Individual Participant Data Meta-Analysis of LR-5 in LI-RADS Version 2018 versus Revised LI-RADS for Hepatocellular Carcinoma Diagnosis.

Background A simplification of the Liver Imaging Reporting and Data System (LI-RADS) version 2018 (v2018), revised LI-RADS (rLI-RADS), has been proposed for imaging-based diagnosis of hepatocellular carcinoma (HCC). Single-site data suggest that rLI-RADS category 5 (rLR-5) improves sensitivity while maintaining positive predictive value (PPV) of the LI-RADS v2018 category 5 (LR-5), which indicates definite HCC. Purpose To compare the diagnostic performance of LI-RADS v2018 and rLI-RADS in a multicenter data set of patients at risk for HCC by performing an individual patient data meta-analysis. Materials and Methods Multiple databases were searched for studies published from January 2014 to January 2022 that evaluated the diagnostic performance of any version of LI-RADS at CT or MRI for diagnosing HCC. An individual patient data meta-analysis method was applied to observations from the identified studies. Quality Assessment of Diagnostic Accuracy Studies version 2 was applied to determine study risk of bias. Observations were categorized according to major features and either LI-RADS v2018 or rLI-RADS assignments. Diagnostic accuracies of category 5 for each system were calculated using generalized linear mixed models and compared using the likelihood ratio test for sensitivity and the Wald test for PPV. Results Twenty-four studies, including 3840 patients and 4727 observations, were analyzed. The median observation size was 19 mm (IQR, 11-30 mm). rLR-5 showed higher sensitivity compared with LR-5 (70.6% [95% CI: 60.7, 78.9] vs 61.3% [95% CI: 45.9, 74.7]; P < .001), with similar PPV (90.7% vs 92.3%; P = .55). In studies with low risk of bias (n = 4; 1031 observations), rLR-5 also achieved a higher sensitivity than LR-5 (72.3% [95% CI: 63.9, 80.1] vs 66.9% [95% CI: 58.2, 74.5]; P = .02), with similar PPV (83.1% vs 88.7%; P = .47). Conclusion rLR-5 achieved a higher sensitivity for identifying HCC than LR-5 while maintaining a comparable PPV at 90% or more, matching the results presented in the original rLI-RADS study. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Sirlin and Chernyak in this issue.

A Multicenter Assessment of Interreader Reliability of LI-RADS Version 2018 for MRI and CT.

Background Various limitations have impacted research evaluating reader agreement for Liver Imaging Reporting and Data System (LI-RADS). Purpose To assess reader agreement of LI-RADS in an international multicenter multireader setting using scrollable images. Materials and Methods This retrospective study used deidentified clinical multiphase CT and MRI and reports with at least one untreated observation from six institutions and three countries; only qualifying examinations were submitted. Examination dates were October 2017 to August 2018 at the coordinating center. One untreated observation per examination was randomly selected using observation identifiers, and its clinically assigned features were extracted from the report. The corresponding LI-RADS version 2018 category was computed as a rescored clinical read. Each examination was randomly assigned to two of 43 research readers who independently scored the observation. Agreement for an ordinal modified four-category LI-RADS scale (LR-1, definitely benign; LR-2, probably benign; LR-3, intermediate probability of malignancy; LR-4, probably hepatocellular carcinoma [HCC]; LR-5, definitely HCC; LR-M, probably malignant but not HCC specific; and LR-TIV, tumor in vein) was computed using intraclass correlation coefficients (ICCs). Agreement was also computed for dichotomized malignancy (LR-4, LR-5, LR-M, and LR-TIV), LR-5, and LR-M. Agreement was compared between research-versus-research reads and research-versus-clinical reads. Results The study population consisted of 484 patients (mean age, 62 years ± 10 [SD]; 156 women; 93 CT examinations, 391 MRI examinations). ICCs for ordinal LI-RADS, dichotomized malignancy, LR-5, and LR-M were 0.68 (95% CI: 0.61, 0.73), 0.63 (95% CI: 0.55, 0.70), 0.58 (95% CI: 0.50, 0.66), and 0.46 (95% CI: 0.31, 0.61) respectively. Research-versus-research reader agreement was higher than research-versus-clinical agreement for modified four-category LI-RADS (ICC, 0.68 vs 0.62, respectively; P = .03) and for dichotomized malignancy (ICC, 0.63 vs 0.53, respectively; P = .005), but not for LR-5 (P = .14) or LR-M (P = .94). Conclusion There was moderate agreement for LI-RADS version 2018 overall. For some comparisons, research-versus-research reader agreement was higher than research-versus-clinical reader agreement, indicating differences between the clinical and research environments that warrant further study. © RSNA, 2023 Supplemental material is available for this article. See also the editorials by Johnson and Galgano and Smith in this issue.

Differentiation of focal nodular hyperplasia and hepatocellular adenoma using qualitative and quantitative imaging features and classification and regression tree analysis.

PURPOSE: To assess qualitative and quantitative analysis of gadoxetate disodium-enhanced hepatobiliary phase MR imaging (MRI) and assess the performance of classification and regression tree analysis for the differentiation of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA). MATERIALS AND METHODS: This retrospective study was approved by our local ethics committee. One hundred seventy patients suspected of having FNH or HCA underwent gadoxetate disodium-enhanced MRI. The reference standard was either pathology or follow-up imaging. Two readers reviewed images to identify qualitative imaging features and measure signal intensity on unenhanced, dynamic, and hepatobiliary phase images. For quantitative analysis, contrast enhancement ratio (CER), lesion-to-liver contrast (LLC), signal intensity ratio (SIR), and relative signal enhancement ratio (RSER) were calculated. A classification and regression tree (CART) analysis was developed. RESULTS: Eighty-five patients met the inclusion criteria, with a total of 97 FNHs and 43 HCAs. For qualitative analysis, the T1 signal intensity on the hepatobiliary phase provided the highest overall classification performance (91.9% sensitivity, 90.1% specificity, and 90.9% accuracy). For quantitative analysis, RSER in the hepatobiliary phase with a threshold of 0.723 provided the highest classification performance (92.6% sensitivity and 89.4% specificity) to differentiate FNHs from HCAs. A CART model based on five qualitative imaging features provided an accuracy of 94.4% (95% confidence interval 90.0-98.9%). CONCLUSION: Gadoxetate disodium-enhanced hepatobiliary phase provides high diagnostic performance as demonstrated in quantitative and qualitative analysis in differentiation of FNH and HCA, supported by a CART decision model.

MRI-based R2* mapping in patients with suspected or known iron overload.

PURPOSE: R2* relaxometry is a quantitative method for assessment of iron overload. The purpose is to analyze the cross-sectional relationships between R2* in organs across patients with primary and secondary iron overload. Secondary analyses were conducted to analyze R2* according to treatment regimen. METHODS: This is a retrospective, cross-sectional, institutional review board-approved study of eighty-one adult patients with known or suspected iron overload. R2* was measured by segmenting the liver, spleen, bone marrow, pancreas, renal cortex, renal medulla, and myocardium using breath-hold multi-echo gradient-recalled echo imaging at 1.5 T. Phlebotomy, transfusion, and chelation therapy were documented. Analyses included correlation, Kruskal-Wallis, and post hoc Dunn tests. p < 0.01 was considered significant. RESULTS: Correlations between liver R2* and that of the spleen, bone marrow, pancreas, and heart were respectively 0.49, 0.33, 0.27, and 0.34. R2* differed between patients with primary and secondary overload in the liver (p < 0.001), spleen (p < 0.001), bone marrow (p < 0.01), renal cortex (p < 0.001), and renal medulla (p < 0.001). Liver, spleen, and bone marrow R2* were higher in thalassemia than in hereditary hemochromatosis (all p < 0.01). Renal cortex R2* was higher in sickle cell disease than in hereditary hemochromatosis (p < 0.001) and in thalassemia (p < 0.001). Overall, there was a trend toward lower liver R2* in patients assigned to phlebotomy and higher liver R2* in patients assigned to transfusion and chelation therapy. CONCLUSION: R2* relaxometry revealed differences in degree or distribution of iron overload between organs, underlying etiologies, and treatment.

Intravoxel incoherent motion diffusion-weighted MRI for the characterization of inflammation in chronic liver disease.

OBJECTIVE: To evaluate the diagnostic performance of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for grading hepatic inflammation. METHODS: In this retrospective cross-sectional dual-center study, 91 patients with chronic liver disease were recruited between September 2014 and September 2018. Patients underwent 3.0-T MRI examinations within 6 weeks from a liver biopsy. IVIM parameters, perfusion fraction (f), diffusion coefficient (D), and pseudo-diffusion coefficient (D*), were estimated using a voxel-wise nonlinear regression on DWI series (10 b-values from 0 to 800 s/mm2). The reference standard was histopathological analysis of hepatic inflammation grade, steatosis grade, and fibrosis stage. Intraclass correlation coefficients (ICC), univariate and multivariate correlation analyses, and areas under receiver operating characteristic curves (AUC) were assessed. RESULTS: Parameters f, D, and D* had ICCs of 0.860, 0.839, and 0.916, respectively. Correlations of f, D, and D* with inflammation grade were ρ = - 0.70, p < 0.0001; ρ = 0.10, p = 0.35; and ρ = - 0.27, p = 0.010, respectively. When adjusting for fibrosis and steatosis, the correlation between f and inflammation (p < 0.0001) remained, and that between f and fibrosis was also significant to a lesser extent (p = 0.002). AUCs of f, D, and D* for distinguishing inflammation grades 0 vs. ≥ 1 were 0.84, 0.53, and 0.70; ≤ 1 vs. ≥ 2 were 0.88, 0.57, and 0.60; and ≤ 2 vs. 3 were 0.86, 0.54, and 0.65, respectively. CONCLUSION: Perfusion fraction f strongly correlated, D very weakly correlated, and D* weakly correlated with inflammation. Among all IVIM parameters, f accurately graded inflammation and showed promise as a biomarker of hepatic inflammation. KEY POINTS: • IVIM parameters derived from DWI series with 10 b-values are reproducible for liver tissue characterization. • This retrospective two-center study showed that perfusion fraction provided good diagnostic performance for distinguishing dichotomized grades of inflammation. • Fibrosis is a significant confounder on the association between inflammation and perfusion fraction.

Predicting the Response to FOLFOX-Based Chemotherapy Regimen from Untreated Liver Metastases on Baseline CT: a Deep Neural Network Approach.

In developed countries, colorectal cancer is the second cause of cancer-related mortality. Chemotherapy is considered a standard treatment for colorectal liver metastases (CLM). Among patients who develop CLM, the assessment of patient response to chemotherapy is often required to determine the need for second-line chemotherapy and eligibility for surgery. However, while FOLFOX-based regimens are typically used for CLM treatment, the identification of responsive patients remains elusive. Computer-aided diagnosis systems may provide insight in the classification of liver metastases identified on diagnostic images. In this paper, we propose a fully automated framework based on deep convolutional neural networks (DCNN) which first differentiates treated and untreated lesions to identify new lesions appearing on CT scans, followed by a fully connected neural networks to predict from untreated lesions in pre-treatment computed tomography (CT) for patients with CLM undergoing chemotherapy, their response to a FOLFOX with Bevacizumab regimen as first-line of treatment. The ground truth for assessment of treatment response was histopathology-determined tumor regression grade. Our DCNN approach trained on 444 lesions from 202 patients achieved accuracies of 91% for differentiating treated and untreated lesions, and 78% for predicting the response to FOLFOX-based chemotherapy regimen. Experimental results showed that our method outperformed traditional machine learning algorithms and may allow for the early detection of non-responsive patients.

Impact of temporal resolution and motion correction for dynamic contrast-enhanced MRI of the liver using an accelerated golden-angle radial sequence.

This paper presents a prospective study evaluating the impact on image quality and quantitative dynamic contrast-enhanced (DCE)-MRI perfusion parameters when varying the number of respiratory motion states when using an eXtra-Dimensional Golden-Angle Radial Sparse Parallel (XD-GRASP) MRI sequence. DCE acquisition was performed using a 3D stack-of-stars gradient-echo golden-angle radial acquisition in free-breathing with 100 spokes per motion state and temporal resolution of 6 s/volume, and using a non-rigid motion compensation to align different motion states. Parametric analysis was conducted using a dual-input single-compartment model. Nonparametric analysis was performed on the time-intensity curves. A total of 22 hepatocellular carcinomas (size: 11-52 mm) were evaluated. XD-GRASP reconstructed with increasing number of spokes for each motion state increased the signal-to-noise ratio (SNR) (p < 0.05) but decreased temporal resolution (0.04 volume/s vs 0.17 volume/s for one motion state) (p < 0.05). A visual scoring by an experienced radiologist show no change between increasing number of motion states with same number of spokes using the Likert score. The normalized maximum intensity time ratio, peak enhancement ratio and tumor arterial fraction increased with decreasing number of motion states (p < 0.05) while the transfer constant from the portal venous plasma to the surrounding tissue significantly decreased (p < 0.05). These same perfusion parameters show a significant difference in case of tumor displacement more than 1 cm (p < 0.05) whereas in the opposite case there was no significant variation. While a higher number of motion states and higher number of spokes improves SNR, the resulting lower temporal resolution can influence quantitative parameters that capture rapid signal changes. Finally, fewer displacement compensation is advantageous with lower number of motion state due to the higher temporal resolution. XD-GRASP can be used to perform quantitative perfusion measures in the liver, but the number of motion states may significantly alter some quantitative parameters.

Deep learning workflow in radiology: a primer.

Interest for deep learning in radiology has increased tremendously in the past decade due to the high achievable performance for various computer vision tasks such as detection, segmentation, classification, monitoring, and prediction. This article provides step-by-step practical guidance for conducting a project that involves deep learning in radiology, from defining specifications, to deployment and scaling. Specifically, the objectives of this article are to provide an overview of clinical use cases of deep learning, describe the composition of multi-disciplinary team, and summarize current approaches to patient, data, model, and hardware selection. Key ideas will be illustrated by examples from a prototypical project on imaging of colorectal liver metastasis. This article illustrates the workflow for liver lesion detection, segmentation, classification, monitoring, and prediction of tumor recurrence and patient survival. Challenges are discussed, including ethical considerations, cohorting, data collection, anonymization, and availability of expert annotations. The practical guidance may be adapted to any project that requires automated medical image analysis.

Assessment of hepatocellular carcinoma treatment response with LI-RADS: a pictorial review.

Computed tomography (CT) and magnetic resonance imaging (MRI) play critical roles for assessing treatment response of hepatocellular carcinoma (HCC) after locoregional therapy. Interpretation is challenging because posttreatment imaging findings depend on the type of treatment, magnitude of treatment response, time interval after treatment, and other factors. To help radiologists interpret and report treatment response in a clear, simple, and standardized manner, the Liver Imaging Reporting and Data System (LI-RADS) has developed a Treatment Response (LR-TR) algorithm. Introduced in 2017, the system provides criteria to categorize response of HCC to locoregional treatment (e.g., chemical ablation, energy-based ablation, transcatheter therapy, and radiation therapy). LR-TR categories include Nonevaluable, Nonviable, Equivocal, and Viable. LR-TR does not apply to patients on systemic therapies. This article reviews the LR-TR algorithm; discusses locoregional therapies for HCC, treatment concepts, and expected posttreatment findings; and illustrates LI-RADS treatment response assessment with CT and MRI.

Dynamic contrast-enhanced MRI to assess hepatocellular carcinoma response to Transarterial chemoembolization using LI-RADS criteria: A pilot study.

PURPOSE: To identify quantitative dynamic contrast-enhanced (DCE)-MRI perfusion parameters indicating tumor response of hepatocellular carcinoma (HCC) to transarterial chemoembolization (TACE). MATERIALS AND METHODS: This prospective pilot study was approved by our institutional review board; written and informed consent was obtained for each participant. Patients underwent DCE-MRI examinations before and after TACE. A variable flip-angle unenhanced 3D mDixon sequence was performed for T1 mapping. A dynamic 4D mDixon sequence was performed after contrast injection for assessing dynamic signal enhancement. Nonparametric analysis was conducted on the time-intensity curves. Parametric analysis was performed on the time-concentration curves using a dual-input single-compartment model. Treatment response according to Liver Reporting and Data System (LI-RADS) v2018 was used as the reference standard. The comparisons within groups (before vs. after treatment) and between groups (nonviable vs. equivocal or viable tumor) were performed using nonparametric bootstrap taking into account the clustering effect of lesions in patients. RESULTS: Twenty-eight patients with 52 HCCs (size: 10-104 mm) were evaluated. For nonviable tumors (n = 27), time to peak increased from 62.5 ±â€¯18.2 s before to 83.3 ±â€¯12.8 s after treatment (P< 0.01). For equivocal or viable tumors (n = 25), time to peak and mean transit time significantly increased (from 54.4 ±â€¯24.1 s to 69.5 ±â€¯18.9 s, P < 0.01 and from 14.2 ±â€¯11.8 s to 33.9 ±â€¯36.8 s, P= 0.01, respectively) and the transfer constant from the extracellular and extravascular space to the central vein significantly decreased from 14.8 ±â€¯14.1 to 8.1 ±â€¯9.1 s-1 after treatment (P= 0.01). CONCLUSION: This prospective pilot DCE-MRI study showed that time to peak significantly changed after TACE treatment for both groups (nonviable tumors and equivocal or viable tumors). In our cohort, several perfusion parameters may provide an objective marker for differentiation of treatment response after TACE in HCC patients.

Cost-Utility Analysis of Imaging for Surveillance and Diagnosis of Hepatocellular Carcinoma.

OBJECTIVE. The purpose of this study is to compare imaging-based surveillance and diagnostic strategies in patients at risk for hepatocellular carcinoma (HCC) while taking into account technically inadequate examinations and patient compliance. MATERIALS AND METHODS. A Markov model simulated seven strategies for HCC surveillance and diagnosis in patients with cirrhosis: strategy A, ultrasound (US) for surveillance and CT for diagnosis; strategy B, US for surveillance and complete MRI for diagnosis; strategy C, US for surveillance and CT for inadequate or positive surveillance; strategy D, US for surveillance and complete MRI for inadequate or positive surveillance; strategy E, surveillance and diagnosis with CT followed by complete MRI for inadequate surveillance; strategy F, surveillance and diagnosis with complete MRI followed by CT for inadequate surveillance; and strategy G, surveillance with abbreviated MRI followed by CT for inadequate surveillance or complete MRI for positive surveillance. Two compliance scenarios were evaluated: optimal and conservative. For each scenario, the most cost-effective strategy was based on a willingness-to-pay threshold of $50,000 (Canadian) per quality-adjusted life year (QALY). Sensitivity analyses were performed. RESULTS. Base-case analysis revealed that strategy E was the most cost-effective when compliance was optimal ($13,631/QALY), and strategy G was the most cost-effective when compliance was conservative ($39,681/QALY). Sensitivity analyses supported the base-case analysis in the optimal compliance scenario, but several parameters altered the most cost-effective strategy in the conservative compliance scenario. CONCLUSION. In an optimal compliance scenario, CT for HCC surveillance and diagnosis and complete MRI for inadequate CT was most cost-effective. In a conservative compliance scenario, abbreviated MRI may be an alternative to US-based surveillance.

Response of locally advanced rectal cancer (LARC) to radiochemotherapy: DW-MRI and multiparametric PET/CT in correlation with histopathology.

AIM: To prospectively evaluate histological significance and predictive value of changes in apparent diffusion coefficient (ADC) and 18F-FDG PET/CT parameters in locally advanced rectal cancer (LARC) after neoadjuvant radiochemotherapy (RCT). METHODS: Twenty-one patients with untreated LARC underwent pre-RCT and post-RCT 18F-FDG PET/CT and diffusion-weighted magnetic resonance imaging (DW-MRI), followed by surgery. For both datasets, two readers measured the tumor SUVmax, SUVmean, MTV, TLG, ADCmin, ADCmean, and respective differences (∆SUVmax, ∆SUVmean, ∆MTV, ∆TLG, ∆ADCmin, ∆ADCmean) for the whole tumor. Tumor regression grade according to Mandard (TRGm), percentage of residual tumor cells and fibrosis were estimated by two pathologists in consensus. Relationship between parameters was assessed on stepwise multivariate regression analysis and ROC curve analysis to evaluate their performance and predict the treatment response. RESULTS: Eighteen LARCs were analyzed. SUVmax and SUVmean decreased from 21.3 ±â€…8.9 to 9.3 ±â€…5.5 g/mL, (p = 0.0002) and 12.3 ±â€…5.1 to 5.4 ±â€…3.1 g/mL, (p = 0.0002), respectively, after RCT, whereas ADCmin and ADCmean increased from 396 ±â€…269 to 573 ±â€…313×10-6 mm2/s (p = 0.014) and 1159 ±â€…212 to 1355 ±â€…194×10-6 mm2/s (p = 0.0008), respectively. TRGm and percentage of residual tumor cells independently correlated with post-RCT SUVmean (ß = 0.73 and ß = 0.76, p < 0.001) and post-RCT SUVmax (ß = 0.72 and ß = 0.78, p < 0.001), whereas percentage of fibrosis independently correlated with ∆ADCmean (ß = 0.38, p = 0.008). Post-RCT, SUVmax and SUVmean performed well in predicting TRGm < 3 and residual tumor cells ≤ 20 %. ΔADCmean predicted fibrosis > 70 % well. CONCLUSION: Post-RCT SUVmean, SUVmax and ∆ADCmean are complementary parameters for respectively evaluating residual tumor burden and amount of fibrosis in LARC. However, only SUV independently correlated with TRGm.

Deep Learning for Automated Segmentation of Liver Lesions at CT in Patients with Colorectal Cancer Liver Metastases.

PURPOSE: To evaluate the performance, agreement, and efficiency of a fully convolutional network (FCN) for liver lesion detection and segmentation at CT examinations in patients with colorectal liver metastases (CLMs). MATERIALS AND METHODS: This retrospective study evaluated an automated method using an FCN that was trained, validated, and tested with 115, 15, and 26 contrast material-enhanced CT examinations containing 261, 22, and 105 lesions, respectively. Manual detection and segmentation by a radiologist was the reference standard. Performance of fully automated and user-corrected segmentations was compared with that of manual segmentations. The interuser agreement and interaction time of manual and user-corrected segmentations were assessed. Analyses included sensitivity and positive predictive value of detection, segmentation accuracy, Cohen κ, Bland-Altman analyses, and analysis of variance. RESULTS: In the test cohort, for lesion size smaller than 10 mm (n = 30), 10-20 mm (n = 35), and larger than 20 mm (n = 40), the detection sensitivity of the automated method was 10%, 71%, and 85%; positive predictive value was 25%, 83%, and 94%; Dice similarity coefficient was 0.14, 0.53, and 0.68; maximum symmetric surface distance was 5.2, 6.0, and 10.4 mm; and average symmetric surface distance was 2.7, 1.7, and 2.8 mm, respectively. For manual and user-corrected segmentation, κ values were 0.42 (95% confidence interval: 0.24, 0.63) and 0.52 (95% confidence interval: 0.36, 0.72); normalized interreader agreement for lesion volume was -0.10 ± 0.07 (95% confidence interval) and -0.10 ± 0.08; and mean interaction time was 7.7 minutes ± 2.4 (standard deviation) and 4.8 minutes ± 2.1 (P < .001), respectively. CONCLUSION: Automated detection and segmentation of CLM by using deep learning with convolutional neural networks, when manually corrected, improved efficiency but did not substantially change agreement on volumetric measurements.© RSNA, 2019Supplemental material is available for this article.

LI-RADS for CT diagnosis of hepatocellular carcinoma: performance of major and ancillary features.

PURPOSE: To evaluate the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS) v2017 major features, the impact of ancillary features, and categories on contrast-enhanced computed tomography (CECT) for the diagnosis of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This retrospective study included 59 patients (104 observations including 72 HCCs) with clinical suspicion of HCC undergoing CECT between 2013 and 2016. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category based on major features only and in combination with ancillary features. The composite reference standard included pathology or imaging. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by generalized estimating equation models. RESULTS: Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) respectively had a sensitivity of 86.1%, 81.6%, 20.7%, and 26.1% and specificity of 39.3%, 67.9%, 89.9%, and 85.0% for HCC. Ancillary features (ultrasound visibility as discrete nodule, subthreshold growth, and fat in mass more than adjacent liver) respectively had a sensitivity of 42.6%, 50.8%, and 15.1% and a specificity of 79.2%, 66.9%, and 96.4% for HCC. Ancillary features modified the final category in 4 of 104 observations. For HCC diagnosis, categories LR-3, LR-4, LR-5, and LR-TIV (tumor in vein) had a sensitivity of 5.3%, 29.0%, 53.7%, and 10.7%; and a specificity of 49.1%, 84.4%, 97.3%, and 96.4%, respectively. CONCLUSION: On CT, LR-5 category has near-perfect specificity for the diagnosis of HCC and ancillary features modifies the final category in few observations.

LI-RADS Version 2018 Ancillary Features at MRI.

The Liver Imaging Reporting and Data System (LI-RADS) standardizes performance of liver imaging in patients at risk for hepatocellular carcinoma (HCC) as well as interpretation and reporting of the results. Developed by experts in liver imaging and supported by the American College of Radiology, LI-RADS assigns to observations categories that reflect the relative probability of benignity, HCC, or other malignancy. While category assignment is based mainly on major imaging features, ancillary features may be applied to improve detection and characterization, increase confidence, or adjust LI-RADS categories. Ancillary features are classified as favoring malignancy in general, HCC in particular, or benignity. Those favoring malignancy in general or HCC in particular may be used to upgrade by a maximum of one category up to LR-4; those favoring benignity may be used to downgrade by a maximum of one category. If there are conflicting ancillary features (ie, one or more favoring malignancy and one or more favoring benignity), the category should not be adjusted. Ancillary features may be seen at diagnostic CT, MRI performed with extracellular agents, or MRI performed with hepatobiliary agents, with the exception of one ancillary feature assessed at US. This article focuses on LI-RADS version 2018 ancillary features seen at MRI. Specific topics include rules for ancillary feature application; definitions, rationale, and illustrations with clinical MRI examples; summary of evidence and diagnostic performance; pitfalls; and future directions. ©RSNA, 2018.

LI-RADS 2017: An update.

The computed tomography / magnetic resonance imaging (CT/MRI) Liver Imaging Reporting & Data System (LI-RADS) is a standardized system for diagnostic imaging terminology, technique, interpretation, and reporting in patients with or at risk for developing hepatocellular carcinoma (HCC). Using diagnostic algorithms and tables, the system assigns to liver observations category codes reflecting the relative probability of HCC or other malignancies. This review article provides an overview of the 2017 version of CT/MRI LI-RADS with a focus on MRI. The main LI-RADS categories and their application will be described. Changes and updates introduced in this version of LI-RADS will be highlighted, including modifications to the diagnostic algorithm and to the optional application of ancillary features. Comparisons to other major diagnostic systems for HCC will be made, emphasizing key similarities, differences, strengths, and limitations. In addition, this review presents the new Treatment Response algorithm, while introducing the concepts of MRI nonviability and viability. Finally, planned future directions for LI-RADS will be outlined. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2018;47:1459-1474.

LI-RADS for MR Imaging Diagnosis of Hepatocellular Carcinoma: Performance of Major and Ancillary Features.

Purpose To evaluate the performance of major features, ancillary features, and categories of Liver Imaging Reporting and Data System (LI-RADS) version 2014 at magnetic resonance (MR) imaging for the diagnosis of hepatocellular carcinoma (HCC). Materials and Methods This retrospective institutional review board-approved study included patients with liver MR imaging and at least one pathologically proved lesion. Between 2004 and 2016, 102 patients (275 observations including 113 HCCs) met inclusion criteria. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by using generalized estimating equation models. Results Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) had a sensitivity of 88.5%, 60.6%, 32.9%, and 41.6%, and a specificity of 18.6%, 84.8%, 98.8%, and 83.2% for HCC, respectively. Ancillary features (mild-moderate T2 hyperintensity, restricted diffusion, mosaic architecture, intralesional fat, lesional fat sparing, blood products, and subthreshold growth) had a sensitivity of 62.2%, 54.8%, 9.9%, 30.9%, 23.1%, 2.8%, and 48.3%, and a specificity of 79.4%, 90.6%, 99.4%, 94.2%, 83.1%, 99.3%, and 91.4% for HCC, respectively. The LR-5 or LR-5 V categories had a per-lesion sensitivity of 50.8% and a specificity of 95.8% for HCC, respectively. The LR-4, LR-5, or LR-5 V categories (determined by using major features only vs combination of major and ancillary features) had a per-lesion sensitivity of 75.9% and 87.9% and a per-lesion specificity of 87.5% and 86.2%, respectively. Conclusion The use of ancillary features in combination with major features increases the sensitivity while preserving a high specificity for the diagnosis of HCC.

Liver Iron Quantification with MR Imaging: A Primer for Radiologists.

Iron overload is a systemic disorder and is either primary (genetic) or secondary (exogenous iron administration). Primary iron overload is most commonly associated with hereditary hemochromatosis and secondary iron overload with ineffective erythropoiesis (predominantly caused by ß-thalassemia major and sickle cell disease) that requires long-term transfusion therapy, leading to transfusional hemosiderosis. Iron overload may lead to liver cirrhosis and hepatocellular carcinoma, in addition to cardiac and endocrine complications. The liver is one of the main iron storage organs and the first to show iron overload. Therefore, detection and quantification of liver iron overload are critical to initiate treatment and prevent complications. Liver biopsy was the historical reference standard for detection and quantification of liver iron content. Magnetic resonance (MR) imaging is now commonly used for liver iron quantification, including assessment of distribution, detection, grading, and monitoring of treatment response in iron overload. Several MR imaging techniques have been developed for iron quantification, each with advantages and limitations. The liver-to-muscle signal intensity ratio technique is simple and widely available; however, it assumes that the reference tissue is normal. Transverse magnetization (also known as R2) relaxometry is validated but is prone to respiratory motion artifacts due to a long acquisition time, is presently available only for 1.5-T imaging, and requires additional cost and delay for off-line analysis. The R2* technique has fast acquisition time, demonstrates a wide range of liver iron content, and is available for 1.5-T and 3.0-T imaging but requires additional postprocessing software. Quantitative susceptibility mapping has the highest sensitivity for detecting iron deposition; however, it is still investigational, and the correlation with liver iron content is not yet established. ©RSNA, 2018.