated with early and overall recurrence (p < 0.05).

CONCLUSION

Based on DCE-MRI, intratumor vascularity can be used to characterize VM-HCC and is of prognostic significance for recurrence in patients with HCC.

Performance of adding hepatobiliary phase image in magnetic resonance imaging for detection of hepatocellular carcinoma: a meta-analysis

OBJECTIVES

To determine the performance of diagnostic algorithm of adding hepatobiliary phase (HBP) images in Gd-EOB-DTPA-enhanced MRI for the detection of hepatocellular carcinoma (HCC) measuring up to 3 cm in patients with chronic liver disease.

METHODS

We searched multiple databases from inception to April 10, 2020, to identify studies on using Gd-EOB-DTPA-enhanced MRI for the diagnostic accuracy of HCC (≤ 3 cm) in patients with chronic liver disease. The diagnostic algorithm of Gd-EOB-DTPA-enhanced MRI with HBP for HCC was defined as a nodule showing hyperintensity during arterial phase and hypointensity during the portal venous, delayed, or hepatobiliary phases. For gadoxetic acid-enhanced MRI without HBP, the diagnostic criteria were a nodule showing arterial enhancement and hypointensity on the portal venous or delayed phases. The data were extracted to calculate summary estimates of sensitivity, specificity, diagnostic odds ratio, likelihood ratio, and summary receiver operating characteristic (sROC) by using a bivariate random-effects model.

RESULTS

Twenty-nine studies with 2696 HCC lesions were included. Overall Gd-EOB-DTPA-enhanced MRI with HBP had a sensitivity of 87%, specificity of 92%, and the area under the sROC curve of 95%. The summary sensitivity of Gd-EOB-DTPA-enhanced MRI with HBP was significantly higher than that without HBP (84% vs 68%, p = 0.01).

CONCLUSION

Gd-EOB-DTPA-enhanced MRI with HBP showed higher sensitivity than that without HBP and had comparable specificity for diagnosis of HCC in patients with chronic liver disease.

KEY POINTS

• Hypointensity on HBP is a major feature for diagnosis of HCC. • Extending washout appearance to the transitional or hepatobiliary phase on Gd-EOB-DTPA provides favorable sensitivity and comparable specificity for diagnosis HCC. • The summary sensitivity of gadoxetic acid-enhanced MRI with HBP was significantly higher than that without HBP (84% vs 68%, p = 0.01) for diagnosis of HCC in patients with chronic liver disease.

Accurate prediction of microvascular invasion occurrence and effective prognostic estimation for patients with hepatocellular carcinoma after radical surgical treatment

Background

Hepatocellular carcinoma (HCC) is the third most common cause of cancer death worldwide, with an overall 5-year survival rate of less than 18%, which may be related to tumor microvascular invasion (MVI). This study aimed to compare the clinical prognosis of HCC patients with or without MVI after radical surgical treatment, and further analyze the preoperative risk factors related to MVI to promote the development of a new treatment strategy for HCC.

Methods

According to the postoperative pathological diagnosis of MVI, 160 study patients undergoing radical hepatectomy were divided into an MVI-negative group (n = 68) and an MVI-positive group (n = 92). The clinical outcomes and prognosis were compared between the two groups, and then the parameters were analyzed by multivariate logistic regression to construct an MVI prediction model. Then, the practicability and validity of the model were evaluated, and the clinical prognosis of different MVI risk groups was subsequently compared.

Result

There were no significant differences between the MVI-negative and MVI-positive groups in clinical baseline, hematological, or imaging data. Additionally, the clinical outcome comparison between the two groups presented no significant differences except for the pathological grading (P = 0.002) and survival and recurrence rates after surgery (P < 0.001). The MVI prediction model, based on preoperative AFP, tumor diameter, and TNM stage, presented superior predictive efficacy (AUC = 0.7997) and good practicability (high H-L goodness of fit, P = 0.231). Compared with the MVI high-risk group, the patients in the MVI low-risk group had a higher survival rate (P = 0.002) and a lower recurrence rate (P = 0.004).

Conclusion

MVI is an independent risk factor for a poor prognosis after radical resection of HCC. The MVI prediction model, consisting of AFP, tumor diameter, and TNM stage, exhibits superior predictive efficacy and strong clinical practicability for MVI prediction and prognostication, which provides a new therapeutic strategy for the standardized treatment of HCC patients.

[Small hepatocellular carcinoma : Diagnostics according to guidelines and established in the clinical setting]

CLINICAL/METHODICAL ISSUE

The diagnosis of hepatocellular carcinoma (HCC)-especially the characterization of small lesions <2 cm-continues to be a radiological challenge.

STANDARD RADIOLOGICAL METHODS

In the current S3 guideline on diagnosis and therapy of HCC, contrast-enhanced imaging examinations, such as contrast-enhanced ultrasonography (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI), are still the diagnostic standard.

METHODOLOGICAL INNOVATIONS

HCC in the cirrhotic liver should be diagnosed by its typical contrast-enhanced pattern in the MRI. In addition, the use of quality assurance instruments such as LI-RADS (Liver Imaging Reporting and Data System) contributes to the desired consistency of findings, even with small ambiguous findings.

PERFORMANCE

Many studies have shown that the LI-RADS classification reflects the likelihood of HCC and other malignant liver lesions.

ACHIEVEMENTS

Guidelines and quality assurance instruments contribute to a more precise diagnosis in patients with suspected HCC.

PRACTICAL RECOMMENDATIONS

A guideline-compliant diagnostic algorithm and the LI-RADS should be used across the board for accurate HCC diagnostics.

[Clinical relevance of the new S3 guideline on hepatocellular carcinoma and biliary tract cancer for practitioners]

The update of the S3 German guideline for the management of the hepatocellular carcinoma and biliary tract cancer contains a comprehensive revision of the guideline for hepatocellular carcinoma and establishes a new guideline for biliary tract cancer. In recent years several studies have been conducted to improve diagnostic and therapeutic options for liver cancer. Magnetic resonance imaging (MRI) and biopsy are important for the diagnosis of hepatocellular carcinoma or cholangiocarcinoma. This guideline shows the progress in the treatment options for hepatocellular carcinoma, including advances in liver transplantation, bridging and downstaging. For cholangiocarcinoma there is a focus on interventional treatment and resection. This guideline also emphasizes the need of molecular diagnostics and the resulting treatment options in targeted therapy.

Preoperative Microvascular Invasion Prediction to Assist in Surgical Plan for Single Hepatocellular Carcinoma: Better Together with Radiomics

BACKGROUND

Prediction models with or without radiomic analysis for microvascular invasion (MVI) in hepatocellular carcinoma (HCC) have been reported, but the potential for model-predicted MVI in surgical planning is unclear. Therefore, we aimed to explore the effect of predicted MVI on early recurrence after anatomic resection (AR) and non-anatomic resection (NAR) to assist surgical strategies.

METHODS

Patients with a single HCC of 2-5 cm receiving curative resection were enrolled from 2 centers. Their data were used to develop (n = 230) and test (n = 219) two prediction models for MVI using clinical factors and preoperative computed tomography images. The two prediction models, clinico-radiologic model and clinico-radiologic-radiomic (CRR) model (clinico-radiologic variables + radiomic signature), were compared using the Delong test. Early recurrence based on model-predicted high-risk MVI was evaluated between AR (n = 118) and NAR (n = 85) via propensity score matching using patient data from another 2 centers for external validation.

RESULTS

The CRR model showed higher area under the curve values (0.835-0.864 across development, test, and external validation) but no statistically significant improvement over the clinico-radiologic model (0.796-0.828). After propensity score matching, difference in 2-year recurrence between AR and NAR was found in the CRR model predicted high-risk MVI group (P = 0.005) but not in the clinico-radiologic model predicted high-risk MVI group (P = 0.31).

CONCLUSIONS

The prediction model incorporating radiomics provided an accurate preoperative estimation of MVI, showing the potential for choosing the more appropriate surgical procedure between AR and NAR.

Tumor attenuation and quantitative analysis of perfusion parameters derived from tri-phasic CT scans in hepatocellular carcinoma: Relationship with histological grade

The aim of the current study was to explore the value of tumor attenuation and quantitative analysis of perfusion parameters obtained from traditional tri-phasic CT scans in grading hepatocellular carcinoma (HCC).Totally 39 patients (42 lesion samples) with pathologically confirmed HCC who underwent tri-phasic CT scans were enrolled. HCC lesions were divided into non-poorly differentiated HCC (NP-HCC; n = 31) and poorly differentiated HCC (pHCC; n = 11). All lesions were divided into 5 groups according to the attenuation on different CT enhancement phase. The values of tumor attenuation on different scanning phases were measured. The following parameters were calculated: arterial enhancement fraction (AEF), portal venous supply coefficient (PVC), and hepatic arterial supply coefficient (HAC). The relationship of perfusion parameters with the histological grade of HCC was analyzed. Receiver operating characteristic curves were generated.No significant correlation was observed between the perfusion parameters and tumor grading. Only HAC showed a non-significant trend in different grades of HCC (pHCC < NP-HCC; P = .07). The pHCC cases had significantly decreased values of tumor attenuation on the unenhanced phase (TAu), tumor attenuation on the portal phase portal phase (TAp), and equilibrium phase (TAe) (P < .01). The difference of tumor attenuation between the portal phase and the unenhanced phase (TAp-TAu) of the pHCC cases was decreased than that of the NP-HCC cases (P < .01), whereas the difference of attenuation between the equilibrium phase and portal phase (TAe-TAp) was significantly higher in the pHCC cases than that in the NP-HCC cases (P < .01). TAe-TAp had the highest area under the curve. The number of tumor enhancement pattern in Group 5 of HCCs with a diameter of 3 cm or more was significantly more than that of HCCs with a diameter of less than 3 cm or with other different enhancement patterns (P < .01).Histological HCC grading cannot be predicted by the perfusion parameters derived from traditional tri-phasic CT scans, whereas the tumor attenuation on different phases and the tumor attenuation differences among different phases, especially the mean value of TAe-TAp, might be useful for non-invasive prediction on the degree of HCC differentiation.

Feasibility of automatic detection of small hepatocellular carcinoma (≤2 cm) in cirrhotic liver based on pattern matching and deep learning

Background and objective.Early detection of hepatocellular carcinoma (HCC) is crucial for clinical management. Current studies have reported large HCC detections using automatic algorithms, but there is a lack of research on automatic detection of small HCCs (sHCCs). This study is to investigate the feasibility of automatic detection of sHCC (≤2 cm) based on pattern matching and deep learning (PM-DL) model.Materials and methods. A retrospective study included 5376 image sets from 56 cirrhosis patients (28 sHCC patients with 32 pathologically confirmed lesions and 28 non-HCC cirrhosis patients) in the training-validation cohort to build and validate the model through five-fold cross-validation. In addition, an external test cohort including 6144 image sets from 64 cirrhosis patients (32 sHCC patients with 38 lesions and 32 non-HCC cirrhosis patients) was applied to further verify the generalization ability of the model. The proposed PM-DL model consisted of three main steps: 3D co-registration and liver segmentation, screening of suspicious lesions on diffusion-weighted imaging images based on pattern matching algorithm, and identification/segmentation of sHCC lesions on dynamic contrast-enhanced images with convolutional neural network.Results.The PM-DL model achieved a sensitivity of 89.74% and a positive predictive value of 85.00% in the external test cohort for per-lesion analysis. No significant difference was observed in volumes (P= 0.13) and the largest sizes (P= 0.89) between manually delineated and segmented lesions. The DICE coefficient reached 0.77 ± 0.16. Similar performances were identified in the validation cohort. Moreover, the PM-DL model outperformed Liver Imaging Reporting and Data System (LI-RADS) in sensitivity (probable HCCs: LR-5 or LR-4,P= 0.18; definite HCCs: LR-5,P< 0.001), with a similar high specificity for per-patient analysis.Conclusion. The PM-DL model may be feasible for accurate automatic detection of sHCC in cirrhotic liver.

Gadoxetic acid-enhanced MRI for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: can hypointensity on the late portal venous phase be used as an alternative to washout?

PURPOSE

To investigate the added value of considering hypointensity on late portal venous phase (LPVP) images as washout for diagnosis of hepatocellular carcinoma (HCC) using gadoxetic acid-enhanced MRI (Gd-EOB-MRI) in patients with chronic liver disease (CLD).

METHODS

This retrospective study comprised 97 patients at high risk for HCC who underwent Gd-EOB-MRI including unenhanced, multi-arterial phase, conventional portal venous phase (CPVP, 60 s), and LPVP (mean, 99.9 ± 9.1 s; range, 90-119 s) images. A total of 115 hepatic lesions were identified by histopathological or clinical diagnosis. Three independent radiologists assessed the MRI images by consensus. Diagnosis of HCC was made using criteria of arterial hyperenhancement and hypointensity relative to the surrounding liver parenchyma (1) on CPVP or (2) on CPVP and/or LPVP images. The generalized estimating equation was used to compare diagnostic performance for HCC between Criterion 1 and 2.

RESULTS

In 82 HCCs, the frequency of hypointensity differed significantly between the CPVP and LPVP images (64.6% [53/82] vs. 84.1% [69/82], P < 0.001). Among 33 non-HCCs, two cHCC-CCs showed additional hypointensity on LPVP than CPVP images (33.3% [11/33] vs. 39.4% [13/33], P = 0.500). Criterion 2 provided significantly greater sensitivity for diagnosing HCC than Criterion 1 (54.9% [45/82] vs. 74.4% [61/82], P < 0.001), with relatively little reduction in specificity (90.9% [30/33] vs. 84.8% [28/33], P = 0.145).

CONCLUSION

Additional use of LPVP hypointensity as washout could significantly improve sensitivity for HCC diagnosis when utilizing Gd-EOB-MRI in patients with CLD, without a significant decrease in specificity.

Hyperintensity at fat spared area in steatotic liver on the hepatobiliary phase MRI

PURPOSE

We aimed to investigate the reasons for hyperintensity at fat spared area in steatotic liver at hepatobiliary phase (HBP) on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced liver magnetic resonance imaging.

METHODS

Twenty-two patients with focal fat spared area demonstrating hyperintensity on HBP images were included. A region of interest was placed on in- and opposed-phase images at fat spared area and liver to measure the fat. The measurement was also performed on precontrast T1-weighted and HBP images. The signal intensities of spleen, kidney, muscle, intervertebral disc, and spinal cord were also recorded.

RESULTS

The mean fat fraction of liver and fat spared area was 24.86% (8%-46%) and 8.41% (1%-34%), respectively (P < 0.001). There was a significant positive correlation between liver parenchyma fat fraction and delta fat fraction (r=0.74, P < 0.001). The mean signal intensity values of fat spared areas were higher compared with liver on precontrast T1-weighted and HBP images (P < 0.001). The mean relative enhancement ratio of liver and fat spared areas were 0.98 (0.05-1.90) and 1.15 (0.22-2.03), respectively (P < 0.001). However, in 6 patients, the relative enhancement ratio of liver and fat spared areas were almost equal. The uptake of Gd-EOB at fat spared area was not correlated with the degree of steatosis (r = -0.01, P = 0.95).

CONCLUSION

Fat spared area in steatotic liver appears hyperintense on HBP images due to increased relative enhancement ratio and/or baseline hyperintensity on precontrast images.

Comparison of values of CT and MRI imaging in the diagnosis of hepatocellular carcinoma and analysis of prognostic factors

Value of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of small hepatocellular carcinoma (HCC), and in analysis of the prognostic factors of primary hepatocellular carcinoma (PHC) were compared. A total of 300 patients with PHC were selected from January 2013 to January 2016. Among them, 170 patients were diagnosed with small HCC. Patients were diagnosed by MRI and CT scans, respectively, and diagnostic efficacy of the methods was compared. A single factor and multivariate analysis of prognostic factors were performed on 300 patients. The sensitivity of MRI screening was 78.82%, specificity was 78.46%, accuracy was 78.67%, positive predictive value was 82.72%, and negative predictive value was 73.91%. CT screening showed a sensitivity of 62.35%, a specificity of 73.85%, an accuracy of 67.33%, a positive predictive value of 75.71%, and a negative predictive value of 60.00%. Differences in sensitivity, accuracy, and negative predictive value between MRI and CT screening were statistically significant (P<0.05). There was no statistically significant difference between two groups in specificity and positive predictive value (P>0.05). Diagnostic efficiency of MRI is better than that of CT diagnosis. Univariate analysis showed that age, hepatitis B cirrhosis background, tumor stage, and portal vein embolization were prognostic factors for PHC. Cox multivariate regression analysis showed that the background of liver cirrhosis, tumor stage, and portal thrombosis were independent risk factors for poor prognosis for PHC patient and the differences were statistically significant (P<0.05). MRI is superior to CT in the sensitivity, specificity and accuracy of the diagnosis of small HCC. Individualized comprehensive treatment plans based on the patient's condition may be effective in prolonging the patient's survival time. Imaging diagnosis can provide survival basis for patients, improve diagnostic accuracy, and help to improve the survival rate.

CT features of hepatic epithelioid angiomyolipoma: differentiation from hepatocellular carcinoma in patients with noncirrhotic livers

Background

Hepatic epithelioid angiomyolipoma (HEA) shares some similarities with other hepatic tumors, such as hepatocellular carcinoma (HCC). Thus, establishing a definite diagnosis of HEA based on medical imaging is often difficult. In this study, we evaluated multiphasic computed tomography (CT) imaging to differentiate HEA from HCC in patients with noncirrhotic livers.

Methods

We retrospectively analyzed the clinical and imaging data of both contrast and non-contrast enhanced CT scans from 25 patients with HEA and 50 patients with HCC in noncirrhotic livers. CT features, including lesion position, size, shape, interior content, border, enhancement degree, and enhancement pattern, were independently evaluated by two radiologists. Intratumoral blood vessels, peripheral supply vessels, the early display of the hepatic vein, peripheral abnormal perfusion, peripheral washout sign, pseudocapsule, and portal tumor thrombus were also evaluated. Next, we quantitatively analyzed difference within results of clinical and CT characteristics between the HEA and HCC groups.

Results

The number of female HEA patients is more than male (76% vs. 24%), with a mean age of 49.44±10.33 years (from 30 to 68 years). The majority (64%) of HEA patients were asymptomatic, without hepatitis (88%). On non-contrast enhanced CT, HEA mainly manifested as a round (92%), hypodense mass (100%) with little fat (12%) and rare complications, such as hemorrhage (4%) and calcification (4%). HEA all manifested as an intensely enhanced mass on contrast-enhanced CT. The differences between HEA and HCC were significant in the imaging characteristics of the early display of the hepatic vein (32% vs. 0%, P=0.000), intratumoral blood vessels during the nonarterial phase (36% vs. 8%, P=0.003), washout enhancement (52% vs. 86%, P=0.001), and prolonged enhancement (40% vs. 4%, P=0.000).

Conclusions

Although HEA is an uncommon hepatic tumor, clinical and CT manifestation may be indicative. Clinical and CT characteristics including asymptomatic, non-hepatic, fat-deficient, early display of the hepatic vein, intratumoral blood vessels during the nonarterial phase and prolonged enhancement are selected to improve the recognition of HEA, supporting for a differential diagnosis from HCC.

Intra-individual comparison of hepatocellular carcinoma imaging features on contrast-enhanced computed tomography, gadopentetate dimeglumine-enhanced MRI, and gadoxetic acid-enhanced MRI

Background Gadoxetic acid is being widely used for detection and characterization of hepatic nodules. However, there are no data regarding intra-individual comparison of imaging features of hepatocellular carcinoma (HCC) on dynamic computed tomography (CT), gadopentetate dimeglumine-enhanced magnetic resonance imaging (Gd-DTPA-MRI), and gadoxetic acid-enhanced MRI (Gd-EOB-MRI). Purpose To evaluate typical imaging features of HCC and capsule appearance with dynamic CT, Gd-DTPA-MRI, and Gd-EOB-MRI. Material and Methods We retrospectively reviewed 56 HCCs in 49 patients. Lesion attenuation/signal intensity was graded using a five-point scale based on dynamic phase and hepatobiliary phase (HBP) imaging. Subjective washout and capsule appearance were evaluated on portal venous phase (PVP) or delayed/transitional phase (DP/TP) imaging. The tumor-to-liver contrast ratio (TLCR) was calculated. Results Gd-DTPA-MRI and Gd-EOB-MRI was graded higher than CT on arterial phase ( P < 0.001). Gd-EOB-MRI was graded lower than Gd-DTPA-MRI on PVP and DP/TP ( P < 0.05). The detection rate of subjective washout and capsule appearance did not differ among the three imaging studies on either PVP or DP/TP. TLCR of Gd-EOB-MRI was lower than CT on PVP ( P = 0.004) and was lower than Gd-DTPA-MRI on DP/TP ( P = 0.001). Conclusion Arterial phase hyperenhancement and washout appearance of HCC were well demonstrated in Gd-EOB-MRI. The detection of capsule appearance using Gd-EOB-MRI was not inferior to Gd-DTPA-MRI or CT.

Does a combined CT and MRI protocol enhance the diagnostic efficacy of LI-RADS in the categorization of hepatic observations? A prospective comparative study

OBJECTIVE

To compare diagnostic performance and agreement between CT, MRI and combined CT/MRI in reference to LI-RADS classification system to categorize hepatic observations detected in hepatic patients during screening ultrasound.

METHODS

240 patients with 296 liver observations detected during ultrasound surveillance underwent hepatic CT and MRI examinations, histopathology, and clinical and radiological follow-up. Using LI-RADS v2014, six radiologists evaluated the observations independently and assigned a LI-RADS category to each observation using CT, MRI and combined CT/MRI.

RESULTS

Combined CT and MRI in LI-RADS yielded better accuracy (91.29 %), sensitivity (90.71 %) and specificity (92.31 %) for hepatocellular carcinoma (HCC) diagnosis than using MRI or CT alone; accuracy, sensitivity and specificity decreased to 85.37 %, 86.34 %, and 83.65 %, respectively, for MRI and 67.6 %, 54.10 % and 91.35 %, respectively, for CT. The intraclass agreement of the LI-RADS scores between CT, MRI and combined CT/MRI was excellent (κ=0.9624 (95 % CI: 0.9318-0.9806)).

CONCLUSION

CT and MRI are complementary to each other. Combined CT/MRI enabled a more precise determination of LI-RADS category of hepatic observations; however, due to the expense and minor increase in accuracy, the combined methodology should only be utilized in cases of suspected HCC.

KEY POINTS

• Hepatic observation may be categorized differently depending on the imaging modality used. • We compared LI-RADS categorization between CT, MRI and combined CT/MRI. • MRI produces higher accuracy and sensitivity, while CT produces higher specificity. • Combining CT and MRI improves LIRADS categorization reports. • Considering additional cost, combined methodology could be restricted to challenging cases.

Imaging for the diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis

Multiphasic computed tomography (CT) and magnetic resonance imaging (MRI) are both used for noninvasive diagnosis of hepatocellular carcinoma (HCC) in patients with cirrhosis. To determine if there is a relative diagnostic benefit of one over the other, we synthesized evidence regarding the relative performance of CT, extracellular contrast-enhanced MRI, and gadoxetate-enhanced MRI for diagnosis of HCC in patients with cirrhosis. We also assessed whether liver biopsy versus follow-up with the same versus alternative imaging is best for CT-indeterminate or MRI-indeterminate liver nodules in patients with cirrhosis. We searched multiple databases from inception to April 27, 2016, for studies comparing CT with extracellular contrast-enhanced MRI or gadoxetate-enhanced MRI in adults with cirrhosis and suspected HCC. Two reviewers independently selected studies and extracted data. Of 33 included studies, 19 were comprehensive, while 14 reported sensitivity only. For all tumor sizes, the 19 comprehensive comparisons showed significantly higher sensitivity (0.82 versus 0.66) and lower negative likelihood ratio (0.20 versus 0.37) for MRI over CT. The specificities of MRI versus CT (0.91 versus 0.92) and the positive likelihood ratios (8.8 versus 8.1) were not different. All three modalities performed better for HCCs ≥2 cm. Performance was poor for HCCs <1 cm. No studies examined whether adults with cirrhosis and an indeterminate nodule are best evaluated using biopsy, repeated imaging, or alternative imaging. Concerns about publication bias, inconsistent study results, increased risk of bias, and clinical factors precluded support for exclusive use of either gadoxetate-enhanced or extracellular contrast-enhanced MRI over CT.

CONCLUSION

CT, extracellular contrast-enhanced MRI, or gadoxetate-enhanced MRI could not be definitively preferred for HCC diagnosis in patients with cirrhosis; in patients with cirrhosis and an indeterminate mass, there were insufficient data comparing biopsy to repeat cross-sectional imaging or alternative imaging. (Hepatology 2018;67:401-421).

Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update

There is great geographical variation in the distribution of hepatocellular carcinoma (HCC), with the majority of all cases worldwide found in the Asia-Pacific region, where HCC is one of the leading public health problems. Since the "Toward Revision of the Asian Pacific Association for the Study of the Liver (APASL) HCC Guidelines" meeting held at the 25th annual conference of the APASL in Tokyo, the newest guidelines for the treatment of HCC published by the APASL has been discussed. This latest guidelines recommend evidence-based management of HCC and are considered suitable for universal use in the Asia-Pacific region, which has a diversity of medical environments.

Diagnosis of Hepatocellular Carcinoma with Gadoxetic Acid-Enhanced MRI: 2016 Consensus Recommendations of the Korean Society of Abdominal Radiology

Diagnosis of hepatocellular carcinoma (HCC) with gadoxetic acid-enhanced liver magnetic resonance imaging (MRI) poses certain unique challenges beyond the scope of current guidelines. The regional heterogeneity of HCC in demographic characteristics, prevalence, surveillance, and socioeconomic status necessitates different treatment approaches, leading to variations in survival outcomes. Considering the medical practices in Korea, the Korean Society of Abdominal Radiology (KSAR) study group for liver diseases has developed expert consensus recommendations for diagnosis of HCC by gadoxetic acid-enhanced MRI with updated perspectives, using a modified Delphi method. During the 39th Scientific Assembly and Annual Meeting of KSAR (2016), consensus was reached on 12 of 16 statements. These recommendations might serve to ensure a more standardized diagnosis of HCC by gadoxetic acid-enhanced MRI.

Comparison between Computer Tomography and Magnetic Resonance Imaging in the Diagnosis of Small Hepatocellular Carcinoma

Background:

Hepatocellular carcinomas (HCCs) less than 2 cm in diameter generally demonstrate a good outcome after curative therapy. However, the diagnosis of small HCC can be problematic and requires one or more dynamic imaging modalities. This study aimed to compare the sensitivity and agreement between CT and MRI for the diagnosis of small HCCs.

Methods:

CT and/or MRI scans of HCCs (1-2 cm) diagnosed by histopathology or typical vascular pattern according to the 2005 AASLD criteria were blindly reviewed by an abdominal radiologist. The reports were defined as conclusive/typical when arterial enhancement and washout during the portal/delayed phases were observed and as inconclusive when typical vascular patterns were not observed. The sensitivity and Cohen’s kappa (k) for agreement were calculated.

Results:

In 27 patients, 27 HCC nodules (1-2 cm) were included. Diagnosis with a single-imaging modality (CT or MRI) was 81 % versus 48 % (p = 0.01). The CT sensitivity was significantly higher than MRI (78 % versus 52 %, p = 0.04). Among 27 nodules that underwent both CT and MRI, a discordance in typical enhancement patterns was found (k = 0.319, p = 0.05). In cases with inconclusive CT results, MRI gave only an additional 3.7 % sensitivity to reach a diagnosis. In contrast, further CT imaging following inconclusive MRI results gave an additional 29.6 % sensitivity.

Conclusions:

A single typical imaging modality is sufficient to diagnose small HCCs. Compared with MRI, multiphasic CT has a higher sensitivity. The limitations of MRI could be explained by the greater need for patient cooperation and the types of MRI contrast agent.

Recent Advances in the Imaging Diagnosis of Hepatocellular Carcinoma: Value of Gadoxetic Acid-Enhanced MRI

Magnetic resonance imaging (MRI) using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DPTA), or gadoxetic acid for short, is a hepatocyte-specific contrast agent which is now increasingly used for the detection and characterization of focal hepatic lesions, particularly in patients at high-risk of developing hepatocellular carcinomas (HCC). In fact, several recent guidelines now recognize gadoxetic acid-enhanced MRI (Gd-EOB-MRI) as the primary diagnostic imaging modality for the noninvasive diagnosis of HCC, although it must be noted that several major guidelines still include only extracellular contrast media-enhanced computed tomography and MRI. The primary merits of Gd-EOB-MRI lie in the fact that it can provide not only dynamic imaging, but also hepatobiliary phase (HBP) imaging which can lead to high lesion-to-liver contrast and give additional information regarding hepatocyte uptake via organic anion transporting polypeptides. This, in turn, allows higher sensitivity in detecting small HCCs and helps provide additional information regarding the multistep process of hepatocarcinogenesis. Indeed, many recent studies have investigated the diagnostic value of Gd-EOB-MRI for early HCCs as well as its role as a potential imaging biomarker in predicting outcome. We herein review the recent advances in the imaging diagnosis of HCCs focusing on the applications of Gd-EOB-MRI and the challenging issues that remain.

Application of Different Imaging Methods in the Early Diagnosis of Primary Hepatic Carcinoma

Primary hepatic carcinoma (PHC) is the one of the most common tumors and the common cause of cancer death in the world. Detecting PHC in its early stage by imaging methods may greatly increase survival rates of patients. Ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography/computed tomography are common imaging methods in the diagnosis of PHC. In this paper, the application of different imaging methods in diagnosing the primary hepatic carcinoma will be discussed.

Surveillance and diagnostic algorithm for hepatocellular carcinoma proposed by the Liver Cancer Study Group of Japan: 2014 update

Surveillance and diagnostic algorithms for hepatocellular carcinoma (HCC) have already been described in guidelines published by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver and the European Organisation for Research and Treatment of Cancer (EASL-EORTC), and the Japan Society of Hepatology (JSH), but the content of these algorithms differs slightly. The JSH algorithm mainly differs from the other two algorithms in that it is highly sophisticated and considers the functional imaging techniques of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRI (EOB-MRI) and Sonazoid contrast-enhanced ultrasound (CEUS) to be very important diagnostic modalities. In contrast, the AASLD and EASL-EORTC algorithms are less advanced and suggest that a diagnosis be made based solely on hemodynamic findings using dynamic CT/MRI and biopsy findings. A consensus meeting regarding the JSH surveillance and diagnostic algorithm was held at the 50th Liver Cancer Study Group of Japan Congress, and a 2014 update of the algorithm was completed. The new algorithm reaffirms the very important role of EOB-MRI and Sonazoid CEUS in the surveillance and diagnosis of liver cancer and is more sophisticated than those currently used in the United States and Europe. This is now an optimized algorithm that can be used to diagnose early-stage to classical HCC easily and highly accurately.

JSH Consensus-Based Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma: 2014 Update by the Liver Cancer Study Group of Japan

The Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma proposed by the Japan Society of Hepatology was updated in June 2014 at a consensus meeting of the Liver Cancer Study Group of Japan. Three important items have been updated: the surveillance and diagnostic algorithm, the treatment algorithm, and the definition of transarterial chemoembolization (TACE) failure/refractoriness. The most important update to the diagnostic algorithm is the inclusion of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging as a first line surveillance/diagnostic tool. Another significant update concerns removal of the term "lipiodol" from the definition of TACE failure/refractoriness.