ESR Essentials: diagnosis of hepatocellular carcinoma-practice recommendations by ESGAR.

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and a leading cause of cancer related death worldwide. Current guidelines for the noninvasive diagnosis of HCC are provided by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD) which endorsed the Liver Imaging Reporting and Data System (LI-RADS) algorithm, the Korean Liver Cancer Association-National Cancer Center (KLCA-NCC), and the Asian-Pacific Association for the Study of the Liver (APASL). These allow the diagnosis of HCC in high-risk patients in the presence of typical imaging features on contrast-enhanced CT, MRI, or contrast-enhanced ultrasound. Size, non-rim arterial phase hyperenhancement, non-peripheral washout, enhancing capsule, and growth are major imaging features and they should be combined for the diagnosis of HCC. This article provides concise and relevant practice recommendations aimed at general radiologist audience, summarizing the best practice and informing on the essential imaging criteria for the diagnosis of HCC, while also discussing the high-risk population criteria, imaging modalities, and imaging features according to the current guidelines. KEY POINTS: • Noninvasive diagnosis of hepatocellular carcinoma (HCC) can be provided only in patients at high risk. • Contrast-enhanced CT or MRI are the first-line imaging exams for the diagnosis of HCC. • Major imaging features should be combined to provide the diagnosis of definitive HCC.

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.

Reliability of extracellular contrast versus gadoxetic acid in assessing small liver lesions using liver imaging reporting and data system v.2018 and European association for the study of the liver criteria.

BACKGROUND & AIMS: The diagnostic accuracy of Liver Imaging Reporting and Data System (LI-RADS) v.2018 and European Association for the Study of the Liver (EASL) criteria for the diagnosis of HCC have been widely evaluated, but their reliability should be investigated. We aimed to assess and compare the reliability of LI-RADS v.2018 and EASL criteria for the diagnosis of HCC using MRI with extracellular contrast agents (ECAs) and gadoxetic acid (GA) and determine the effect of ancillary features on LI-RADS reliability. APPROACH & RESULTS: Ten readers reviewed MRI studies of 92 focal liver lesions measuring <3 cm acquired with ECAs and GA <1 month apart from two prospective trials, assessing EASL criteria, LI-RADS major and ancillary features, and LI-RADS categorization with and without including ancillary features. Inter-reader agreement for definite HCC diagnosis was substantial and similar for the two contrasts for both EASL and LI-RADS criteria. For ECA-MRI and GA-MRI, respectively, inter-reader agreement was k = 0.72 (95% CI, 0.63-0.81) and k = 0.72 (95% CI, 0.63-0.80); for nonrim hyperenhancement, k = 0.63 (95% CI, 0.54-0.72) and k = 0.57 (95% CI, 0.48-0.66); and for nonperipheral washout, k = 0.49 (95% CI, 0.40-0.59) and k = 0.48 (95% CI, 0.37-0.58) for enhancing capsule. The inter-reader agreement for LI-RADS after applying ancillary features remained in the same range of agreement. CONCLUSIONS: Agreement for definite HCC was substantial and similar for both scoring systems and the two contrast agents in small focal liver lesions. Agreement for LI-RADS categorization was lower for both contrast agents, and including LI-RADS ancillary features did not improve agreement.

LI-RADS ancillary features favoring benignity: is there a role in LR-5 observations?

OBJECTIVES: The Liver Imaging Reporting and Data System algorithm allows category downgrade in the presence of ancillary features (AFs) favoring benignity, even in observations categorized as LR-5. This study aims to assess the role of AFs favoring benignity in LR-5 observations and their impact on category downgrade. METHODS: This study included high-risk patients with at least one LR-5 observation imaged with gadoxetate disodium MRI. Three readers with different experience levels independently evaluated the presence of AFs favoring malignancy (not hepatocellular carcinoma (HCC) in particular and HCC in particular) and AFs favoring benignity. Category downgrade was considered possible in the presence of ≥ 1 AF favoring benignity and no AF favoring malignancy. Correlation between observations size and number of AFs was assessed using Spearman's rank correlation coefficient. Cohen's kappa (k) test was used to assess inter-reader agreement. RESULTS: The final study cohort included 162 LR-5 (mean size: 23 ± 16 mm) in 119 patients. AFs favoring benignity were reported in 9 (5.6%), 20 (12.3%), and 10 (6.2%) LR-5 observations by reader 1, reader 2, and reader 3, respectively. Hepatobiliary phase isointensity was observed in 6 (3.7%), 2 (1.2%), and 7 (4.3%) observations, respectively. Category downgrade was considered possible in only one (0.6%) observation by reader 1 and reader 3. There was a significant correlation between observation size and number of AFs favoring malignancy (p < 0.001), not HCC in particular (p ≤ 0.010), and favoring HCC in particular (p < 0.001). Inter-reader agreement of AFs favoring benignity was poor to moderate (k range: - 0.01, 0.43). CONCLUSIONS: AFs favoring benignity are not uncommon in LR-5 observations, but category downgrade is exceptional. KEY POINTS: • Ancillary features favoring benignity are encountered in 5.6-12.3% of observations categorized as LR-5. • Category downgrade of LR-5 observations is very rare (0.6% of observations) in the presence of AFs favoring benignity due to the high prevalence (98-99%) of ancillary features favoring malignancy in LR-5 observations. • The inter-reader agreement of ancillary features favoring benignity is poor to moderate (k range: - 0.01, 0.43) in readers with different levels of experience.

Long-term evolution of LI-RADS observations in HCV-related cirrhosis treated with direct-acting antivirals.

BACKGROUND & AIMS: The risk of progression of indeterminate observations to hepatocellular carcinoma (HCC) after direct-acting antivirals (DAA) is still undetermined. To assess whether DAA therapy changes the risk of progression of observations with low (LR-2), intermediate (LR-3) and high (LR-4) probability for HCC in cirrhotic patients and to identify predictors of progression. METHODS: This retrospective study included cirrhotic patients treated with DAA who achieved sustained virological response between 2015 and 2019. A total of 68 patients had pre-DAA indeterminate observations and at least six months CT/MRI follow-up before and after DAA. Two radiologists reviewed CT/MRI studies to categorize observations according to the LI-RADSv2018 and assess the evolution on subsequent follow-ups. Predictors of evolutions were evaluated by using the Cox proportional hazard model, Kaplan-Meier method and log-rank test. RESULTS: A total of 109 untreated observations were evaluated, including 31 (28.4%) LR-2, 67 (61.5%) LR-3 and 11 (10.1%) LR-4. During a median follow-up of 41 months, 17.4% and 13.3% of observations evolved to LR-5 or LR-M and LR-5, before and after DAA respectively (P = .428). There was no difference in rate of progression of neither LR-2 (P = 1.000), LR-3 (P = .833) or LR-4 (P = .505). At multivariate analysis, only initial LI-RADS category was an independent predictor of progression to LR-5 or LR-M for all observations (hazard ratio 6.75, P < .001), and of progression to LR-5 after DAA (hazard ratio 4.34, P = .047). CONCLUSIONS: DAA therapy does not increase progression of indeterminate observations to malignant categories. The initial LI-RADS category is an independent predictor of observations upgrade.

Are radiological endpoints surrogate outcomes of overall survival in hepatocellular carcinoma treated with transarterial chemoembolization?

BACKGROUND& AIMS: Time to progression (TTP) and progression-free survival (PFS) are commonly used as surrogate endpoints in oncology trials. We aimed to assess the surrogacy relationship of TTP and PFS with overall survival (OS) in studies of transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (u-HCC) by innovative methods. METHODS: A search of databases for studies of TACE for u-HCC reporting both OS and TTP or PFS was performed. Individual patient data were extracted from TTP/PFS and OS Kaplan-Meier curves of TACE arms. Pooled median TTP and OS were obtained from random-effect model. The surrogate relationships of hazard ratios (HRs) and median TTP for OS were evaluated by the coefficient of determination R2 . RESULTS: We identified 13 studies comparing TACE vs systemic therapy or vs TACE plus systemic therapy and including 1932 TACE-treated patients. Pooled median OS was 11.2 months (95% confidence interval [95%CI] 7.9-17.8), and pooled median TTP was 5.4 months (95%CI 3.8-8.0). Heterogeneity among studies was highly significant for both outcomes. The correlation between HR TTP and HR OS was moderate (R2  = 0.65. 95%CI 0.08-0.81). R2 value was 0.04 (95%CI 0.00-0.35) between median TTP and median OS. CONCLUSION: In studies of TACE for u-HCC, the surrogate relationship of radiology-based endpoints with OS is moderate. Multiple endpoints including hepatic decompensation, macrovascular invasion and extrahepatic spread are needed for future trials comparing systemic therapies or combination of TACE with systemic therapies vs TACE alone.

Consensus report from the 9th International Forum for Liver Magnetic Resonance Imaging: applications of gadoxetic acid-enhanced imaging.

OBJECTIVES: The 9th International Forum for Liver Magnetic Resonance Imaging (MRI) was held in Singapore in September 2019, bringing together radiologists and allied specialists to discuss the latest developments in and formulate consensus statements for liver MRI, including the applications of gadoxetic acid-enhanced imaging. METHODS: As at previous Liver Forums, the meeting was held over 2 days. Presentations by the faculty on days 1 and 2 and breakout group discussions on day 1 were followed by delegate voting on consensus statements presented on day 2. Presentations and discussions centered on two main meeting themes relating to the use of gadoxetic acid-enhanced MRI in primary liver cancer and metastatic liver disease. RESULTS AND CONCLUSIONS: Gadoxetic acid-enhanced MRI offers the ability to monitor response to systemic therapy and to assist in pre-surgical/pre-interventional planning in liver metastases. In hepatocellular carcinoma, gadoxetic acid-enhanced MRI provides precise staging information for accurate treatment decision-making and follow-up post therapy. Gadoxetic acid-enhanced MRI also has potential, currently investigational, indications for the functional assessment of the liver and the biliary system. Additional voting sessions at the Liver Forum debated the role of multidisciplinary care in the management of patients with liver disease, evidence to support the use of abbreviated imaging protocols, and the importance of standardizing nomenclature in international guidelines in order to increase the sharing of scientific data and improve the communication between centers. KEY POINTS: • Gadoxetic acid-enhanced MRI is the preferred imaging method for pre-surgical or pre-interventional planning for liver metastases after systemic therapy. • Gadoxetic acid-enhanced MRI provides accurate staging of HCC before and after treatment with locoregional/biologic therapies. • Abbreviated protocols for gadoxetic acid-enhanced MRI offer potential time and cost savings, but more evidence is necessary. The use of gadoxetic acid-enhanced MRI for the assessment of liver and biliary function is under active investigation.

A case of infective colitis due to Yersinia enterocolitica complicated by microliver abscesses mimicking multiple liver occult metastases: a case report.

BACKGROUND: We report an unusual case of infective colitis by Yersinia enterocolitica complicated by microliver abscesses mimicking multiple liver metastases in a 79 yr old female without any risk factors for bacteriaemia by this pathogen. CASE PRESENTATION: The patient was admitted to the Internal Medicine with Stroke Care ward of University Policlinico "P. Giaccone" in Palermo because of the appearance of diarrhoea. After the antimicrobial treatment for infective colitis, the clinicians observed a persistently increased white blood cells (WBC) count and multiple hepatic lesions; after having excluded any neoplastic disease and inflammatory bowel disease (IBD), blood cultures positive for Y. enterocolitica allowed to establish the final diagnosis was infective micro liver abscesses consequent to infective colitis due to Y. enterocolitica, which were successfully treated with cefixime and doxycycline. CONCLUSIONS: This case report should make clinicians reflect on how complex the differential diagnosis between microliver abscesses and metastasis could be and the possibility of bacteriaemia by Y. enterocolitica even without iron overload conditions.

Hepatobiliary phase in cirrhotic patients with different Model for End-stage Liver Disease score: comparison of the performance of gadoxetic acid to gadobenate dimeglumine.

OBJECTIVES: The purpose of this study was to compare the performance of gadobenate dimeglumine-enhanced MRI and gadoxetic acid-enhanced MRI in the hepatobiliary phase (HBP) in cirrhotic patients with different degrees of liver dysfunction. METHODS: In this retrospective cross-sectional study, we analyzed the unenhanced phase and the HBP of 131 gadobenate dimeglumine-enhanced MRI examinations (gadobenate dimeglumine group) and 127 gadoxetic acid-enhanced MRI examinations (gadoxetic acid group) performed in 249 cirrhotic patients (181 men and 68 women; mean age, 64.8 years) from August 2011 to April 2017. For each MRI, the contrast enhancement index of the liver parenchyma was calculated and correlated to the Model For End-Stage Liver Disease (MELD) score (multiple linear regression analysis). A qualitative analysis of the adequacy of the HBP, adjusted for the MELD score (logistic regression analysis), was performed. RESULTS: The contrast enhancement index was inversely related (r = - 0.013) with MELD score in both gadoxetic acid and gadobenate dimeglumine group. At the same MELD score, the contrast enhancement index in the gadoxetic acid group was increased by a factor of 0.23 compared to the gadobenate dimeglumine group (p < 0.001), and the mean odds ratio to have an adequate HBP with gadoxetic acid compared to gadobenate dimeglumine was 3.64 (p < 0.001). The adequacy of the HBP in the gadoxetic acid group compared to the gadobenate dimeglumine group increased with the increase of the MELD score (exp(b)interaction = 1.233; p = 0.011). CONCLUSION: In cirrhotic patients, the hepatobiliary phase obtained with gadoxetic acid-enhanced MRI is of better quality in comparison to gadobenate dimeglumine-enhanced MRI, mainly in patients with high MELD score. KEY POINTS: • In cirrhotic patients, the adequacy of the hepatobiliary phase with gadoxetic acid-enhanced MRI is better compared to gadobenate dimeglumine-enhanced MRI. • Gadoxetic acid-enhanced MRI should be preferred to gadobenate dimeglumine-enhanced MRI in cirrhotic patients with MELD score > 10, if the hepatobiliary phase is clinically indicated. • In patients with high MELD score (> 15), the administration of the hepatobiliary agent could be useless; even though, if it is clinically indicated, we recommend to use gadoxetic acid given the higher probability of obtaining clinically relevant information.

Interreader Reliability of LI-RADS Version 2014 Algorithm and Imaging Features for Diagnosis of Hepatocellular Carcinoma: A Large International Multireader Study.

Purpose To determine in a large multicenter multireader setting the interreader reliability of Liver Imaging Reporting and Data System (LI-RADS) version 2014 categories, the major imaging features seen with computed tomography (CT) and magnetic resonance (MR) imaging, and the potential effect of reader demographics on agreement with a preselected nonconsecutive image set. Materials and Methods Institutional review board approval was obtained, and patient consent was waived for this retrospective study. Ten image sets, comprising 38-40 unique studies (equal number of CT and MR imaging studies, uniformly distributed LI-RADS categories), were randomly allocated to readers. Images were acquired in unenhanced and standard contrast material-enhanced phases, with observation diameter and growth data provided. Readers completed a demographic survey, assigned LI-RADS version 2014 categories, and assessed major features. Intraclass correlation coefficient (ICC) assessed with mixed-model regression analyses was the metric for interreader reliability of assigning categories and major features. Results A total of 113 readers evaluated 380 image sets. ICC of final LI-RADS category assignment was 0.67 (95% confidence interval [CI]: 0.61, 0.71) for CT and 0.73 (95% CI: 0.68, 0.77) for MR imaging. ICC was 0.87 (95% CI: 0.84, 0.90) for arterial phase hyperenhancement, 0.85 (95% CI: 0.81, 0.88) for washout appearance, and 0.84 (95% CI: 0.80, 0.87) for capsule appearance. ICC was not significantly affected by liver expertise, LI-RADS familiarity, or years of postresidency practice (ICC range, 0.69-0.70; ICC difference, 0.003-0.01 [95% CI: -0.003 to -0.01, 0.004-0.02]. ICC was borderline higher for private practice readers than for academic readers (ICC difference, 0.009; 95% CI: 0.000, 0.021). Conclusion ICC is good for final LI-RADS categorization and high for major feature characterization, with minimal reader demographic effect. Of note, our results using selected image sets from nonconsecutive examinations are not necessarily comparable with those of prior studies that used consecutive examination series. © RSNA, 2017.

Focal Nodular Hyperplasia After Treatment With Oxaliplatin: A Multiinstitutional Series of Cases Diagnosed at MRI.

OBJECTIVE: Benign hepatic lesions may occur after chemotherapy treatment and may mimic metastases at imaging. We describe focal nodular hyperplasia (FNH) lesions diagnosed at MRI that occurred de novo after treatment with oxaliplatin. MATERIALS AND METHODS: This is a multiinstitutional case series. We report 14 adult patients with cancer (eight men and six women) with a history of treatment with oxaliplatin and development of new hepatic lesions diagnosed as FNH at pathologic analysis or MRI or both. Imaging and pathology features of the included lesions, the interval since chemotherapy, and the temporal evolution were reviewed. RESULTS: The mean interval between the completion of oxaliplatin treatment and the identification of new hepatic FNH at imaging was 47.6 months. In seven of 14 (50%) patients, the index lesion was diagnosed at pathologic analysis (biopsy or resection) as FNH. In the remaining seven cases, the diagnosis was based on highly accurate MRI features (e.g., hyper- or isointensity of the lesion on hepatobiliary phase images). Lesion growth or occurrence of new lesions was present in 75% of patients at imaging follow-up. CONCLUSION: FNH lesions can occur de novo after treatment with oxaliplatin. Recognizing the typical MRI appearance of these lesions may avoid unnecessary biopsy or surgery and reduce patients' anxiety.

Osteonecrosis detected by whole body magnetic resonance in patients with Hodgkin Lymphoma treated by BEACOPP.

OBJECTIVES: The purpose of our retrospective review of prospectively acquired Whole Body Magnetic Resonance (WB-MRI) scans was to assess the incidence of osteonecrosis in patients who received different chemotherapies. METHODS: We evaluated the WB-MRI scans performed on 42 patients with Hodgkin Lymphoma treated by three chemotherapy regimens (6ABVD, 2ABVD + 4BEACOPP, 2ABVD + 8BEACOPP), excluding patients with the main risk factors for osteonecrosis. RESULTS: Six out of seven patients (86 %) who received eight BEACOPP and one out of five patients (20 %) treated by four BEACOPP presented osteonecrosis, with a statistically significant difference of frequency between the two groups of patients (p < 0.05); no injury has been reported in patients treated by only ABVD. Among a total of 48 osteonecrotic lesions observed, 48 % were detected in the knee; multifocal osteonecrosis were detected in six out of seven patients (86 %). CONCLUSIONS: The development of osteonecrosis is strictly related to the chemotherapy protocol adopted and the number of cycles received, with a strong correlation between the dose of corticosteroids included in the BEACOPP scheme and this complication. WB-MRI can be considered as a helpful tool that allows detecting earlier osteonecrotic lesions in patients treated with corticosteroids. KEY POINTS: • Osteonecrosis is a possible complication of patients with Lymphoma treated by chemotherapy. • Osteonecrosis is related to the corticosteroids included within the BEACOPP protocol. • WB-MRI allows detecting osteonecrotic lesions in patients treated with corticosteroids.

Acute extrahepatic infectious or inflammatory diseases are a cause of transient mosaic pattern on CT and MR imaging related to sinusoidal dilatation of the liver.

PURPOSE: To report the association of a mosaic enhancement pattern on contrast-enhanced CT or MR imaging and hepatic sinusoidal dilatation (SD) with acute inflammatory conditions affecting extrahepatic organs. METHODS: From 2007 to 2012, patients with acute inflammatory diseases who underwent contrast-enhanced CT and/or MRI of the liver with a mosaic enhancement pattern were selected. Clinico-biological and other imaging features were collected at diagnosis and during follow-up. RESULTS: Sixteen patients were included (15 women, median age 27 years; range 18-68). Five women (33 %) were receiving oral contraceptives. Acute inflammatory diseases included pyelonephritis (n = 10), pancreatitis (n = 2), pneumonia (n = 1), septicemia (n = 1), active Crohn's disease (n = 1), and infectious colitis (n = 1). Median white blood cell count was 13,250 cells/µL (range 11,500-18,000 cells/µL) and CRP level 94 mg/L (range 60-121 mg/L). Mosaic enhancement pattern was present in the whole liver and was prominent in the subcapsular areas. Four patients underwent liver biopsy confirming SD. Eleven patients underwent follow-up imaging showing normalized aspect in 9/11 patients after a median of 2 months. CONCLUSION: Acute diseases of extrahepatic organs, associated with a marked systemic inflammatory syndrome should be added to the list of conditions causing a reversible hepatic sinusoidal dilatation as manifested by a mosaic enhancement pattern on contrast-enhanced CT or MR imaging. KEY POINTS: • Acute extrahepatic infectious/inflammatory diseases are a cause of transient MP. • In most patients, MP was seen during both arterial and portal venous phase. • In all patients, the mosaic enhancement pattern was diffuse, but more conspicuous in subcapsular areas. • MP was no longer seen after resolution of the acute disease. • No liver biopsy should be performed.

Recurrence of hepatocellular carcinoma after liver transplantation: an update.

Liver transplantation is the only curative alternative for selected patients with hepatocellular carcinoma (HCC) who are not eligible for resection and/or with decompensated cirrhosis. According to Milan criteria the 5-year survival rate is 70-85%, with a recurrence-free survival of 75%. However, HCC recurrence rate after liver transplantation remains a significant problem in the clinical practice. The prognosis in patients with HCC recurrence is poor. The treatment of choice for HCC recurrence is surgery, but it seems that a systemic treatment based on combination of an mTOR inhibitor with sorafenib can be used. Data on safety and efficacy are limited, clinical monitoring is necessary. The aim of this review is to underline the main concerns, pitfalls and warnings for these patients.

Imaging findings of hepatic focal nodular hyperplasia in men and women: are they really different?

PURPOSE: This study was undertaken to compare the imaging findings of focal nodular hyperplasia (FNH) in men and women, as seen on multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS: Two radiologists reviewed 195 imaging studies (17 MDCT, 81 MRI and 97 CEUS examinations) pertaining to 111 FNHs (mean size 3 cm) in 91 patients (mean age 39 years). For each lesion, the readers assessed size, location, echogenicity, attenuation, or signal intensity in comparison with adjacent liver parenchyma on both unenhanced and postcontrast images. RESULTS: Eighty-nine FNHs (mean size 3.1 cm) were observed in 73 women (mean age 37.9 years) and 22 FNHs (mean size 2.7 cm) in 18 men (mean age 41.2 years). No statistically significant differences were found between men and women in terms of age, FNH lesions per patient (1.22 and 1.21, respectively), size, baseline and enhancement pattern on MRI, CEUS and MDCT (p < 0.05). A central scar in FNHs was depicted in 4/18 (22.2%) men and 16/63 (25.4%) women on MRI (p < 0.05), and in 1/2 (50%) men and 7/15 (46.7%) women on MDCT (p < 0.05), whereas a spoke-wheel pattern, central scar, and/or feeding vessel were seen in 5/17 (29.4%) men and 22/80 (27.5%) women on CEUS (p < 0.05). CONCLUSIONS: Our results did not show any differences in imaging features, age of occurrence and size of FNH between men and women.

Hepatocellular carcinoma enhancement on contrast-enhanced CT and MR imaging: response assessment after treatment with sorafenib: preliminary results.

PURPOSE: This study was undertaken to compare response evaluation criteria in solid tumours (RECIST) 1.1 and modified RECIST (mRECIST) in patients with unresectable hepatocellular carcinoma (HCC) on sorafenib, and to describe HCC enhancement changes before and after sorafenib treatment. METHODS AND MATERIALS: Seventeen patients (12 men, 5 women; mean age 69 years; age range 58-79 years) were included. Tumour response was assessed according to RECIST and mRECIST. Two readers placed a region of interest (ROI) within each target lesion, on the portion showing enhancement during the arterial phase. The lesion attenuation values measured within the ROIs on computed tomography or the signal intensity measured on magnetic resonance imaging, during the unenhanced phase, hepatic arterial phase and venous phase were recorded. Changes in arterial and venous contrast enhancement before and after treatment were compared among the mRECIST groups using Mann-Whitney U test. RESULTS: Agreement between mRECIST and RECIST was good (Cohen's k coefficient, 0.791). Patients with partial response had a greater decrease in arterial enhancement (-79.8%) than did patients with stable disease (SD) (-24.8%; p = 0.011) or progressive disease (PD) (-32.9%; p = 0.034). No statistically significant difference in arterial enhancement variation was found among patients with SD and PD. No statistically significant difference in venous enhancement was found among the mRECIST groups. CONCLUSIONS: mRECIST showed a more favourable response compared to RECIST 1.1 in patients with unresectable HCC receiving sorafenib.

Liver imaging and pregnancy: what to expect when your patient is expecting.

Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.

Changes in the ultrasound presentation of hepatocellular carcinoma: a center's three decades of experience.

PURPOSE: Ultrasound (US) surveillance is a cornerstone for early diagnosis of HCC, anyway US presentation has undergone significant changes. With the aim of evaluating the effects of US surveillance program in the real-world clinical practice, we wanted to evaluate US presentation of HCCs over the last 30 years and the differences of HCCs presentation according to etiology. METHODS: 174 patients diagnosed between 1993 and 98 (G1), 96 between 2003 and 08 (G2), 102 between 2013 and 18 (G3), were compared. US patterns were: single, multiple or diffuse nodules. The echo-patterns: iso-, hypo-, hyper-echoic, or mixed. In G1, the HCC diagnosis was mainly histologic; in G2 by EASL 2001 and AASLD 2005, in G3 AASLD 2011, EASL 2012, and AISF 2013 guidelines. RESULTS: HCV was the most frequent etiology, dropping between G1 (81%) and G3 (66%) (P < 0.01), metabolic increased between G1 (5%) and G3 (14%) (P < 0.01). Single HCC was more prevalent in G3 vs G1 (65.6% vs 40%) (P < 0.0001), multiple nodules in G1 (50%) vs G3 (33.3%) (P < 0.02) and diffuse in G1 (16%) vs G2 (2%) and vs G3 (1%) (P < 0.001). The most frequent echo-pattern was hypo-echoic G1 (50%) vs G2 (79%) and G1 vs G3 (65%) (P < 0.01). Iso-echoic pattern was the least frequent (7-12%). Mixed pattern decreased from G1 (28%) to G3 (12%) (P < 0.002). In G3 there were more multiple or diffuse HCCs in metabolic (P < 0.03). CONCLUSION: US presentation became less severe due to surveillance programs. HCV remains the most frequent cause, an increase in metabolic etiology has been shown throughout the decades.