Diagnostic accuracy of CT and MR features for detecting atypical lipomatous tumors and malignant liposarcomas: a systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis evaluated the diagnostic accuracy of CT and MRI for differentiating atypical lipomatous tumors and malignant liposarcomas from benign lipomatous lesions. METHODS: MEDLINE, EMBASE, Scopus, the Cochrane Library, and the gray literature from inception to January 2022 were systematically evaluated. Original studies with > 5 patients evaluating the accuracy of CT and/or MRI for detecting liposarcomas with a histopathological reference standard were included. Meta-analysis was performed using a bivariate mixed-effects regression model. Risk of bias was evaluated using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). This study is registered on PROSPERO, number CRD42022306479. RESULTS: Twenty-six studies with a total of 2613 patients were included. Mean/median reported patient ages ranged between 50 and 63 years. The summary sensitivity and specificity of radiologist gestalt for detecting liposarcomas was 85% (79-90% 95% CI) and 63% (52-72%), respectively. Deep depth to fascia, thickened septations, enhancing components, and lesion size (≥ 10 cm) all demonstrated sensitivities ≥ 85%. Other imaging characteristics including heterogenous/amorphous signal intensity, irregular tumor margin, and nodules present demonstrated lower sensitivities ranging from 43 to 65%. Inter-reader reliability for radiologist gestalt within studies ranged from fair to substantial (k = 0.23-0.7). Risk of bias was predominantly mixed for patient selection, low for index test and reference standard, and unclear for flow and timing. CONCLUSION: Higher sensitivities for detecting liposarcomas were achieved with radiologist gestalt, deep depth to fascia, thickened septations, enhancing components, and large size. Combined clinical and imaging scoring and/or radiomics both show promise for optimal performance, though require further analysis with prospective study designs. CLINICAL RELEVANCE: This pooled analysis evaluates the accuracy of CT and MRI for detecting atypical lipomatous tumors and malignant liposarcomas. Radiologist gestalt, deep depth to fascia, thickened septations, enhancing components, and large size demonstrate the highest overall sensitivities. KEY POINTS: • The summary sensitivity and specificity of radiologist gestalt for detecting liposarcomas was 85% (79-90% 95% CI) and 63% (52-72%), respectively. • Radiologist gestalt, deep depth to fascia, thickened septations, enhancing components, and large tumor size (≥ 10 cm) showed the highest sensitivities for detecting atypical lipomatous tumors/well-differentiated liposarcomas and malignant liposarcomas. • A combined clinical and imaging scoring system and/or radiomics is likely to provide the best overall diagnostic accuracy, although currently proposed scoring systems and radiomic feature analysis require further study with prospective study designs.

Radiomics-based approaches outperform visual analysis for differentiating lipoma from atypical lipomatous tumors: a review.

BACKGROUND: Differentiating atypical lipomatous tumors (ALTs) and well-differentiated liposarcomas (WDLs) from benign lipomatous lesions is important for guiding clinical management, though conventional visual analysis of these lesions is challenging due to overlap of imaging features. Radiomics-based approaches may serve as a promising alternative and/or supplementary diagnostic approach to conventional imaging. PURPOSE: The purpose of this study is to review the practice of radiomics-based imaging and systematically evaluate the literature available for studies evaluating radiomics applied to differentiating ALTs/WDLs from benign lipomas. REVIEW: A background review of the radiomic workflow is provided, outlining the steps of image acquisition, segmentation, feature extraction, and model development. Subsequently, a systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and the grey literature was performed from inception to June 2022 to identify size studies using radiomics for differentiating ALTs/WDLs from benign lipomas. Radiomic models were shown to outperform conventional analysis in all but one model with a sensitivity ranging from 68 to 100% and a specificity ranging from 84 to 100%. However, current approaches rely on user input and no studies used a fully automated method for segmentation, contributing to interobserver variability and decreasing time efficiency. CONCLUSION: Radiomic models may show improved performance for differentiating ALTs/WDLs from benign lipomas compared to conventional analysis. However, considerable variability between radiomic approaches exists and future studies evaluating a standardized radiomic model with a multi-institutional study design and preferably fully automated segmentation software are needed before clinical application can be more broadly considered.

Diagnostic accuracy of dual-energy CT for the detection of bone marrow edema in the appendicular skeleton: a systematic review and meta-analysis.

OBJECTIVES: This meta-analysis evaluated the diagnostic accuracy of dual-energy CT (DECT) for detecting bone marrow edema (BME) in the appendicular skeleton. METHODS: A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and gray literature from inception through January 31, 2020, was performed. Original articles with > 10 patients evaluating the accuracy of DECT for detecting BME in the appendicular skeleton with a reference standard of MRI and/or clinical follow-up were included. Study details were independently extracted by two reviewers. Meta-analysis was performed using a bivariate random-effects model with multivariable meta-regression. Risk of bias (RoB) was evaluated with QUADAS-2. RESULTS: Twenty studies evaluating 790 patients for BME in the appendicular skeleton were included in analysis. The summary sensitivity, specificity, and AUC values for BME in the appendicular skeleton were 86% (95% confidence interval [CI] 82-89%), 93% (95% CI 90-95%), and 0.95, respectively. Quantitative analysis had a higher sensitivity than qualitative analysis on meta-regression (p = 0.01), but no difference in specificity (p = 0.28). No other covariates contributed to variability in accuracy (etiology (trauma vs non-trauma); location (upper vs lower extremity); and RoB). Studies demonstrated generally low or unclear RoB and applicability. Eight studies included index tests with high RoB when quantitative assessments used a retrospective cut-off value. CONCLUSIONS: DECT demonstrates a higher specificity than sensitivity and AUC > 0.9. In scenarios where MRI availability is limited or contraindicated, DECT could be an alternative to MRI for detecting BME in the appendicular skeleton. However, limitations in sources of variability and RoB warrant continued study. KEY POINTS: • Twenty studies evaluating 790 patients for bone marrow edema in the appendicular skeleton with dual-energy CT were included in analysis. • The summary sensitivity, specificity, and AUC values for detecting bone marrow in the appendicular skeleton were 86% (95% confidence interval [CI] 82-89%), 93% (95% CI 90-95%), and 0.95, respectively. • In scenarios where MRI availability is limited or is contraindicated, DECT could be an alternative to MRI for detecting bone marrow edema in the appendicular skeleton.

Diagnostic Accuracy of MRI for the Detection of Malignant Peripheral Nerve Sheath Tumors: A Systematic Review and Meta-Analysis.

OBJECTIVE. This systematic review and meta-analysis evaluates the diagnostic accuracy of MRI for differentiating malignant (MPNSTs) from benign peripheral nerve sheath tumors (BPNSTs). MATERIALS AND METHODS. A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature from inception to December 2019 was performed. Original articles that involved at least 10 patients and that evaluated the accuracy of MRI for detecting MPNSTs were included. Two reviewers independently extracted clinical and radiologic data from included articles to calculate sensitivity, specificity, PPV, NPV, and accuracy. A meta-analysis was performed using a bivariate mixed-effects regression model. Risk of bias was evaluated using QUADAS-2. RESULTS. Fifteen studies involving 798 lesions (252 MPNSTs and 546 BPNSTs) were included in the analysis. Pooled and weighted sensitivity, specificity, and AUC values for MRI in detecting MPNSTs were 68% (95% CI, 52-80%), 93% (95% CI, 85-97%), and 0.89 (95% CI, 0.86-0.92) when using feature combination and 88% (95% CI, 74-95%), 94% (95% CI, 89-96%), and 0.97 (95% CI, 0.95-0.98) using diffusion restriction with or without feature combination. Subgroup analysis, such as patients with neurofibromatosis type 1 (NF1) versus those without NF1, could not be performed because of insufficient data. Risk of bias was predominantly high or unclear for patient selection, mixed for index test, low for reference standard, and unclear for flow and timing. CONCLUSION. Combining features such as diffusion restriction optimizes the diagnostic accuracy of MRI for detecting MPNSTs. However, limitations in the literature, including variability and risk of bias, necessitate additional methodologically rigorous studies to allow subgroup analysis and further evaluate the combination of clinical and MRI features for MPNST diagnosis.

Diagnostic accuracy of dual-energy CT for detecting bone marrow edema in patients with acute knee injuries: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis evaluated the diagnostic accuracy of dual-energy CT (DECT) for detecting bone marrow edema (BME) in adult patients with acute knee injuries. METHODS: A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and gray literature was performed from inception to January 31, 2020, using PRISMA-DTA guidelines. The review included studies assessing the diagnostic accuracy of DECT for detecting BME in at least 10 adult patients with acute knee injuries and with an MRI reference standard. Study details were independently extracted by two reviewers. Meta-analysis was performed using a bivariate mixed-effects regression model with subgroup analysis performed to evaluate for sources of variability. Risk of bias (ROB) was evaluated using the QUADAS-2 tool. RESULTS: Eight studies evaluating 267 patients between the ages of 25-54 with acute knee injuries undergoing DECT and MRI were included in analysis. Summary sensitivity, specificity, and AUROC values for BME were 84% (95% confidence interval (CI) 74-91%), 96% (95% CI 93-98%), and 0.97 (95% CI 0.95-0.98), respectively. Bone-based characterization was found to have lower specificity than region-based characterization (83% (57-95%) versus 97 (96-98%), p < 0.05), but no difference in sensitivity. No other statistical differences were identified amongst study subgroups to account for presumed variability amongst studies. Most studies were rated low risk for bias and applicability concerns. CONCLUSION: DECT is specific and accurate for detecting BME in adult patients with acute knee injuries and can be used as an alternative to MRI, particularly when MRI is contraindicated or unavailable.

Diagnostic Performance of MRI in the Detection of Renal Lipid-Poor Angiomyolipomas: A Systematic Review and Meta-Analysis.

Background Lipid-poor angiomyolipomas (AMLs) are challenging to differentiate from other renal lesions at imaging and often necessitate biopsy or surgery. If sufficiently accurate, MRI may play a role as a replacement test for biopsy. Purpose To perform a systematic review to evaluate the diagnostic performance of MRI for lipid-poor AMLs in patients with renal masses. Materials and Methods A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and the "gray literature" (conference proceedings) was performed without language restriction through July 18, 2019, with the assistance of a health sciences librarian. Original articles with more than 10 patients evaluating the diagnostic performance of MRI, with histopathologic findings used as the reference standard, for the diagnosis of lipid-poor AMLs in patients with renal masses were included. Studies including AMLs with macroscopic fat and studies with insufficient data were excluded. Patient, clinical, MRI, and diagnostic performance parameters were independently acquired by two authors. Meta-analysis was performed by using a random-effects or bivariate mixed-effects regression model depending on the number of studies. Risk of bias of individual studies was evaluated by using Quality Assessment of Diagnostic Accuracy Studies-2. Results Twenty-three studies with 2196 patients and 25 contingency tables were included. The pooled sensitivity, specificity, and area under the receiver operating characteristic curve were 83% (95% confidence interval [CI]: 72%, 90%), 90% (95% CI: 84%, 94%), and 0.93 (95% CI: 0.91, 0.95), respectively. Considerable variability was present for several variables, including MRI parameters; however, subgroup analysis did not identify MRI sequence or field strength as sources for variability. All studies were at high risk of bias for index test domain because no reported thresholds were prespecified. Conclusion MRI shows promising accuracy for detecting lipid-poor angiomyolipomas (area under the receiver operating characteristic curve, >0.9), indicating a potential role as a replacement test for biopsy in selected patients. Studies evaluating MRI accuracy with a pragmatic algorithm and prespecified threshold may be helpful to confirm this potential role in the management pathway. © RSNA, 2020 Online supplemental material is available for this article.

Diagnostic Accuracy of Limited MRI Protocols for Detecting Radiographically Occult Hip Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVE. This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of limited MRI protocols for detecting radiographically occult proximal femoral fractures. MATERIALS AND METHODS. A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature through November 15, 2019, was performed. Original articles with 10 or more patients evaluating limited MRI protocols for the diagnosis of radiographically occult proximal femoral fractures compared with multiparametric MRI with or without clinical outcome as the reference standard were included in the analysis. Patient, clinical, MRI, and performance parameters were independently acquired by two reviewers. Meta-analysis was performed using a bivariate mixed-effects regression model. RESULTS. Eleven studies with 938 patients and 247 proximal femoral fractures met inclusion criteria, and five of these studies were included in the meta-analysis. The pooled and weighted summary sensitivity and specificity and the area under the summary ROC curve for limited MRI protocols in detecting radiographically occult hip fractures were 99% (95% CI, 91-100%), 99% (95% CI, 97-100%), and 1 (95% CI, 0.99-1), respectively. The aggregate sensitivity and specificity values for a single-plane T1-weighted sequence only, STIR sequence only, T1-weighted and STIR sequences, and T2-weighted sequence only were as follows: 97% (89/92) and 100% (76/76), 99% (126/127) and 99% (865/873), 100% (118/118) and 99% (867/874), and 86% (51/59) and 97% (137/141), respectively. Sensitivity was 100% (58/58) when images were acquired on 3-T scanners only and 99% (284/288) when interpreted only by certified radiologists. The mean scanning time for the limited MRI protocols was less than 5 minutes. CONCLUSION. Limited MRI protocols can be used as the standard of care in patients with a suspected but radiographically occult hip fracture. A protocol composed of coronal T1-weighted and STIR sequences is 100% sensitive.

Canadian Radiology Medical Student Interest Groups: What They Are and How We Can Help Them Improve.

BACKGROUND: Radiology interest groups (RIGs) can serve as a means of increasing exposure of the radiology specialty early in the medical curriculum while also increasing educational opportunities. However, the organizational structure and various functions of individual RIGs in Canada are not well-documented. We performed a survey of all active RIGs in Canada for the purpose of better understanding their structure, function, and opportunities for improvement. METHODS: A 21-question survey was sent to current or recent former medical student leaders of all active RIGs in Canada during the 2016-2017 academic year. RESULTS: Radiology interest groups were identified in 88% (15/17) of Canadian medical schools. We received a 100% (15/15) response rate. Events held by RIGs consist mostly of lunch and learns (67%, 10/15), career panels (53%, 8/15), networking events (40%, 6/15), and curriculum-related events (40%, 6/15). General mentorship (93%, 13/14), shadowing opportunities (86%, 12/14), and research mentorship (63%, 8/14) were most often cited in their top 3 choices for opportunities for improvement. Sixty-six percent indicated that if a radiology society were to host a page for their interest group, they would be interested in posting content and/or links. CONCLUSIONS: Canadian RIGs offer increased early awareness and education about radiology in the medical curriculum. Radiology departments can facilitate improvement in Canadian RIGs through targeted institutional mentorship, research opportunities, and shadowing programs for their members.

Cushing's syndrome diagnosed incidentally on CT imaging.

In this case report, we describe an uncommon presentation of Cushing's syndrome in a patient in their 60s who presented to the emergency department with left-sided chest pain. The initial workup for the patient was unremarkable except for an elevated blood pressure and elevated fasting plasma glucose. A CT scan of the chest, abdomen and pelvis was performed, demonstrating a splenic artery thrombus with multiple splenic infarcts, in addition to a combination of macronodular adrenal hyperplasia, bilateral gynecomastia, centripetal fat distribution and suspected mild bone demineralisation. Adrenocorticotropic hormone-independent macronodular adrenal hyperplasia, a rare aetiology responsible for Cushing's syndrome, was raised as a potential unifying diagnosis for the patient's hypercoagulable status, which was subsequently confirmed on an endocrinological investigation. The case report underscores the importance of communicating clinically relevant details to the imaging specialist in combination with considering a broad differential, including endocrine disorders, when evaluating an undifferentiated patient with atypical imaging findings.

The retrocaval ureter - A rare developmental cause for urinary tract obstruction.

Retrocaval ureter is a rare congenital anomaly with few reported cases worldwide. In this case report, we describe a clinical presentation that demonstrates the stereotypical imaging features of a retrocaval ureter on ultrasound, computed tomography and nuclear imaging studies in a 38-year-old male patient who fits the classic reported patient demographics.

Diagnostic accuracy of contrast-enhanced CT versus PET/CT for advanced ovarian cancer staging: a comparative systematic review and meta-analysis.

PURPOSE: Accurate staging of ovarian cancer is critical to guide optimal management pathways. North American guidelines recommend contrast-enhanced CT as the primary work-up for staging ovarian cancer. This meta-analysis aims to compare the diagnostic accuracy of contrast-enhanced CT alone to PET/CT for detecting abdominal metastases in patients with a new or suspected diagnosis of ovarian cancer. MATERIALS AND METHODS: A systematic review of MEDLINE, EMBASE, Scopus, the Cochrane Library, and the gray literature from inception to October 2022 was performed. Studies with a minimum of 5 patients evaluating the diagnostic accuracy of contrast-enhanced CT and/or PET/CT for detecting stage 3 ovarian cancer as defined by a surgical/histopathological reference standard ± clinical follow-up were included. Study, clinical, imaging, and accuracy data for eligible studies were independently acquired by two reviewers. Primary meta-analysis was performed in studies reporting accuracy on a per-patient basis using a bivariate mixed-effects regression model. Risk of bias was evaluated using QUADAS-2. RESULTS: From 3701 citations, 15 studies (918 patients with mean age ranging from 51 to 65 years) were included in the systematic review. Twelve studies evaluated contrast-enhanced CT (6 using a per-patient assessment and 6 using a per-region assessment) and 11 studies evaluated PET/CT (7 using a per-patient assessment and 4 using a per-region assessment). All but one reporting study used consensus reading. Respective sensitivity and specificity values on a per-patient basis were 82% (67-91%, 95% CI) and 72% (59-82%) for contrast-enhanced CT and 87% (75-94%) and 90% (82-95%) for PET/CT. There was no significant difference in sensitivities between modalities (p = 0.29), but PET/CT was significantly more specific than CT (p < 0.01). Presumed variability could not be assessed in any single category due to limited studies using per-patient assessment. Studies were almost entirely low risk for bias and applicability concerns using QUADAS-2. CONCLUSION: Contrast-enhanced CT demonstrates non-inferior sensitivity compared to PET/CT, although PET/CT may still serve as an alternative and/or supplement to CT alone prior to and/or in lieu of diagnostic laparoscopy in patients with ovarian cancer. Future revisions to existing guidelines should consider these results to further refine the individualized pretherapeutic diagnostic pathway.

Impact of Size Thresholds on the Diagnosis of Incidental Adrenal Lesions: A Systematic Review and Meta-Analysis.

BACKGROUND: Preferred size-threshold recommendations for management of incidental adrenal lesions remain controversial. PURPOSE: This meta-analysis aimed to compare the diagnostic accuracy of different size thresholds for detecting malignancy in patients with incidental adrenal lesions on imaging. MATERIALS AND METHODS: A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature, covering the period from inception to September 2021, was performed. Studies with >10 patients evaluating the diagnostic accuracy of imaging size thresholds for detecting malignancy in patients with incidental adrenal lesions and no prior history of cancer were included. Study, clinical, imaging, and accuracy data for eligible studies were independently acquired by two reviewers. Primary meta-analysis was performed using a bivariate mixed-effects regression model. Risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: From 2,690 citations, 40 studies (9,794 patients with mean age ranging from 41 to 66 years) were included. Most (36 of 40) were retrospective single-center studies. CT with or without MRI served as the index test(s). Sensitivity and specificity values, respectively, by size threshold used in the included studies were as follows: 85% (95% confidence interval [CI] 74%-91%) and 39% (95% CI 23%-57%) for 3-cm thresholds; 85% (95% CI 78%-90%) and 75% (95% CI 62%-85%) for 4-cm thresholds; 70% (95% CI 56%-81%) and 74% (95% CI 59%-85%) for 5-cm thresholds; and 75% (95% CI 67%-82%) and 77% (95% CI 62%-87%) for 6-cm thresholds. No cause for variability in sensitivity or specificity was identified on subgroup analysis of the 4-cm threshold. Nearly half of the studies (19 of 40) had at least one QUADAS-2 domain with a high risk of bias. CONCLUSIONS: A 4-cm size threshold demonstrates the highest combined sensitivity and specificity, with a preserved specificity compared with higher size thresholds, but with a trend toward improved sensitivity. Future research reevaluating 4-5 cm size thresholds while excluding characteristically benign lesions by imaging may help redefine a size threshold that has improved specificity but preserved sensitivity, compared with the existing 4-cm threshold.

Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review.

Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.

Unilateral renal agenesis, blind-ended ureter, and ectopic ureterocele inserting into the seminal vesicle: A very rare developmental association.

Congenital renal anomalies are common imaging findings and can often be detected antenatally. In some cases, these anomalies may go undetected and present in adulthood. We report a very rare case of unilateral renal agenesis in a 22-year-old male associated with an ipsilateral dilated blind-ended ureter that ectopically inserted into the seminal vesicle. This unique combination of developmental anomalies can lead to a variety of clinical presentations and requires careful monitoring and management.

Multiparametric MR assessment of liver fat, iron, and fibrosis: a concise overview of the liver "Triple Screen".

Chronic liver disease (CLD) is a common source of morbidity and mortality worldwide. Non-alcoholic fatty liver disease (NAFLD) serves as a major cause of CLD with a rising annual prevalence. Additionally, iron overload can be both a cause and effect of CLD with a negative synergistic effect when combined with NAFLD. The development of state-of-the-art multiparametric MR solutions has led to a change in the diagnostic paradigm in CLD, shifting from traditional liver biopsy to innovative non-invasive methods for providing accurate and reliable detection and quantification of the disease burden. Novel imaging biomarkers such as MRI-PDFF for fat, R2 and R2* for iron, and liver stiffness for fibrosis provide important information for diagnosis, surveillance, risk stratification, and treatment. In this article, we provide a concise overview of the MR concepts and techniques involved in the detection and quantification of liver fat, iron, and fibrosis including their relative strengths and limitations and discuss a practical abbreviated MR protocol for clinical use that integrates these three MR biomarkers into a single simplified MR assessment. Multiparametric MR techniques provide accurate and reliable non-invasive detection and quantification of liver fat, iron, and fibrosis. These techniques can be combined in a single abbreviated MR "Triple Screen" assessment to offer a more complete metabolic imaging profile of CLD.

Two-point Dixon and six-point Dixon magnetic resonance techniques in the detection, quantification and grading of hepatic steatosis.

BACKGROUND: Hepatic steatosis is a very common problem worldwide. AIM: To assess the performance of two- and six-point Dixon magnetic resonance (MR) techniques in the detection, quantification and grading of hepatic steatosis. METHODS: A single-center retrospective study was performed in 62 patients with suspected parenchymal liver disease. MR sequences included two-point Dixon, six-point Dixon, MR spectroscopy (MRS) and MR elastography. Fat fraction (FF) estimates on the Dixon techniques were compared to the MRS-proton density FF (PDFF). Statistical tests used included Pearson's correlation and receiver operating characteristic. RESULTS: FF estimates on the Dixon techniques showed excellent correlation (≥ 0.95) with MRS-PDFF, and excellent accuracy [area under the receiver operating characteristic (AUROC) ≥ 0.95] in: (1) Detecting steatosis; and (2) Grading severe steatosis, (P < 0.001). In iron overload, two-point Dixon was not evaluable due to confounding T2* effects. FF estimates on six-point Dixon vs MRS-PDFF showed a moderate correlation (0.82) in iron overload vs an excellent correlation (0.97) without iron overload, (P < 0.03). The accuracy of six-point Dixon in grading mild steatosis improved (AUROC: 0.59 to 0.99) when iron overload cases were excluded. The excellent correlation (> 0.9) between the Dixon techniques vs MRS-PDFF did not change in the presence of liver fibrosis (P < 0.01). CONCLUSION: Dixon techniques performed satisfactorily for the evaluation of hepatic steatosis but with exceptions.