Prognosis of Single Early-Stage Hepatocellular Carcinoma (HCC) with CEUS Inconclusive Imaging (LI-RADS LR-3 and LR-4) Is No Better than Typical HCC (LR-5)

The American College of Radiology (ACR) released the Liver Imaging Report and Data System (LI-RADS) scheme, which categorizes hepatic nodules in risk classes from LR-1 to LR-5 (according to the degree of risk to be HCC) and LR-M (probable malignancy not specific for HCC). The aim of this study was to test whether HCC with different LR patterns on CEUS have different overall survival (OS) and recurrence-free survival (RFS). We retrospectively enrolled 167 patients with the first definitive diagnosis of single HCC (by using CT/MRI or histological techniques if CT/MRI were inconclusive) for whom CEUS examination was available. The median size of HCC lesions was 2.2 cm (range 1.0–7.2 cm). According to CEUS LI-RADS classification, 28 patients were in LR-3, 48 in LR-4, 83 in LR-5, and 8 in LR-M. Patient liver function and nodule characteristics were not statistically different between CEUS LI-RADS classes. Using univariate analysis, CEUS LI-RADS class was not found to be a predictor of survival (p = 0.347). In conclusion, HCC showing the CEUS LI-RADS classes LR-3 and LR-4 have no better clinical outcome than typical HCC. Such data support the EASL policy, aimed at conclusive diagnostic investigations of indeterminate nodules up to obtaining histological proof to avoid leaving aggressive HCC not timely treated.

Noninvasive Diagnosis of Hepatocellular Carcinoma on Sonazoid-Enhanced US: Value of the Kupffer Phase

The aim of this study was to compare the diagnostic performance of Contrast-Enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) version 2017, which includes portal- and late-phase washout as a major imaging feature, with that of modified CEUS LI-RADS, which includes Kupffer-phase findings as a major imaging feature. Participants at risk of hepatocellular carcinoma (HCC) with treatment-naïve hepatic lesions (≥1 cm) were recruited and underwent Sonazoid-enhanced US. Arterial phase hyperenhancement (APHE), washout time, and echogenicity in the Kupffer phase were evaluated using both criteria. The diagnostic performance of both criteria was analyzed using the McNemar test. The evaluation was performed on 102 participants with 102 lesions (HCCs (n = 52), non-HCC malignancies (n = 36), and benign (n = 14)). Among 52 HCCs, non-rim APHE was observed in 92.3% (48 of 52). By 5 min, 73.1% (38 of 52) of HCCs showed mild washout, while by 10 min or in the Kupffer phase, 90.4% (47 of 52) of HCCs showed hypoenhancement. The sensitivity (67.3%; 35 of 52; 95% CI: 52.9%, 79.7%) of modified CEUS LI-RADS criteria was higher than that of CEUS LI-RADS criteria (51.9%; 27 of 52; 95% CI: 37.6%, 66.0%) (p = 0.0047). In conclusion, non-rim APHE with hypoenhancement in the Kupffer phase on Sonazoid-enhanced US is a feasible criterion for diagnosing HCC.

Added value of enhanced CT on LR-3 and LR-4 observation of Gd-EOB-DTPA MRI for the diagnosis of HCC: are CT and MR washout features interchangeable?

Objective: To characterize the use of portal venous or delayed phase CT as an alternative to estimate washout for the non-invasive diagnosis of hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced MRI in combination with other features. Methods: This retrospective study included 226 observations (n = 162 patients) at high risk for HCC imaged with gadoxetic acid-enhanced MRI and enhanced liver CT between March 2015 and March 2018. Two radiologists independently evaluated two sets of images and assigned the final Liver Imaging Reporting and Data System (LI-RADS) categories by consensus using gadoxetic acid-enhanced MRI. LR-1, LR-2, LR-5, and LR-M were excluded from the study. The observations were divided using different criteria for washout: hypointensity on the portal venous phase (PVP) at MRI (criteria 1), hypointensity on PVP at MRI and/or hypoattenuation on the PVP/delayed phase at dynamic CT (criteria 2), and hypointensity on the PVP and/or hepatobiliary phase at MRI (criteria 3). The sensitivity, specificity, and accuracy for the diagnosis of HCC were analyzed for each criterion. Results: Using gadoxetic acid-enhanced, 226 lesions were diagnosed as LR-3 or LR-4 by LI-RADS. Among them, 98 and 152 had “washout” at criteria 1 and 2, respectively. For the diagnosis of HCC, criteria 2 and 3 showed significantly higher sensitivities (67.3 and 92.5%, respectively) compared with criteria 1 (35.5%) (p < 0.001). The specificity of criteria 3 (13%) was significantly lower than those of criteria 1 and 2 (40.7% and 38.4%, respectively, p < 0.001). The specificities between criteria 1 and 2 were not statistically different (p = 0.427). Conclusion: Although the LI-RADS lexicon does not permit the interchange of image features among various image modalities, the sensitivity of HCC diagnosis could be improved without any decrease in specificity by adding CT image washout features. Advances in knowledge: Although the LI-RADS lexicon does not permit the interchange of image features among various image modalities, complementary use of dynamic CT in LR-3 or LR-4 categories on the basis of gadoxetic acid-enhanced MRI may contribute to major imaging feature.

LI-RADS Classification and Outcomes of Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization Combined with Radiofrequency Ablation

PurposeThe aim of this study was to clarify the usefulness of the Liver Imaging Reporting and Data System (LI-RADS) to predict the patients’ prognosis after transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (TACE-RFA) for hepatocellular carcinoma (HCC) of Barcelona-Clinic Liver Cancer Stage (BCLC) 0 or A.Materials and MethodsWe retrospectively analyzed cases of HCC patients who underwent TACE-RFA (Jan 2005 to Dec 2015). Patients’ nodules were categorized based on their LI-RADS v2018 core. The LI-RADS category was assigned to each nodule using dynamic contrast-enhanced CT. LR-3, LR-4 and LR-5 nodules were extracted. We assessed the overall survival (OS) and recurrence-free survival (RFS) among BCLC 0 and BCLC A patients.ResultsOf the 64 nodules extracted, 22 were LR-3 or -4 (14.8±6.7 mm) and 42 were LR-5 (17.1±6.9 mm). Regarding OS, there was no significant difference between LR-3 or -4 and LR-5 (p=0.278). In terms of RFS, there was a significant difference between LR-3 or -4 and LR-5 (p=0.03). In particular, patients with BCLC A with LR-5 nodules showed significantly poorer RFS than those with LR-3 or -4 (p=0.016) nodules. ConclusionsFor patients with BCLC A, LR-3 or -4 are associated with a better prognosis than LR-5 nodules.

3-D MODELING - THE FUTURE OF HEPATOBILIARY SURGERY(LITERATURE REVIEW)

3D-печать в хирургии печени является новым многообещающим инструментом хирургического планирования. В обзоре приведены шесть исследований, непосредственно связанных с 3D-визуализацией печени. Однако стоимость 3-Д визуализации и время являются основными ограничивающими факторами при создании надежной модели. Со временем эта техника осуществима и применима к резекции печени и может помочь в предоперационном планировании резекции печени. 3D printing in liver surgery is a promising new surgical planning tool. The review lists six studies directly related to 3D liver imaging. However, 3-D rendering cost and time are the main limiting factors in creating a robust model. Over time, this technique is feasible and applicable to liver resection and may aid in preoperative liver resection planning.

Diagnostic Value of CEUS LI-RADS Version 2017 in Differentiating AFP-Negative Hepatocellular Carcinoma from Other Primary Malignancies of the Liver

Purpose: To explore the diagnostic value of Contrast-enhanced Ultrasound Liver Imaging Reporting and Data System version 2017 (CEUS LI-RADS v2017) in differentiating alpha-fetoprotein (AFP)-negative hepatocellular carcinoma (HCC) from other primary malignancies (OM) of the liver. Methods: The data of 99 patients with primary liver malignant tumors confirmed by surgical pathology and AFP-negative from January 2018 to January 2021 were retrospectively analyzed, and the lesions were divided into 61 cases in the AFP-negative HCC group and 38 cases in the OM group according to the pathological findings, the CEUS features of the lesions were analyzed and the lesions were classified according to the CEUS LI-RADS v2017. Comparison of CEUS features between the two groups was performed using the χ2 test. The sensitivity, specificity, positive predictive value, negative predictive value, and coincidence rate of CEUS LI-RADS v2017 for the diagnosis of AFP-negative HCC and OM were calculated using pathological findings as the gold standard. Results: The differences in features of arterial phase enhancement and wash-out between the HCC and OM groups were statistically significant (p < 0.05). The sensitivity of diagnosing HCC by LR-5 was 62.3% and the specificity was 92.1%. The sensitivity of diagnosing OM by LR-M was 92.1% and the specificity was 83.6%. Conclusions: When AFP is negative in patients with intrahepatic focal lesions, LR-5 has high specificity but low sensitivity in the diagnosis of HCC, and LR-M has high sensitivity and specificity in the diagnosis of OM. CEUS LI-RADS is a tool to differentiate AFP-negative HCC and OM effectively.

Advances in liver US, CT, and MRI: moving toward the future

Over the past two decades, the epidemiology of chronic liver disease has changed with an increase in the prevalence of nonalcoholic fatty liver disease in parallel to the advent of curative treatments for hepatitis C. Recent developments provided new tools for diagnosis and monitoring of liver diseases based on ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), as applied for assessing steatosis, fibrosis, and focal lesions. This narrative review aims to discuss the emerging approaches for qualitative and quantitative liver imaging, focusing on those expected to become adopted in clinical practice in the next 5 to 10 years. While radiomics is an emerging tool for many of these applications, dedicated techniques have been investigated for US (controlled attenuation parameter, backscatter coefficient, elastography methods such as point shear wave elastography [pSWE] and transient elastography [TE], novel Doppler techniques, and three-dimensional contrast-enhanced ultrasound [3D-CEUS]), CT (dual-energy, spectral photon counting, extracellular volume fraction, perfusion, and surface nodularity), and MRI (proton density fat fraction [PDFF], elastography [MRE], contrast enhancement index, relative enhancement, T1 mapping on the hepatobiliary phase, perfusion). Concurrently, the advent of abbreviated MRI protocols will help fulfill an increasing number of examination requests in an era of healthcare resource constraints.

Role of Contrast-Enhanced Ultrasonography in Hepatocellular Carcinoma by Using LI-RADS and Ancillary Features: A Single Tertiary Centre Experience

Clinical utility of ancillary features (AFs) in contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS®) is yet to be established. In this study, we assessed the diagnostic yield of CEUS LI-RADS and AFs in hepatocellular carcinoma (HCC). We retrospectively included patients with risk factors for HCC and newly diagnosed focal liver lesions (FLL). All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule-in nodule architecture. From the total of 141 HCC cases, 83.6% were correctly classified: 57.4%- LR-5 and 26.2%- LR-4. In 9.21% cases, CEUS indicated LR-M; 2.12% cases- LR-3. The LR-5 category was 96.2% predictive (PPV) of HCC. LR-5 had 60.4% sensitivity and 93.6% specificity. PPV for primitive malignancy (LR-4 + LR-5) was 95.7%, with 88% sensitivity, 89.3% specificity and 88.4% accuracy for HCC. LR-4 category had 94.8% PPV and 26.2% sensitivity. CEUS LR4 + LR5 had 81,8% sensitivity for HCCs over 2 cm and 78.57% sensitivity for smaller HCCs. CEUS LR-5 remains an excellent diagnostic tool for HCC, despite the size of the lesion. The use of AFs might improve the overarching goal of LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy.