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Background: This study aimed to evaluate the risk factors related to a technical failure after laparoscopic radiofrequency ablation (RFA) for subcapsular hepatocellular carcinomas (HCCs). Materials and methods: A total of 110 patients with 114 HCCs who underwent laparoscopic RFA for HCCs (new HCC [n = 85] and local tumor progression [LTP] [n = 29]) between January 2013 and December 2018 were included. We evaluated the incidence of technical failure on immediate post-RFA CT images. Risk factors for a technical failure after laparoscopic RFA were assessed using univariable logistic regression analyses. The cumulative LTP rate was estimated using the Kaplan–Meier method. Results: Technical failure was noted in 3.5% (4/114) of the tumors. All four tumors that showed a technical failure were cases of LTP from previous treatment and were invisible on laparoscopy. On univariate analysis, LTP lesion, invisibility of the index tumor on laparoscopy, and peri-hepatic vein location of the tumor were identified as risk factors for a technical failure. The cumulative LTP rates at 1, 3, and 5 years were estimated to be 2.8%, 4.8%, and 4.8%, respectively. Conclusions: LTP lesion, invisibility of the index tumor on laparoscopy, and peri-hepatic vein location of the tumor were identified as the risk factors for a technical failure after laparoscopic RFA. [ABSTRACT FROM AUTHOR]

Objectives: To compare the presence of washout and the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) for hepatocellular carcinoma (HCC) according to the presence of hepatic steatosis.Methods: This retrospective study included 566 patients with chronic liver disease who had undergone hepatic resection for hepatic tumors (482 HCCs and 84 non-HCCs) between January 2016 and June 2018 and had available multiphasic CT and MR images. Patients were allocated in the fatty liver (n = 141) or non-fatty liver (n = 425) group according to the presence of hepatic steatosis, defined as lipid droplets in at least 5% of hepatocytes on pathological examination. The presence of HCC washout and the diagnostic performance of CT and MRI for HCC were compared between the groups.Results: HCC washout was less frequently seen in the fatty liver group than in the non-fatty liver group on CT (61.5% vs. 88.9%, p < 0.001), whereas it was similarly present on MRI in both groups (77.0% vs. 74.4%, p = 0.565). For diagnosis of HCC, the sensitivity (53.3% vs. 80.0%, p < 0.001) and accuracy (53.9% vs. 80.9%, p < 0.001) of CT were lower in the fatty liver group than in the non-fatty liver group. However, for MRI, these values were not significantly different between the groups (p > 0.05).Conclusions: Hepatic steatosis significantly decreased the performance of CT for the diagnosis of HCC, whereas it did not significantly alter the performance of MRI.Key Points: • Unlike MRI, there is vanishing HCC washout on CT caused by the background hepatic steatosis. • The diagnostic performance of CT for the diagnosis of HCC was significantly altered by hepatic steatosis. • The optimal cutoff HU value of the liver parenchyma for the vanishing washout of HCC was < 50 HU on unenhanced CT images. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the 10-year overall survival and local tumor progression (LTP) of percutaneous radiofrequency ablation (RFA) for single nodular hepatocellular carcinoma (HCC) < 3 cm using a large longitudinal hospital registry and clinical factors associated with overall survival and LTP.Methods: A total of 467 newly diagnosed patients with single nodular HCC < 3 cm who underwent RFA as first-line therapy between January 2008 to December 2016 were analyzed. Overall survival and LTP were estimated using the Kaplan-Meier method. Cox regression and competing risks Cox regression analysis were performed to identify prognostic factors for overall survival and LTP, respectively.Results: The 5- and 10-year overall survival rates after RFA were 83.7% and 74.2%, respectively. LTP (hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.19-3.47) was one of the important factors for overall survival after RFA. The 5- and 10-year LTP rates after RFA were 20.4% and 25.1%, respectively. Periportal location (subdistribution HR, 2.29; 95% CI, 1.25-4.21), subphrenic location (2.25, 1.34-3.86), size ≥ 1.5-< 2.0 cm (1.88, 1.05-3.39), and size ≥ 2.0 cm (2.10, 1.14-3.86) were independent factors for LTP.Conclusion: Ten-year therapeutic outcomes of percutaneous RFA as first-line therapy were excellent for single HCC < 3 cm. LTP was an important prognostic factor for overall survival after RFA. Periportal and subphrenic location of HCCs and tumor size were predictors for the development of LTP after RFA.Key Points: • Updated 10-year survival outcome of percutaneous radiofrequency ablation as first-line therapy for single hepatocellular carcinoma < 3 cm was higher than previously reported. • Local tumor progression was an important prognostic factor for overall survival after percutaneous radiofrequency ablation. • Periportal and subphrenic location of hepatocellular carcinomas and tumor size were predictors for the development of local tumor progression after percutaneous radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Objectives: To compare the therapeutic outcomes and safety of radiofrequency (RF) ablation for subcardiac and non-subcardiac hepatocellular carcinoma (HCC) and to evaluate the risk factors for technical failure of the procedure.Methods: This retrospective study was approved by the institutional review board. Between September 2002 and May 2016, 73 patients with subcardiac HCC and the same number of patients with non-subcardiac HCC matched by tumor size were included. Subcardiac HCC was defined as an index tumor that was located ≤ 1 cm from the pericardium in axial or coronal images. Cumulative local tumor progression (LTP) was compared between the two groups using the log-rank test. Prognostic factors for technical failure were assessed using multivariable logistic analysis.Results: Technical success rates between both groups were not significantly different (91.8% in the subcardiac HCC group vs. 95.9% in the non-subcardiac HCC group; p = 0.494). The cumulative LTP rates were 15.4% and 19.1% at 3 and 5 years, respectively, in the subcardiac HCC group, and 10.7% and 15.5% in the non-subcardiac HCC group, without significant difference (p = 0.862). The distance between the index tumor and pericardium (odds ratio [OR], 0.14; p = 0.023) and tumor in segment IV (reference, left lateral sector; OR, 36.53; p = 0.029) were significant factors for technical failure in patients with subcardiac HCC.Conclusions: RF ablation was an effective treatment for subcardiac HCC. However, tumor location should be considered in the planning of treatment to avoid technical failure.Key Points: • RF ablation for subcardiac HCC is technically feasible without major complications. • RF ablation was an effective treatment for subcardiac HCC in terms of LTP. • Risk factors for technical failure were distance of the index tumor from the heart (cutoff value of 0.5 cm) and the location of the tumor (segment IV). [ABSTRACT FROM AUTHOR]

Purpose: To assess the differences in early imaging features and progression pattern on CT between intrahepatic biliary metastasis (IBM) and non-mass-forming cholangiocarcinoma (NMFC) in patients with extrabiliary malignancy. Methods: This retrospective study included 35 patients who were surgically and pathologically confirmed with IBM (n = 14) or NMFC (n = 21) at the time of or after surgery for extrabiliary malignancy. Two observers evaluated the following aspects of biliary lesions on initial or follow-up CT images: location, characteristics of intrahepatic duct (IHD) dilatation, presence of duct wall thickening, and periductal infiltration lesion or periductal expansile mass. Results: All IBMs were associated with colorectal cancer (p = 0.032). As early imaging features on CT, smooth tapered localized IHD dilatation without duct wall thickening and peripheral duct involvement were observed significantly more often in IBM, and IHD dilatation with abrupt tapering or irregularity of transition site and bile duct wall thickening were significantly more common in NMFC (all p < 0.05). Regarding progression pattern, periductal expansile mass was present only in IBM, whereas periductal infiltrative lesion was present only in NMFC (p < 0.001). Conclusion: In the differentiation between IBM and NMFC in patients with extrabiliary malignancy, the differences in early imaging features and progression pattern of the two diseases revealed in this study would be helpful for diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: To compare the sensitivity of Liver Imaging Reporting and Data System (LI-RADS) v2017 for diagnosis of hepatocellular carcinoma (HCC) using multiphasic computed tomography (CT) between patients with and without moderate to severe fatty liver (MSFL).Methods: This retrospective study included a total of 106 high-risk patients with 112 pathologically proven HCCs who underwent multiphasic CT. Patients were classified as MSFL (24 men, 2 women; mean age, 59.5 years [range, 38-79 years]) and non-MSFL (64 men, 16 women; mean age, 62.9 years [range, 40-89 years]) groups according to unenhanced CT liver and spleen parenchymal attenuation. Two independent radiologists assigned LI-RADS categories and accessed HCC features on CT. Sensitivities for LR-5 assignment and frequencies of HCC features were compared between the two groups.Results: Sensitivities of LR-5 assignment for diagnosing HCCs were not significantly different between MSFL and non-MSFL groups (65.4% [17/26] vs. 76.7% [66/86] for reviewer 1, p = 0.247; 73.1% [19/26] vs. 76.74% [66/86] for reviewer 2, p = 0.702). No significant differences in the frequencies of arterial hyperenhancement, washout, and capsule were observed between the two groups (96.2% [25/26] vs. 98.8% [85/86], p = 0.412; 80.8% [21/26] vs. 89.5% [77/86], p = 0.308; and 53.8% [14/26] vs. 57% [49/86], p = 0.778, respectively).Conclusions: LI-RADS v2017 using CT showed comparable sensitivity for diagnosing HCC regardless of MSFL.Key Points: • Using LI-RADS v2017 with CT, diagnosis of HCC in patients with MSFL showed similar sensitivity to that in patients without MSFL. • Frequencies of major HCC features (arterial hyperenhancement, washout, and capsule) on CT between the MSFL and non-MSFL groups were not significantly different. • LI-RADS using CT may be feasible for diagnosing HCC in patients with fatty liver. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the correlation between grade of hepatic neuroendocrine tumours (NETs) according to the 2010 World Health Organization (WHO) classification and the apparent diffusion coefficient (ADC) and to assess whether ADC value can predict overall survival (OS) after diagnosis of hepatic NETs.Methods: The study included 63 patients who underwent magnetic resonance (MR) imaging with diffusion-weighted images for the evaluation of hepatic NETs. The correlation between qualitative and quantitative MR imaging findings, including ADC values, and WHO classifications was assessed. The association between ADC value and OS was analyzed.Results: The ADC values and WHO classification of hepatic NETs were moderately negatively correlated in a statistically significant manner (ρ = -0.57, p < 0.001). The OS rates were significantly different according to the ADC value (low ADC vs. high ADC, p = 0.006) as well as WHO classifications (G1+ G2 vs. G3, p = 0.038). However, multivariate analysis revealed that the only independent predictor for OS was a low ADC value (hazard ratio: 3.37, p = 0.010).Conclusion: There was a significant correlation between the ADC value of hepatic NETs and the WHO tumour grade. Additionally, the ADC value of a hepatic NET might be more accurate than the current WHO tumour grade for predicting OS.Key Points: • ADC values of hepatic NET and WHO tumour grade were negatively correlated. • Lower ADC values of hepatic NET were significantly correlated with worse OS. • ADC value might be more accurate than WHO grade for predicting OS. [ABSTRACT FROM AUTHOR]

Objectives: To determine ancillary features that help distinguish between scirrhous hepatocellular carcinoma (S-HCC) and intrahepatic cholangiocarcinoma (ICC) and investigate added value of ancillary features to enhancement pattern-based diagnosis on gadoxetic acid-enhanced MRI.Methods: This retrospective study included 96 patients with S-HCCs and 120 patients with ICCs who underwent gadoxetic acid MRI before surgical resection. Two observers reviewed MRIs of the tumours. After determining ancillary features for differentiating tumour types, we measured the diagnostic performance of adding ancillary features to enhancement pattern-based diagnosis.Results: T2 central darkness, capsule and septum were significant and independent features differentiating S-HCC from ICC (p ≤ .06). Adding ancillary features to enhancement pattern led to increased accuracy (observer 1, 78.9 vs. 93.8 %; observer 2, 80.3 vs. 92.8 %; p < .001), sensitivity (observer 1, 74.5 vs. 96.4 %; observer 2, 77.1 vs. 93.2 %; p < .001 and .001), and specificity (observer 1, 82.5 vs. 91.7 %; observer 2, 82.9 vs. 92.5 %; p = .006 and .005) for diagnosis of S-HCC by differentiation from ICC.Conclusions: Adding ancillary features capsule, septum and T2 central darkness to conventional enhancement patterns on gadoxetic acid-enhanced MRI improved accuracy, sensitivity and specificity for S-HCC diagnosis with differentiation from ICC.Key Points: • Capsule, septum, and T2 central darkness were ancillary features for S-HCC. • A typical HCC enhancement was seen in 31.3% of S-HCCs. • Ancillary MRI features were useful in differentiation between S-HCC and ICC. [ABSTRACT FROM AUTHOR]

Background: Ultrasonography (US) is recommended as a standard surveillance tool for patients with a high risk of developing hepatocellular carcinoma (HCC). However, the low sensitivity of US for small HCC can lead to surveillance failure, resulting in advanced stage tumor presentations. For the early detection of HCC in high-risk patients and to improve survival and prognosis, a new efficient imaging tool with a high sensitivity for HCC detection is needed. The purpose of this study is to evaluate and compare the feasibility and efficacy of non-contrast magnetic resonance imaging (MRI) with US as a surveillance tool for HCC in patients with liver cirrhosis.Methods: MAGNUS-HCC is a prospective, multicenter clinical trial with a crossover design for a single arm of patients. This study was approved by six Institutional Review Boards, and informed consent was obtained from all participants. All patients will undergo liver US every 6 months and non-contrast liver MRI every 12 months during a follow-up period of 3 years. If a focal liver lesion suspected of harboring HCC is detected, dynamic liver computed tomography (CT) will be performed to confirm the diagnosis. After the last surveillance round, patients without suspicion of HCC or who are not diagnosed with HCC will be evaluated with a dynamic liver CT to exclude false-negative findings. The primary endpoint is to compare the rate of detection of HCC by US examinations performed at 6-month intervals with that of yearly non-contrast liver MRI studies during a 3-year follow-up. The secondary endpoint is the survival of the patients who developed HCC within the 3-year follow-up period.Discussion: MAGNUS-HCC is the first study to compare the feasibility of non-contrast MRI with US as a surveillance tool for the detection of HCC in high-risk patients. We anticipate that the evidence presented in this study will establish the efficacy of non-contrast MRI as a surveillance tool for HCC in high-risk patients.Trial Registration: The date of trial registration ( NCT02551250 ) in this study was September 15, 2015, and follow-up is still ongoing. [ABSTRACT FROM AUTHOR]

Background A major drawback of conventional manual image fusion is that the process may be complex, especially for less-experienced operators. Recently, two automatic image fusion techniques called Positioning and Sweeping auto-registration have been developed. Purpose To compare the accuracy and required time for image fusion of real-time ultrasonography (US) and computed tomography (CT) images between Positioning and Sweeping auto-registration. Material and Methods Eighteen consecutive patients referred for planning US for radiofrequency ablation or biopsy for focal hepatic lesions were enrolled. Image fusion using both auto-registration methods was performed for each patient. Registration error, time required for image fusion, and number of point locks used were compared using the Wilcoxon signed rank test. Results Image fusion was successful in all patients. Positioning auto-registration was significantly faster than Sweeping auto-registration for both initial (median, 11 s [range, 3-16 s] vs. 32 s [range, 21-38 s]; P < 0.001] and complete (median, 34.0 s [range, 26-66 s] vs. 47.5 s [range, 32-90]; P = 0.001] image fusion. Registration error of Positioning auto-registration was significantly higher for initial image fusion (median, 38.8 mm [range, 16.0-84.6 mm] vs. 18.2 mm [6.7-73.4 mm]; P = 0.029), but not for complete image fusion (median, 4.75 mm [range, 1.7-9.9 mm] vs. 5.8 mm [range, 2.0-13.0 mm]; P = 0.338]. Number of point locks required to refine the initially fused images was significantly higher with Positioning auto-registration (median, 2 [range, 2-3] vs. 1 [range, 1-2]; P = 0.012]. Conclusion Positioning auto-registration offers faster image fusion between real-time US and pre-procedural CT images than Sweeping auto-registration. The final registration error is similar between the two methods. [ABSTRACT FROM AUTHOR]

Purpose: To assess the association between non-hypervascular hypointense nodules (NHHNs) on gadoxetic acid-enhanced magnetic resonance imaging (MRI) and liver stiffness (LS) in patients with chronic liver disease, and analyzed their progression to overt hepatocellular carcinoma (HCC).Methods: Between August 2012 and March 2016, a total of 714 consecutive patients who had undergone transient elastography for LS measurement and gadoxetic acid-enhanced MRI were investigated. The association between the presence of NHHNs on the hepatobiliary phase and LS, and the patient's HCC status [none, presence of treatment-naïve HCC, or a history of previous HCC treatment] was assessed. In patients with these nodules, cumulative progression rates of nodules to overt HCC were compared with rates of new HCC development in other parts of the liver.Results: The prevalence of NHHNs was 16.8% (120/714). The presence of these nodules was significantly associated with the log LS (Odds ratio [OR], 1.48, p=0.002) and hepatitis B virus infection (OR, 3.14, p=0.017), regardless of the patient's HCC status. The two year cumulative progression rate of overt HCC from corresponding nodules and rate of progression to HCC in other parts of the liver were 34.1% and 18.3%, respectively (p=0.071).Conclusion: The presence of NHHNs on gadoxetic acid-enhanced MRI was associated with higher LS and hepatitis B virus infection. Furthermore, these lesions frequently progressed to overt HCC. [ABSTRACT FROM AUTHOR]

The trapezium is rare site of osteoid osteoma development. The diagnostic challenge lies in its rare occurrence, and requires differentiation from various disease entities causing thumb basal joint pain. We report the case of a 29-year-old male who presented with severe thumb basal joint pain. He was initially treated for calcific periarthritis because of concomitant calcifications around the thumb basal joint, but had undiscovered osteoid osteoma. A high index of suspicion to a patient with wrist pain unresponsive to prior treatment is necessary for diagnosis of osteoid osteoma. [ABSTRACT FROM AUTHOR]

Purpose: To compare computed tomography (CT) findings in patients with pancreatic metastasis from renal cell carcinoma (pRCC) and patients with hypervascular pancreatic neuroendocrine tumour (pNET) with a focus on the relative percentage washout (RPW).Methods: We evaluated 16 patients with 37 pRCCs and 28 patients with 31 hypervascular pNETs using a protocol consisting of arterial and portal phase CT. Imaging findings were analyzed for comparison between the two groups. The RPW of each tumour using biphasic CT was obtained by two observers for evaluation of diagnostic performance. Interobserver agreement of each value and optimal cut-off level of RPW for discrimination between groups were evaluated.Results: Tumour multiplicity showed significant difference in both groups. The mean RPW of the pRCC group (observer 1, 27.0%; observer 2, 29.4%) was significantly higher than that of the pNET group (observer 1, 0.5%; observer 2, 3.2%) (p<0.001 for each observer). Interobserver agreement for both attenuation values and RPWs was excellent. A RPW value of 19% was selected as the optimal cut-off for pRCC determination, and showed good performance (accuracy 83.8%, sensitivity 83.8%, and specificity 83.9%).Conclusion: With multiplicity, RPW of the tumour on CT could be helpful for differentiating pRCCs from hypervascular pNETs. [ABSTRACT FROM AUTHOR]

Background: The role of computed tomography (CT)/magnetic resonance imaging (MRI) surveillance for hepatocellular carcinoma (HCC) is unclear. We aimed to determine whether the intensity of imaging surveillance using CT and MRI is associated with tumor stage at diagnosis or survival in patients with HCC.Methods: This retrospective cohort study included 529 patients with newly diagnosed HCC under regular surveillance (twice a year testing) at a tertiary academic center. All patients were divided into a standard surveillance group (n = 62; ultrasonography [US] with alpha-fetoprotein) and an intensive imaging surveillance group (US and CT/MRI with alpha-fetoprotein); the latter was divided into a low- (n = 232) and high-intensive (n = 235) imaging surveillance group based on the median percentage of CT/MRI investigations (cut-off, 27%). Relationship between surveillance imaging, stage of HCC at diagnosis, and overall survival (OS) were analyzed.Results: The low- and high-intensive imaging surveillance groups (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.20-0.95; p = 0.034 and OR, 0.40; 95% CI, 0.19-0.86; p = 0.014, respectively) had better performances than the standard surveillance group to detect very early-stage HCC. OS was associated with albumin-bilirubin grade (hazard ratio [HR], 1.98; 95% CI, 1.28-3.07; p < 0.001 for grade 2 and HR, 3.03; 95% CI, 1.11-8.30; p = 0.027 for grade 3) and the applicability of curative treatment (HR, 2.34; 95% CI, 1.63-3.36; p < 0.001). However, surveillance intensity did not affect OS (p > 0.05).Conclusions: Imaging surveillance for HCC using alternative CT/MRI in addition to US compared to standard practice of US only facilitates the diagnosis of very early-stage HCC but may not improve OS. [ABSTRACT FROM AUTHOR]

Factors affecting the registration error (RE) and motion of focal hepatic lesions (FHLs) in image fusion of real-time ultrasonography (US) with computed tomography (CT) images were prospectively assessed by focusing on respiratory movement and FHL location. Real-time US and pre-acquired CT images at end-inspiration were fused with FHLs for 103 patients. Three-dimensional US data containing FHLs were obtained during end-inspiratory/expiratory phases. Multivariate analysis revealed that diaphragm motion (p < 0.001), chronic liver disease (p = 0.02) and the absolute difference in distance between the FHL and the central portal vein (CPV) during respiration (p = 0.03) were the independent factors that revealed the maximum effect on RE. In contrast, diaphragm motion (p < 0.001) and distance between the FHL and CPV at inspiration (p = 0.036) revealed the maximum effect on FHL motion. In conclusion, RE and FHL motion are affected by the degree of respiratory movement and the location of the FHL. Therefore, image fusion with CT images should be used with caution if the degree of respiratory motion is significant or if the FHL is located at the periphery of the liver. [ABSTRACT FROM AUTHOR]