Reproducibility of Lung and Liver Volume Measurements on Fetal Magnetic Resonance Imaging in Left-Sided Congenital Diaphragmatic Hernia

Variability in antenatal prognostication of congenital diaphragmatic hernia by magnetic resonance imaging across the North American Fetal Therapy Network (NAFTNet)

OBJECTIVE

To evaluate the variability in magnetic resonance imaging (MRI)-based parameters used for fetal lung volume estimation in the prediction of pulmonary hypoplasia and the degree of liver herniation in cases of antenatally diagnosed left congenital diaphragmatic hernia (CDH) across North American Fetal Therapy Network (NAFTNet) centers.

METHODS

In this study, 14 NAFTNet radiologists reviewed MRI exams of 15 cases of left CDH of variable severity, eight of which had liver herniation confirmed at surgery. Images were obtained at a median gestational age of 29.3 (range, 25.0-37.6) weeks, between 2020 and 2022. All participants were asked to rate image quality using a scale of 1-4 (where 1 represents excellent quality and 4 represents poor quality (unable to perform measurements)) and to determine the observed-to-expected total fetal lung volume (o/e-TFLV) using the formulae of Rypens et al. and Meyers et al., the percent predicted lung volume (PPLV), the presence or absence of liver herniation and the percentage of liver herniation (%LH). Fleiss' κ was used to assess inter-rater agreement for image-quality ratings. Concordance between participants was evaluated by determining a coefficient of variation (CV), with CV < 30 defined as acceptable. Additionally, the variation of individual participant's assessment of a case from the group average was also assessed. Data were also evaluated by center case volume, for which high volume was indicated by ≥ 15 CDH cases/year and low volume was indicated by < 15 CDH cases/year managed prenatally.

RESULTS

Overall, there was acceptable concordance for o/e-TFLV among reviewers using the formula of either Rypens et al. or Meyers et al. (median CV, 24 (interquartile range (IQR), 19-34)). Slightly lower but acceptable concordance was noted for PPLV (median CV, 26 (IQR, 18-42)). For the determination of liver herniation, most participants agreed with the final diagnosis at surgery in 14/15 cases; however, concordance was lowest among reviewers for the quantification of %LH (median CV, 46 (IQR, 44-53)). Among the three MRI exams rated as being of poor quality by the majority of participants, CV was higher for o/e-TFLV (median CV, 39) and PPLV (median CV, 43), indicating poor concordance among reviewers. No significant difference was noted in concordance among reviewers for the assessment of lung volume and liver herniation based on a center's CDH volume.

CONCLUSION

Noticeable variability with acceptable agreement was noted for o/e-TFLV, PPLV and determination of liver herniation between NAFTNet radiologists from 14 centers in cases of left CDH. However, significant heterogeneity was noted for %LH. Concordance among reviewers was similar, irrespective of center case volume, highlighting the need for standardization of imaging protocols and CDH prognostication by MRI. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal MRI radiomics: non-invasive and reproducible quantification of human lung maturity

OBJECTIVES

To assess the reproducibility of radiomics features extracted from the developing lung in repeated in-vivo fetal MRI acquisitions.

METHODS

In-vivo MRI (1.5 Tesla) scans of 30 fetuses, each including two axial and one coronal T2-weighted sequences of the whole lung with all other acquisition parameters kept constant, were retrospectively identified. Manual segmentation of the lungs was performed using ITK-Snap. One hundred radiomics features were extracted from fetal lung MRI data using Pyradiomics, resulting in 90 datasets. Intra-class correlation coefficients (ICC) of radiomics features were calculated between baseline and repeat axial acquisitions and between baseline axial and coronal acquisitions.

RESULTS

MRI data of 30 fetuses (12 [40%] females, 18 [60%] males) at a median gestational age of 24 + 5 gestational weeks plus days (GW) (interquartile range [IQR] 3 + 3 GW, range 21 + 1 to 32 + 6 GW) were included. Median ICC of radiomics features between baseline and repeat axial MR acquisitions was 0.92 (IQR 0.13, range 0.33 to 1), with 60 features exhibiting excellent (ICC > 0.9), 27 good (> 0.75-0.9), twelve moderate (0.5-0.75), and one poor (ICC < 0.5) reproducibility. Median ICC of radiomics features between baseline axial and coronal MR acquisitions was 0.79 (IQR 0.15, range 0.2 to 1), with 20 features exhibiting excellent, 47 good, 29 moderate, and four poor reproducibility.

CONCLUSION

Standardized in-vivo fetal MRI allows reproducible extraction of lung radiomics features. In the future, radiomics analysis may improve diagnostic and prognostic yield of fetal MRI in normal and pathologic lung development.

KEY POINTS

• Non-invasive fetal MRI acquired using a standardized protocol allows reproducible extraction of radiomics features from the developing lung for objective tissue characterization. • Alteration of imaging plane between fetal MRI acquisitions has a negative impact on lung radiomics feature reproducibility. • Fetal MRI radiomics features reflecting the microstructure and shape of the fetal lung could complement observed-to-expected lung volume in the prediction of postnatal outcome and optimal treatment of fetuses with abnormal lung development in the future.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.

The interplay between prenatal liver growth and lung development in congenital diaphragmatic hernia

OBJECTIVE

Liver herniation is a known risk factor for increased severity in CDH and is associated with clinically significant pulmonary hypoplasia and pulmonary hypertension. Better studies are needed to understand the growth of the herniated liver compared to the liver that remains in the abdomen and how this liver growth then affects lung development. Serial hi-resolution fetal MRI enables characterization of liver growth throughout gestation and examination of macroscopic features that may regulate liver growth. Here, we hypothesized that the nature of liver herniation affects liver growth and, in turn, affects lung growth.

METHODS

Clinical data were retrospectively collected from consecutive cases of prenatally diagnosed isolated left-sided or right-sided CDH from June 2006 to August 2021. Only those cases with MRI lung volumetry for both mid-gestation and late-gestation time points were recruited for analysis. Cases with fetal chromosomal abnormalities and other major structural abnormalities were excluded. Fractional liver volume and liver growth was indexed to estimated fetal weight and compared to lung growth.

RESULTS

Data was collected from 28 fetuses with a left liver-down CDH (LLD), 37 left liver-up CDH (LLU) and 9 right liver-up CDH (RLU). Overall, RLU fetuses had greater overall and fractional (intra-thoracic vs. intra-abdominal) liver growth when compared to LLD and LLU fetuses. Additionally, intra-thoracic liver growth was consistently slower than intra-abdominal liver growth for either right- or left-sided CDH. When the liver was not herniated, a positive correlation was seen between liver growth and lung growth. However, when the liver was herniated above the diaphragm, this positive correlation was lost.

CONCLUSION

Right-sided CDH fetuses exhibit greater liver growth compared to left-sided CDH. Liver herniation disrupts the normal positive correlation between liver and lung growth that is seen when the liver is entirely within the abdomen.

The role of magnetic resonance imaging in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia

In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity.

CONCLUSION

Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment.

WHAT IS KNOWN

• MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling.

WHAT IS NEW

• Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.