Congestive Hepatopathy: Pathophysiology, Workup, and Imaging Findings with Pathologic Correlation.

Liver congestion is increasingly encountered in clinical practice and presents diagnostic pitfalls of which radiologists must be aware. The complex altered hemodynamics associated with liver congestion leads to diffuse parenchymal changes and the development of benign and malignant nodules. Distinguishing commonly encountered benign hypervascular lesions, such as focal nodular hyperplasia (FNH)-like nodules, from hepatocellular carcinoma (HCC) can be challenging due to overlapping imaging features. FNH-like lesions enhance during the hepatic arterial phase and remain isoenhancing relative to the background liver parenchyma but infrequently appear to wash out at delayed phase imaging, similar to what might be seen with HCC. Heterogeneity, presence of an enhancing capsule, washout during the portal venous phase, intermediate signal intensity at T2-weighted imaging, restricted diffusion, and lack of uptake at hepatobiliary phase imaging point toward the diagnosis of HCC, although these features are not sensitive individually. It is important to emphasize that the Liver Imaging Reporting and Data System (LI-RADS) algorithm cannot be applied in congested livers since major LI-RADS features lack specificity in distinguishing HCC from benign hypervascular lesions in this population. Also, the morphologic changes and increased liver stiffness caused by congestion make the imaging diagnosis of cirrhosis difficult. The authors discuss the complex liver macro- and microhemodynamics underlying liver congestion; propose a more inclusive approach to and conceptualization of liver congestion; describe the pathophysiology of liver congestion, hepatocellular injury, and the development of benign and malignant nodules; review the imaging findings and mimics of liver congestion and hypervascular lesions; and present a diagnostic algorithm for approaching hypervascular liver lesions. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Understanding the role of radiologists in complex treatment decisions for patients with hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and represents a significant global health burden. Management of HCC can be challenging due to multiple factors, including variable expectations for treatment outcomes. Several treatment options are available, each with specific eligibility and ineligibility criteria, and are provided by a multidisciplinary team of specialists. Radiologists should be aware of the types of treatment options available, as well as the criteria guiding the development of individualized treatment plans. This awareness enables radiologists to contribute effectively to patient-centered multidisciplinary tumor boards for HCC and play a central role in reassessing care plans when the treatment response is deemed inadequate. This comprehensive review aims to equip radiologists with an overview of HCC staging systems, treatment options, and eligibility criteria. The review also discusses the significance of imaging in HCC diagnosis, treatment planning, and monitoring treatment response. Furthermore, we highlight the crucial branch points in the treatment decision-making process that depend on radiological interpretation.

Universal Liver Imaging Lexicon: Imaging Atlas for Research and Clinical Practice.

The use of standardized terms in assessing and reporting disease processes has well-established benefits, such as clear communication between radiologists and other health care providers, improved diagnostic accuracy and reproducibility, and the enhancement and facilitation of research. Recently, the Liver Imaging Reporting and Data System (LI-RADS) Steering Committee released a universal liver imaging lexicon. The current version of the lexicon includes 81 vetted and precisely defined terms that are relevant to acquisition of images using all major liver imaging modalities and contrast agents, as well as lesion- and organ-level features. Most terms in the lexicon are applicable to all patients undergoing imaging of the liver, and only a minority of the terms are strictly intended to be used for patients with high risk factors for hepatocellular carcinoma. This pictorial atlas familiarizes readers with the liver imaging lexicon and includes discussion of general concepts, providing sample definitions, schematics, and clinical examples for a subset of the terms in the liver imaging lexicon. The authors discuss general, technical, and imaging feature terms used commonly in liver imaging, with the goal of illustrating their use for clinical and research applications. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material is available for this article.

Liver imaging: it is time to adopt standardized terminology.

Liver imaging plays a vital role in the management of patients at risk for hepatocellular carcinoma (HCC); however, progress in the field is challenged by nonuniform and inconsistent terminology in the published literature. The Steering Committee of the American College of Radiology (ACR)'s Liver Imaging Reporting And Data System (LI-RADS), in conjunction with the LI-RADS Lexicon Writing Group and the LI-RADS International Working Group, present this consensus document to establish a single universal liver imaging lexicon. The lexicon is intended for use in research, education, and clinical care of patients at risk for HCC (i.e., the LI-RADS population) and in the general population (i.e., even when LI-RADS algorithms are not applicable). We anticipate that the universal adoption of this lexicon will provide research, educational, and clinical benefits. KEY POINTS: •To standardize terminology, we encourage authors of research and educational materials on liver imaging to use the standardized LI-RADS Lexicon. •We encourage reviewers to promote the use of the standardized LI-RADS Lexicon for publications on liver imaging. •We encourage radiologists to use the standardized LI-RADS Lexicon for liver imaging in clinical care.

Interobserver and intraobserver variability of RECIST assessment in ovarian cancer.

OBJECTIVES: Measurement of Response Evaluation Criteria In Solid Tumors (RECIST) relies on reproducible unidimensional tumor measurements. This study assessed intraobserver and interobserver variability of target lesion selection and measurement, according to RECIST version 1.1 in patients with ovarian cancer. METHODS: Eight international radiologists independently viewed 47 images demonstrating malignant lesions in patients with ovarian cancer and selected and measured lesions according to RECIST V.1.1 criteria. Thirteen images were viewed twice. Interobserver variability of selection and measurement were calculated for all images. Intraobserver variability of selection and measurement were calculated for images viewed twice. Lesions were classified according to their anatomical site as pulmonary, hepatic, pelvic mass, peritoneal, lymph nodal, or other. Lesion selection variability was assessed by calculating the reproducibility rate. Lesion measurement variability was assessed with the intra-class correlation coefficient. RESULTS: From 47 images, 82 distinct lesions were identified. For lesion selection, the interobserver and intraobserver reproducibility rates were high, at 0.91 and 0.93, respectively. Interobserver selection reproducibility was highest (reproducibility rate 1) for pelvic mass and other lesions. Intraobserver selection reproducibility was highest (reproducibility rate 1) for pelvic mass, hepatic, nodal, and other lesions. Selection reproducibility was lowest for peritoneal lesions (interobserver reproducibility rate 0.76 and intraobserver reproducibility rate 0.69). For lesion measurement, the overall interobserver and intraobserver intraclass correlation coefficients showed very good concordance of 0.84 and 0.94, respectively. Interobserver intraclass correlation coefficient showed very good concordance for hepatic, pulmonary, peritoneal, and other lesions, and ranged from 0.84 to 0.97, but only moderate concordance for lymph node lesions (0.58). Intraobserver intraclass correlation coefficient showed very good concordance for all lesions, ranging from 0.82 to 0.99. In total, 85% of total measurement variability resulted from interobserver measurement difference. CONCLUSIONS: Our study showed that while selection and measurement concordance were high, there was significant interobserver and intraobserver variability. Most resulted from interobserver variability. Compared with other lesions, peritoneal lesions had the lowest selection reproducibility, and lymph node lesions had the lowest measurement concordance. These factors need consideration to improve response assessment, especially as progression free survival remains the most common endpoint in phase III trials.

Chronic Liver Disease and Liver Cancer: What the Hepatologists, Oncologists, and Surgeons Want to Know from Radiologists.

Effective communication between radiologists and physicians involved in the management of patients with chronic liver disease is paramount to ensuring appropriate and advantageous incorporation of liver imaging findings into patient care. This review discusses the clinical benefits of innovations in radiology reporting, what information the various stakeholders wish to know from the radiologist, and how radiology can help to ensure the effective communication of findings.

LI-RADS treatment response assessment of combination locoregional therapy for HCC.

HCC incidence continues to increase worldwide and is most frequently discovered at an advanced stage when limited curative options are available. Combination locoregional therapies have emerged to improve patient survival and quality of life or downstage patients to curative options. The increasing options for locoregional therapy combinations require an understanding of the expected post-treatment imaging appearance in order to assess treatment response. This review aims to describe the synergy between TACE combined with thermal ablation and TACE combined with SBRT. We will also illustrate expected imaging findings that determine treatment efficacy based on the mechanism of tissue injury using the LI-RADS Treatment Response Algorithm.

LI-RADS treatment response lexicon: review, refresh and resolve with emerging data.

The imaging findings after loco regional treatment of hepatocellular carcinoma are variable based on the type of treatment used, the timing interval of imaging after treatment, and the cross-sectional modality used for treatment response assessment. Liver Imaging Reporting and Data System (LI-RADS) Treatment Response Algorithm (TRA) is a relatively new standardized method of evaluating treatment response after loco regional therapy to hepatocellular carcinoma. In this article, we provide an overview of the evolution of the treatment response algorithm, its current applicability and its outlook for the future. We will review current guidelines and discuss proposed changes to the algorithm as a means to continually improve LI-RADS TRA as an assessment tool post-loco regional treatment of hepatocellular carcinoma.

Role of the radiologist at HCC multidisciplinary conference and use of the LR-TR algorithm for improving workflow.

Multidisciplinary conferences (MDCs) play a major role in management and care of oncology patients. Hepatocellular carcinoma (HCC) is a complex disease benefiting from multidisciplinary discussions to determine optimal patient management. A multitude of liver-directed locoregional therapies have emerged allowing for more options for treatment of HCC. A radiologist dedicated to HCC-MDC is an important member of the team contributing to patient care in multiple ways. The radiologist plays a key role in image interpretation guiding initial therapy discussions as well as interpreting post-treatment imaging following liver-directed therapy. Standardization of image interpretation can lead to more consistent treatment received by the patient as well as accurate assessment of transplant eligibility. The radiologist can facilitate this process using structured reporting that is also supported by stakeholders involved in interdisciplinary management of liver diseases. The Liver Imaging Reporting and Data System (LI-RADS), is a living document which offers a standardized reporting algorithm for consistent communication of radiologic findings for HCC screening and characterization of liver observations in patients at risk for HCC. The LI-RADS post-treatment algorithm (LR-TR algorithm) has been developed to standardize liver observations following liver-directed locoregional therapy. This review article focuses on the role of the radiologist at HCC-MDC and implementation of the LR-TR algorithm for improving workflow.

Association of Splanchnic Vein Thrombosis on Survival: 15-Year Institutional Experience With 1561 Cases.

Background Previous studies regarding survival in patients with splanchnic vein thrombosis (SVT) are limited. This study measured overall survival in a large cohort of SVTs through linkage to population-based data. Methods and Results Using a previously derived text-search algorithm, we screened the reports of all abdominal ultrasound and contrast-enhanced computed tomography studies at The Ottawa Hospital over 14 years. Screen-positive reports were manually reviewed by at least 2 authors to identify definite SVT cases by consensus. Images of uncertain studies were independently reviewed by 2 radiologists. One thousand five hundred sixty-one adults with SVT (annual incidence ranging from 2.8 to 5.9 cases/10 000 patients) were linked with population-based data sets to measure the presence of concomitant cancer and survival status. Thrombosis involved multiple veins in 314 patients (20.1%), most commonly the portal vein (n=1410, 90.3%). Compared with an age-sex-year matched population, patients with SVT had significantly reduced survival in particular with local cancer (adjusted relative excess risk for recent cases 12.0 [95% CI, 9.8-14.6] and for remote cases 9.7 [7.7-12.2]), distant cancer (relative excess risk for recent cases 5.7 [4.5-7.3] and for remote cases 5.4 [4.4-6.6]), cirrhosis (relative excess risk 8.2 [5.3-12.7]), and previous venous thromboembolism (relative excess risk 3.8 [2.4-6.0]). One hundred fifty (23.9%) of patients >65 years of age were anticoagulated within 1 month of diagnosis. Conclusions SVT is more common than expected. Most patients have cancer and the portal vein is by far the most common vein involved. Compared with the general population, patients with SVT had significantly reduced survival, particularly in patients with concomitant cancer, cirrhosis, and previous venous thromboembolic disease. Most elderly patients did not receive anticoagulant therapy.

Imaging and Management of Liver Cancer.

Imaging of primary hepatic neoplasms in patients at risk for hepatocellular carcinoma (HCC) and in patients with otherwise normal livers relies on proper multiphase image acquisition technique, with emphasis on a high-quality, late arterial phase, using either CT or MRI for accurate image interpretation. The introduction of liver imaging reporting and data system in 2011, with subsequent multiple updates, the most recent in 2018, has provided standardization of image interpretation, reporting and management recommendations for liver observations in patients at risk for HCC. This review article will emphasize key points of imaging primary liver tumors with emphasis on liver imaging reporting and data system, including strengths of this system. We will also review imaging of less common primary liver tumors such as cholangiocarcinoma and angiosarcomas. Imaging pitfall associated with primary liver malignancies will be demonstrated as well as ways to mitigate them. Finally, imaging and reporting of findings following locoregional treatment of HCC will be reviewed.

Imaging of Renal Cancer.

Renal masses are common incidental findings on cross-sectional imaging. Accurate characterization of renal masses is essential to guide management. Renal mass CT protocol comprises of a good quality noncontrast, corticomedullary and nephrographic phases, with each phase providing complementary information for diagnosis. Attenuation measurements in different phases are central to the 'golden-rules' in renal mass imaging in the characterization of renal masses. Newer modalities like dual energy CT scan obviate need for repeat imaging by generation of iodine-overlay image and also help in eliminating artifactual pseudoenhancement which can be problematic, especially in small endophytic cysts. Contrast- enhanced ultrasound (CEUS) is extremely sensitive in identification of enhancing components in indeterminate masses, especially in the setting of renal failure as the microbubbles are not excreted via the renal route. The Bosniak classification for renal cystic masses has been revised in 2019 to standardize terminology and further improve upon the original version. The current version includes CT and MRI, although CEUS is yet to be included. Image- guided biopsy of renal mass helps confirm the diagnosis and also gives information regarding the subtype and grading and is useful in avoiding overtreatment of benign entities, and in active surveillance. Multiparametric MRI can potentially help avoid needle biopsy in a subset of patients by accurate characterization through a previously validated algorithm.

Clinicians and surgeon survey regarding current and future versions of CT/MRI LI-RADS.

PURPOSE: To determine preferences of clinicians and surgeons regarding radiology reporting of liver observations in patients at risk for hepatocellular carcinoma (HCC). METHODS: Members of the American College of Radiology Liver Imaging and Data Reporting System (LI-RADS) Outreach & Education Group (30 members) as well as Society of Abdominal Radiology Disease-Focused Panel on HCC diagnosis (27 members) created and distributed an 18-question survey to clinicians and surgeons, with focus on preferences regarding radiology reporting of liver observations in patients. The survey questions were directed to physician demographics, current use of LI-RADS by their local radiologists, their opinions about current LI-RADS and potential improvements. RESULTS: A total of 152 physicians responded, 66.4% (101/152) from North America, including 42 surgeons, 81 physicians and 29 interventional radiologists. Participants were predominantly from academic centers 83% (126/152), while 13.8% (21/152) worked in private/community centers and 3.2% (5/152) worked in a hybrid practice. Almost 90% (136/152) of participants preferred the use of LI-RADS (compared to nothing or other standardized reporting systems; OPTN and AASLD) to communicate liver-related observations. However, only 28.5% (43/152) of participants input was sought at the time of implementing LI-RADS in their institutions. Fifty-eight percent (88/152) of all participants found standardized LI-RADS management recommendations in radiology reports to be clinically helpful. However, a subgroup analysis of surgeons in academic centers showed that 61.8% (21/34) prefer not to receive standardized LI-RADS recommendations. CONCLUSIONS: Most participants preferred the use LI-RADS in reporting CT and MRI examination. When considering inclusion of management recommendations, radiologists should consult with their referring physicians, as preference may differ.

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.

User and system pitfalls in liver imaging with LI-RADS.

The Liver Imaging Reporting and Data System (LI-RADS) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver imaging, created specifically for patients at risk for hepatocellular carcinoma. Over the past years, LI-RADS has been progressively implemented into clinical practice, but pitfalls remain related to user error and inherent limitations of the system. User pitfalls include the inappropriate application of LI-RADS to a low-risk patient population, incorrect measurement techniques, inaccurate assumptions about LI-RADS requirements, and improper usage of LI-RADS terminology and categories. System pitfalls include areas of discordance with the Organ Procurement and Transplantation Network (OPTN) as well as pitfalls related to rare ancillary features. This article reviews common user pitfalls in applying LI-RADS v2018 and how to avoid preventable errors and also highlights deficiencies of the current version of LI-RADS and how it might be improved in the future. Level of Evidence:3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019. J. Magn. Reson. Imaging 2019;50:1673-1686.

Hepatic complications of oral contraceptive pills and estrogen on MRI: Controversies and update - Adenoma and beyond.

Hepatic complications of oral contraceptive pills and exogenous estrogens include intrahepatic canalicular cholestasis, neoplasm formation and vascular pathologies. While it remains controversial as to whether estrogen plays a role in focal nodular hyperplasia, hemangioma or hamartoma, exposure to oral contraceptive pills and estrogen has a strong association with hepatic adenomas. Four different subgroups of adenomas have been described: Inflammatory, HNF-1α-mutated, ß-catenin-mutated and unclassified. Vascular complications may include Budd-Chiari syndrome, vascular thrombosis, dilated sinusoids and peliosis.