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Background & Aims: Accumulating evidence suggests that certain imaging features of hepatocellular carcinoma (HCC) may have prognostic implications. This study aimed to intraindividually compare MRIs with extracellular contrast agent (ECA‐MRI) and hepatobiliary agent (HBA‐MRI) for prognostic imaging features of HCC and to compare the prediction of microvascular invasion (MVI) and early recurrence between the two MRIs. Methods: The present study included 102 prospectively enrolled at‐risk patients (median age, 61.0 years; 83 men) with surgically resected single HCC with both preoperative ECA‐MRI and HBA‐MRI between July 2019 and June 2023. The McNemar test was used to compare each prognostic imaging feature between the two MRIs. Significant imaging features associated with MVI were identified by multivariable logistic regression analysis, and early recurrence rates (<2 years) were compared between the two MRIs. Results: The frequencies of prognostic imaging features were not significantly different between the two MRIs (p =.07 to >.99). Non‐smooth tumour margin (ECA‐MRI, odds ratio [OR] = 5.30; HBA‐MRI, OR = 7.07) and peritumoral arterial phase hyperenhancement (ECA‐MRI, OR = 4.26; HBA‐MRI, OR = 4.43) were independent factors significantly associated with MVI on both MRIs. Two‐trait predictor of venous invasion (presence of internal arteries and absence of hypoattenuating halo) on ECA‐MRI (OR = 11.24) and peritumoral HBP hypointensity on HBA‐MRI (OR = 20.42) were other predictors of MVI. Early recurrence rates of any two or more significant imaging features (49.8% on ECA‐MRI vs 51.3% on HBA‐MRI, p =.75) were not significantly different between the two MRIs. Conclusion: Prognostic imaging features of HCC may be comparable between ECA‐MRI and HBA‐MRI. [ABSTRACT FROM AUTHOR]

Background & Aims: Fatty change is commonly observed in hepatocellular carcinoma (HCC); however, the characteristics of steatotic and steatohepatitic HCCs are not well understood. Methods: This retrospective study included patients with HCCs who underwent resection between January 2014 and December 2019 to evaluate clinicopathological and magnetic resonance imaging features. Tumours were categorized as magnetic resonance imaging‐steatotic, pathology‐steatotic and steatohepatitic HCCs and were defined as HCCs with ≥50% steatosis on in‐and‐oppose phase images, ≥34% tumour cells with lipid droplets and ≥50% tumour areas with steatohepatitic features on light microscopy respectively. Results: Of 465 HCCs, 38 (8%), 23 (5%) and 15 (3%) were diagnosed as magnetic resonance imaging‐steatotic, pathology‐steatotic and steatohepatitic HCCs respectively. These HCC variants were less likely to be associated with hepatitis B virus infections than with type 2 diabetes mellitus, metabolic syndrome, non‐tumour liver steatosis and steatohepatitis. Moreover, microvascular invasion was less likely to be associated with them than either tumour size or differentiation. Type 2 diabetes and non‐tumour steatosis were independent risk factors for magnetic resonance imaging‐steatotic HCCs. Pathology‐steatotic HCCs and steatohepatitic HCCs were significantly associated with magnetic resonance imaging‐steatotic HCCs. A targetoid appearance in the transitional or hepatobiliary phase was also more prevalent in steatohepatitic‐HCCs than in non–steatohepatitic‐HCCs. When magnetic resonance imaging‐steatotic HCCs were combined with one or more ancillary features, the sensitivity and specificity were 60% and 97% respectively. Conclusion: Underlying fatty liver disease and metabolic syndrome are strongly associated with both steatotic and steatohepatitic HCCs. Clinicoradiological characteristics help identify steatohepatitic HCC with high specificity. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the imaging findings of macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) on CT and MRI, and examine their diagnostic performance and prognostic significance. Methods: We retrospectively enrolled 220 consecutive patients who underwent hepatic resection between June 2009 and December 2013 for single treatment–naïve HCC, who have preoperative CT and gadoxetic acid–enhanced MRI. Independent reviews of histopathology and imaging were performed by two reviewers. Previously reported imaging findings, LI-RADS category, and CT attenuation of MTM-HCC were investigated. The diagnostic performance of the MTM-HCC diagnostic criteria was compared across imaging modalities. Results: MTM-HCC was associated with ≥ 50% arterial phase hypovascular component, intratumoral artery, arterial phase peritumoral enhancement, and non-smooth tumor margin on CT and MRI (p <.05). Arterial phase hypovascular components were less commonly observed on MRI subtraction images than on CT or MRI, while non-rim arterial phase hyperenhancement and LR-5 were more commonly observed on MRI subtraction images than on MRI (p <.05). MTM-HCC showed lower tumor attenuation in the CT arterial phase (p =.01). Rhee's criteria, defined as ≥ 50% hypovascular component and ≥ 2 ancillary findings (intratumoral artery, arterial phase peritumoral enhancement, and non-smooth tumor margin), showed similar diagnostic performance for MRI (sensitivity, 41%; specificity, 97%) and CT (sensitivity, 31%; specificity, 94%). Rhee's criteria on CT were independent prognostic factors for overall survival. Conclusion: The MRI diagnostic criteria for MTM-HCC are applicable on CT, showing similar diagnostic performance and prognostic significance. For MTM-HCC, arterial phase subtraction images can aid in the HCC diagnosis by depicting subtle arterial hypervascularity. Key points: • MTM-HCC on CT demonstrated previously described MRI findings, including arterial phase hypovascular component, intratumoral artery, arterial phase peritumoral enhancement, and necrosis. • The MRI diagnostic criteria for MTM-HCC were also applicable to CT, showing comparable diagnostic performance and prognostic significance. • On arterial phase subtraction imaging, MTM-HCC more frequently demonstrated non-rim enhancement and LR-5 and less frequently LR-M than MRI arterial phase, which may aid in the diagnosis of HCC. [ABSTRACT FROM AUTHOR]

Background: According to the Liver Imaging Reporting and Data System (LI-RADS), the LI-RADS category M (LR-M), which are probably or definitely malignant but are not specific for hepatocellular carcinomas (HCCs), does not exclude HCCs. A gap in knowledge remains, including their characteristics and recurrence of HCCs categorized as LR-M.Purpose: To compare the characteristics of HCCs categorized as LR-M with HCCs categorized as LR-4 or LR-5 (LR-4/5) using the LI-RADS version 2018 and evaluate the relationship of these categories with the risk of early recurrence after curative resections of single HCCs.Study Type: Retrospective.Subjects: Two hundred and eighty-one patients (mean age, 57 years; 191 men and 90 women) who underwent curative resections for single HCCs and preoperative contrast-enhanced MRI between 2015 and 2017.Field Strength/sequence: 3T Dual gradient-echo T1 WI with in- and opposed-phase, turbo spin-echo T2 WI, diffusion-weighted echo-planar images, and three-dimensional gradient-echo T1 WI before and after administration of contrast agent.Assessment: MRI features according to the LI-RADS version 2018 were evaluated and LI-RADS category were assigned for each observation. Clinical, imaging, and histopathological features were compared based on LI-RADS categorization. Early recurrence rates (<2 years) and associated factors were also evaluated.Statistical Tests: Fisher's exact test, two-sample t test after satisfying assumption of normality through Shapiro-Wilk test, Fleiss κ coefficient, Cox proportional hazards regression analysis, Kaplan-Meier method, and log-rank test.Results: Forty-one HCCs (14.6%) were categorized as LR-M and 240 HCCs (85.4%) were categorized as LR-4/5. LR-M HCCs showed poorer differentiation than LR-4/5 HCCs. In the multivariate analysis, the LR-M category was an independent predictor for early recurrence (hazard ratio, 1.904; 95% confidence interval, 1.024-3.542; P < 0.05). Early recurrence rates were significantly higher in patients with LR-M HCCs than in patients with LR-4/5 HCCs (32.0% vs. 18.4%, respectively, P < 0 05).Data Conclusion: Compared to LR-4/5 HCCs, LR-M HCCs were associated with poorer tumor differentiation and higher early recurrence rates after curative resections of single HCCs.Level Of Evidence: 3 Technical Efficacy Stage: 2. [ABSTRACT FROM AUTHOR]

Objectives: The current LR-5 criteria of Liver Imaging Reporting and Data System (LI-RADS) determined by only major features provide high specificity, but unsatisfactorily low sensitivity for the noninvasive diagnosis of hepatocellular carcinoma (HCC). This study aimed to identify significant ancillary features (AFs) in LI-RADS version 2018 and develop the upgraded LR-5 criteria to improve diagnostic performance on gadoxetic acid–enhanced magnetic resonance imaging (MRI). Methods: This retrospective study included 280 patients (366 observations including 281 HCCs) at high-risk for HCC who underwent gadoxetic acid–enhanced MRI between 2015 and 2017. Two readers evaluated major features and AFs for each observation and assigned a LI-RADS category. Independently significant AFs were identified through logistic regression analysis. Upgraded LR-5 criteria were developed by combining independently significant AFs with LR-4 assigned by major features alone. Sensitivities and specificities of the diagnostic criteria were compared using McNemar's test. Results: Two of the AFs favoring malignancy in general (mild-moderate T2 hyperintensity and hepatobiliary phase hypointensity) and two of the AFs favoring HCC in particular (nonenhancing "capsule" and mosaic architecture) were independently significant features for diagnosing HCC. By using the upgraded LR-5 criteria (LR-4 by major features alone + each aforementioned AF), sensitivities were significantly increased (69.4–76.9%) compared with the standard LR-5 (66.2%; all, p ≤ 0.004), whereas specificities (95.3–96.5%) were not significantly different (96.5%; all, p > 0.999). Conclusions: Independently significant AFs may be used to upgrade from LR-4 to LR-5 to improve sensitivity without impairing specificity on gadoxetic acid–enhanced MRI. Key Points: • Independently significant AFs for HCC on gadoxetic acid–enhanced MRI were mild-moderate T2 hyperintensity, hepatobiliary phase hypointensity, nonenhancing "capsule," and mosaic architecture. • When LR-4 criteria by major features alone in combination with significant AFs were upgraded to LR-5, sensitivities were higher than the standard LR-5, without impairing specificity. • Independently significant ancillary features in Liver Imaging Reporting and Data System version 2018 may be used to upgrade from LR-4 to LR-5 to improve sensitivity without impairing specificity on gadoxetic acid–enhanced MRI. [ABSTRACT FROM AUTHOR]

The Liver Imaging Reporting and Data System (LI-RADS) is widely adopted for the noninvasive diagnosis of hepatocellular carcinoma (HCC). Herein, possible strategies to improve the diagnostic performance of LR-5 without reducing specificity for HCC were investigated. This retrospective study included 792 patients who underwent gadoxetate disodium-enhanced magnetic resonance imaging. Hepatic observations were categorized according to LI-RADS v2018 and categories were readjusted by upgrading LR4 to LR5 using ancillary features, arterial phase hyperenhancement (APHE) interpreted with subtraction images, indication of no washout when APHE was absent, extension of washout to the transitional phase, and subthreshold growth as a major feature. Based on LI-RADS v2018, LR-5 showed a sensitivity of 71.9% and a specificity of 97.9% for the diagnosis of HCC. Category-readjusted LR-5 after upgrading LR-4 to LR-5 using ancillary features favoring HCC in particular, subthreshold growth as a major feature, extending washout to transitional phase and APHE interpreted using subtraction images showed significantly increased sensitivity (P<0.001) without decreased specificity (Ps>0.05). The sensitivity of LR-5 can be improved without loss of specificity via category readjustment using AFs favoring HCC in particular, subthreshold growth as a major feature, extending washout to transitional phase and APHE interpreted with subtraction images. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the diagnostic performance of the Liver Imaging Reporting and Data System (LI-RADS) in patients with both chronic liver disease and a history of extrahepatic malignancy. Materials and methods: This retrospective study included 59 hepatocellular carcinomas (HCCs) and 45 metastases pathologically confirmed between 2008 and 2017 in 104 patients with chronic liver disease (cirrhosis or chronic hepatitis B) and a history of extrahepatic malignancy. Two radiologists blinded to the final diagnosis independently reviewed MRI (95 patients) or CT (9 patients) images, and their consensus data were used to calculate the diagnostic performance of LI-RADS categories. Serum tumor markers, tumor multiplicity, and suspected metastatic lymph nodes were also evaluated. Results: The sensitivity, specificity, and accuracy of LR-5 for diagnosing HCC were 69% (95% confidence intervals [CI] 56–81), 98% (95% CI 88–99), and 82% (95% CI 73–89), respectively, and those of LR-M for diagnosing metastasis were 89% (95% CI 76–96), 88% (95% CI 77–95), and 88% (95% CI 81–94), respectively. Elevation of serum carcinoembryonic antigen (P = 0.01) or carbohydrate antigen 19–9 levels (P = 0.02) and tumor multiplicity (P = 0.004) were more frequently observed in metastasis than in HCC. Three of four metastases categorized as LR-4 or LR-5 were smaller than 2 cm. Conclusions: The LI-RADS provides high specificity (98%) for differentiating HCC from metastases in patients with both chronic liver disease and a history of extrahepatic malignancy. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the diagnostic performance of LR-M criteria for differentiating hepatocellular carcinoma, intrahepatic mass-forming cholangiocarcinoma, and combined hepatocellular-cholangiocarcinoma and to compare the imaging features of each type. Methods: In this retrospective study, 110 patients were surgically diagnosed with cholangiocarcinoma (n = 67) and combined hepatocellular-cholangiocarcinoma (n = 43) at a single tertiary hospital between 2013 and 2018. Among them, those with risk factors were enrolled (16 cholangiocarcinomas and 33 combined hepatocellular-cholangiocarcinomas). Forty-nine other patients with size-matched hepatocellular carcinoma were selected as a control group. Two independent readers evaluated the imaging findings of the preoperative MRIs based on LI-RADS version 2018 and assigned an LI-RADS category. The diagnostic performance of the LR-M criteria for diagnosing cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma was evaluated, and the imaging features were compared. The imaging findings of the tumors in patients without risk factors (51 cholangiocarcinomas and 10 combined hepatocellular-cholangiocarcinomas) were evaluated for subgroup analysis. Results: In the non-hepatocellular carcinoma group, 33 patients were categorized into LR-M and 14 patients into LR-5 (67.3% and 28.6%, respectively), while 5 patients with hepatocellular carcinoma were categorized into LR-M and 38 patients into LR-5 (10.2% and 77.6%, respectively). Sensitivity and specificity of the LR-M criteria were 67.3% and 89.8%, respectively. When more than two LR-M features were present, cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma were suggested with a specificity of 95.9%. Conclusion: The diagnostic performance of the LR-M criteria is acceptable with moderate sensitivity and high specificity for both cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma. Imaging findings of primary hepatic carcinomas should be understood as a spectrum. [ABSTRACT FROM AUTHOR]

Background & Aims: The liver Imaging Reporting and Data System (LI‐RADS) is a comprehensive system for standardizing liver imaging in patients at high risk for hepatocellular carcinoma (HCC). We performed a meta‐analysis to determine the diagnostic performance of the LR‐5 category for HCC and the pooled proportions of HCCs in each LI‐RADS category using CT/MRI LI‐RADS v2017. Methods: We searched multiple databases for original studies reporting on the diagnostic accuracy of CT/MRI LI‐RADS v2017. Random‐effects models were used to determine the summary estimates of the diagnostic performance of the LR‐5 category and the pooled proportions of HCCs for each LI‐RADS category. Risk of bias and concerns regarding applicability were evaluated with the Quality Assessment of Diagnostic Accuracy Studies‐2 tool. Results: Fourteen studies (3 prospective studies and 11 retrospective studies) were included in the final analysis, consisting of 2056 patients, 2589 observations, and 1693 HCCs. The pooled per‐observation sensitivity was 67% (95% confidence interval [CI], 62%‐72%) with specificity of 92% (95% CI, 88%‐95%) in the LR‐5 category of CT/MRI LI‐RADS v2017 for diagnosing HCC. The pooled proportions of HCCs were 0% (95% CI, 0%‐0%) for LR‐1, 4% (95% CI, 0%‐8%) for LR‐2, 34% (95% CI, 23%‐44%) for LR‐3, 67% (95% CI, 53%‐81%) for LR‐4, and 92% (95% CI, 87%‐96%) for LR‐5. The proportions of HCCs were significantly different among LI‐RADS categories 1‐5 (P =.034). Conclusions: The LR‐5 category of CT/MRI LI‐RADS v2017 shows moderate sensitivity and high specificity for diagnosing HCC. Higher LI‐RADS categories contained higher proportions of HCCs. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the value of preoperative gadoxetic acid-enhanced MRI for tumor staging and recurrence prediction of hepatocellular carcinoma (HCC) after primary liver transplantation (LT).Methods: This multicenter retrospective study included 122 recipients who underwent living donor LT (LDLT) for untreated HCC and pre-transplant gadoxetic acid-enhanced MRI from January 2009 to December 2013. Disease-free survival (DFS) was evaluated. Milan criteria, tumor grade, and microvascular invasion (MVI) were analyzed on the pathological examination of the explanted liver.Results: The 1-, 3-, 5-, and 7-year DFS rates were 93.3%, 90.7%, 88.9%, and 86.1%, respectively. In the multivariable analysis, independent predictors of HCC recurrence were "beyond the Milan criteria" (hazard ratio [HR], 3.54; 95% confidence interval [CI], 1.13-11.12; p = 0.030) and peritumoral hypointensity on hepatobiliary phase (HBP) (HR, 18.30; 95% CI, 4.33-77.34; p < 0.001). Pre-transplant MRI yielded a 90.2% accuracy to categorize the Milan criteria when compared with the explanted liver. Peritumoral hypointensity on HBP was significantly associated with a worse tumor grade (p = 0.010) and MVI (p < 0.001). The 5-year DFS rate in patients with "beyond the Milan criteria" but the absence of peritumoral hypointensity on HBP was not different from that in patients "within the Milan criteria" (92.2% vs. 92.9%, p = 0.438).Conclusions: Pre-transplant gadoxetic acid-enhanced MRI may assist in the HCC recurrence risk prediction.Key Points: • Lesions beyond the Milan criteria and peritumoral hypointensity on hepatobiliary phase (HBP) were independent predictors of HCC recurrence. • Peritumoral hypointensity on HBP significantly associated with a worse tumor grade and microvascular invasion. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) is a unique malignancy that can be diagnosed and treated based on non-invasive imaging criteria without histological confirmation in cirrhotic patients, which opens the possibility, although rare, of false-positive diagnosis of the tumor. This brief review illustrates benign and non-HCC malignant lesions arising in cirrhotic liver that could have been erroneously diagnosed as HCC based on imaging criteria: focal nodular hyperplasia-like nodules, serum amyloid A-positive nodules, dysplastic nodules, spontaneously regressing lesions, combined hepatocellular-cholangiocarcinoma, cholangiocarcinoma, sarcomatoid carcinoma, lymphoepithelioma-like carcinoma, hepatoblastoma, and metastatic adenocarcinoma. To determine the potential differences in clinical courses and post-treatment outcome of HCC diagnosed by imaging alone and those histologically, we suggest the terms HCCi and HCCp to distinguish between lesions that are diagnosed as HCC based on imaging alone from those diagnosed based on pathological examination, respectively.Key Points • Benign lesions, such as focal nodular hyperplasia-like nodules, serum amyloid A-positive nodules, dysplastic nodules, and spontaneously regressing lesions, may show imaging findings that mislead to the diagnosis of HCC. • Non-hepatocellular malignant lesions, such as sarcomatoid carcinoma, lymphoepithelioma-like carcinoma, hepatoblastoma, and metastatic adenocarcinomas, can be erroneously diagnosed as HCC based on imaging findings alone, even in cirrhotic liver. [ABSTRACT FROM AUTHOR]

The 2017 Core of the computed tomography (CT)/magnetic resonance imaging (MRI) Liver Imaging Reporting and Data System (LI-RADS) provides clear definitions and concise explanations of the CT/MRI diagnostic algorithm. Nevertheless, there remain some practical and controversial issues that radiologists should be aware of when using the system. This article discusses pitfalls and problems which may be encountered when the version 2017 diagnostic algorithm is used for CT and MRI. The pitfalls include challenges in applying major features and assigning the LR-M category, as well as categorisation discrepancy between CT and MRI. The problems include imprecision of category codes, application of ancillary features, and regional practice variations in hepatocellular carcinoma (HCC) diagnosis. Potential solutions are presented along with these pitfalls and problems. KEY POINTS: • Although the diagnostic algorithm provides clear and detailed explanations, major feature evaluation can be subject to pitfalls and differentiation of HCC and non-HCC malignancy remains challenging. • Ancillary features are optional and equally weighted. However, features such as hepatobiliary phase hypointensity and restricted diffusion have greater impact on HCC diagnosis than other ancillary features and may merit greater emphasis or weighting. • LI-RADS was initially developed from a Western paradigm, which may limit its applicability in the East due to regional practice variations. In Eastern Asia, high sensitivity is prioritised over near-perfect specificity for HCC diagnosis in order to detect tumours at early stages. [ABSTRACT FROM AUTHOR]

• Differentiating hepatic AML from HCC is clinically important. • We developed and AML-HCC score based on sex and imaging findings of AML and HCC. • Our AML-HCC score showed good performance in differentiating AML from HCC. To develop a practical method for differentiating hepatocellular carcinoma (HCC) from angiomyolipoma (AML) in individuals who are not at-risk for HCC. We retrospectively enrolled consecutive patients who underwent gadoxetic acid-enhanced liver magnetic resonance imaging (MRI) and pathological confirmation between January 2008 and April 2022. Patients who underwent prior treatment, those with multiple lesions, or those at-risk for HCC were excluded. The training cohort included patients with pathological confirmation between 2008 and 2019, whereas the validation cohort included the remaining cases. Independent reviews of the MRI were performed by two reviewers. Using the clinical and MRI findings, we developed AML-HCC score using Firth's logistic regression in the training cohort, and the diagnostic performance was validated in the validation cohort. Of the 206 patients, 156 were assigned to the training cohort (25 and 131 patients with AML and HCC, respectively) and 50 were assigned to the validation cohort (4 and 46 patients with AML and HCC, respectively). The AML-HCC score was defined as the sum of female (score 1), early draining vein (score 2), T2 homogeneity (score 1), necrosis or severe ischaemia (score −2), and HBP hyperintensity to spleen (score −1). When the AML-HCC score was ≥1, the sensitivity and specificity were 80% and 95% for the training cohort and 100% and 80% for the validation cohort, respectively. We developed and validated an AML-HCC score to differentiate between AML and HCC in individuals who are not at-risk for HCC, and our model demonstrated good diagnostic performance. [ABSTRACT FROM AUTHOR]

Background Data comparing EASL and mRECIST criteria for response evaluation in treatment of hepatocellular carcinoma are rare. We evaluated inter-observer variability by these two response evaluation criteria in treatment-naïve patients undergoing chemoembolization. Methods For 133 patients undergoing chemoembolization, two radiologists independently measured sum of bi-dimensional and uni-dimensional diameters at baseline using both EASL criteria and mRECIST, and their changes on first follow-up for up to 5 target lesions. Results Concordance correlation coefficients for sum of bi-dimensional and uni-dimensional diameters at baseline between two observers were 0.992 and 0.988, respectively. However, those for their changes on follow-up were 0.865 and 0.877, respectively. Similarly, mean differences in sum of bi-dimensional and uni-dimensional diameters at baseline between two observers were small; −0.455 and 0.079 cm, respectively. However, mean differences in changes (%) in sum of bi-dimensional and uni-dimensional diameters on first follow-up between observers increased by −9.715% and −9.320%, respectively. Regarding tumour numbers, kappa-value between observers was 0.942. For treatment response (complete or partial response, stable disease and progression), kappa-value was 0.941 by both criteria. When only up to two target lesions were assessed, kappa-value was 1.000 by both criteria. Conclusions Inter-observer agreements using both response evaluation criteria were excellent, especially when up to two targets were assessed. [ABSTRACT FROM AUTHOR]

Background & Aims Computed tomography ( CT) and magnetic resonance imaging ( MRI) play important roles in diagnosis and staging of hepatocellular carcinoma ( HCC). However, prognostic roles of radiological characteristics are not yet determined. Methods Eighty-eight patients treated with chemoembolization were analysed. Radiological parameters at baseline were assessed in all patients using both dynamic CT and MRI. Treatment responses were assessed using modified RECIST 4 weeks after the first chemoembolization. Results Gross vascular invasion ( GVI), bile duct invasion, irregular tumour margin ( ITM), peripheral ragged enhancement ( PRE) and satellite nodules on CT or MRI were associated with non-response (stable disease or progression) after chemoembolization respectively (all P ≤ 0.05). GVI, ITM and PRE on CT or MRI were also independently associated with poor overall survival ( OS) respectively (all P ≤ 0.05). Using these results, a prognostic scoring system for CT and MRI were developed; 0, absence of all three features ( GVI, ITM and PRE); 1, presence of one feature; 2, presence of two features; and 3, presence of three features. After adjusting tumour size, tumour number and alpha-foetoprotein level, both CT and MRI scores were independently associated with OS (both P < 0.001). Patients with CT or MRI score ≥2 had a worse OS than those with score <2 (adjusted hazard ratios, 3.837 and 2.938 respectively). MRI-specific parameters such as signal intensity on T2- or T1-weighted images, fat signal or hyperintensity on diffusion-weighted images did not have prognostic value (all P > 0.05). Conclusions Radiological parameters by CT and MRI may be useful in biological characterization of tumours and prognostification for HCC treated with chemoembolization. [ABSTRACT FROM AUTHOR]

The original version of this article, published on 15 August 2019, unfortunately contained a mistake. [ABSTRACT FROM AUTHOR]

Purpose To assess whether MR perfusion and diffusion parameters taken before concurrent chemoradiotherapy (CCRT) are useful imaging biomarkers for predicting progression-free survival (PFS) in patients with hepatocellular carcinoma (HCC). Materials and Methods Twenty patients with locally advanced HCC who had no treatment before CCRT underwent dynamic contrast-enhanced (DCE) and diffusion-weighted MRI. Mean values of the volume transfer constant (Ktrans), reflex constant (Kep), extravascular extracellular volume fraction (Ve) and the apparent diffusion coefficient (ADC) were estimated on a region of interest. The best cutoff value for each factor was assessed to differentiate between patients who had PFS shorter or longer than the median PFS. Patients were dichotomized in terms of the cutoff value. The survival outcome of the two groups and the predictive ability of each factor on PFS were evaluated. Results Median time to PFS was 179 days. The best cutoff values for ADC, Ktrans, Kep, and Ve was 1.008 × 10−3 mm2 s−1, 0.108 min−1, 0.570 min−1, and 0.298%. Patients with higher ADC had significantly longer PFS than those with lower ADC( P < 0.0001). Conclusion The ADC of HCC acquired before CCRT correlated with PFS and was valuable in the prediction of the clinical outcome of HCC treated with CCRT. J. Magn. Reson. Imaging 2014;39:286-292. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objectives: Glucose metabolism, perfusion, and water diffusion may have a relationship or affect each other in the same tumor. The understanding of their relationship could expand the knowledge of tumor characteristics and contribute to the field of oncologic imaging. The purpose of this study was to evaluate the relationships between metabolism, vasculature and cellularity of advanced hepatocellular carcinoma (HCC), using multimodality imaging such as 18F-FDG positron emission tomography (PET), dynamic contrast enhanced (DCE)-MRI, and diffusion weighted imaging(DWI). Materials and Methods: Twenty-one patients with advanced HCC underwent 18F-FDG PET, DCE-MRI, and DWI before treatment. Maximum standard uptake values (SUVmax) from 18F-FDG-PET, variables of the volume transfer constant (Ktrans) from DCE-MRI and apparent diffusion coefficient (ADC) from DWI were obtained for the tumor and their relationships were examined by Spearman’s correlation analysis. The influence of portal vein thrombosis on SUVmax and variables of Ktrans and ADC was evaluated by Mann-Whitney test. Results: SUVmax showed significant negative correlation with Ktransmax (ρ = −0.622, p = 0.002). However, variables of ADC showed no relationship with variables of Ktrans or SUVmax (p>0.05). Whether portal vein thrombosis was present or not did not influence the SUV max and variables of ADC and Ktrans (p>0.05). Conclusion: In this study, SUV was shown to be correlated with Ktrans in advanced HCCs; the higher the glucose metabolism a tumor had, the lower the perfusion it had, which might help in guiding target therapy. [ABSTRACT FROM AUTHOR]

Purpose: To define the histological characteristics of hepatocellular carcinomas (HCCs) showing atypical dynamic enhancement patterns on gadoxetic acid-enhanced dynamic magnetic resonance imaging (EOB-MRI). Materials and Methods: We evaluated a total of 130 small (≤3 cm) HCCs from 114 patients that were surgically removed after EOB-MRI. Two radiologists blinded to the histological findings retrospectively classified the HCCs into typical or atypical lesions. Gross morphology, nuclear histological grade, presence of vascular invasion, and capsule formation and infiltration were compared between the two groups using Chi-square or Fisher tests. Results: Atypical dynamic enhancement patterns were seen in 23 HCCs (17.7%). None of the atypical HCC showed vascular invasion ( P < 0.001). Atypical HCCs also showed more frequently smaller size (1.6 ± 0.6 cm versus 2.1 ± 0.6 cm, P = 0.001) with 86.9% (n = 20) of which 2 cm or less in diameter ( P = 0.001), vaguely nodular appearance (56.5% vs 3.7%, P < 0.001), and nuclear grade I (69.6% versus 6.5%, P < 0.001), while less frequently showed capsule formation (26.1% versus 77.6%, P < 0.001) or capsular infiltration (16.7% versus 77.1%, P = 0.005). Conclusion: Atypical HCCs on EOB-MRI may be characterized by the absence of vascular invasion, smaller (< 2 cm or less) size, vaguely nodular appearance, and well differentiation, and infrequent capsule formation or capsular infiltration. J. Magn. Reson. Imaging 2013;37:1384-1391. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To retrospectively determine whether the hyperintense hepatocellular carcinomas (HCCs) seen on the hepatobiliary phase of gadoxetic acid-enhanced MR imaging (EOB-MRI) might have different histologic characteristics from usual hypointense HCCs. Materials and methods: Two hundred three surgically proven HCCs from 192 patients who underwent preoperative EOB-MRI were analyzed. The demographic and histologic characteristics of hyperintense HCCs were compared with usual hypointense HCCs by using the t-test or Fisher''s exact test. Results: By visual assessment, 18 (8.8%) tumors were classified as hyperintense HCCs. Patients with hyperintense HCC were significantly (p <0.05) older (60.1 vs. 55.2 years) than those with hypointense HCCs. Hyperintense HCCs showed significantly lower rate of microvascular invasion (27.8% vs. 53.5%) and significantly higher rate of peliosis (61.1% vs. 30.8%). Hyperintense HCCs were more frequently expanding type, and none showed infiltrative type or scirrhous histologic pattern. Conclusions: Hyperintense HCCs seem to have clinical and histologic features that might be related with more favorable outcomes. [Copyright &y& Elsevier]

Abstract: Objectives: Detection of hepatocellular carcinomas (HCCs) before microvascular invasion (MVI) occurs is important due to the poor outcomes associated with MVI. We retrospectively investigated the imaging features of small HCCs with MVI on gadoxetic acid-enhanced MR imaging. Methods: Fifty patients (40 men and 10 women; mean age, 54 years) with 58 surgically proven small (2cm or less) HCCs were evaluated by gadoxetic acid-enhanced MRI. Signal intensities on imaging sequences and the presence of the typical dynamic enhancement pattern (arterial enhancement and washout) were assessed. Fisher''s exact tests were performed to evaluate the relationships between the presence of MVI, tumor size, and imaging findings. Results: None of the 12 small HCCs with diameters of 1cm or less had MVI, while 15 (33%) of the 46 small HCCs with diameters of 1.1–2.0cm had MVI (p =0.025, Fisher''s exact test). Among the small HCCs with diameters of 1.1–2.0cm, all HCCs with MVI showed the typical dynamic pattern and hyperintensity on T2- and diffusion-weighted images. Most HCCs (54 lesions, 93%) were hypointense on hepatobiliary phase images regardless of the presence of MVI. Conclusions: All small HCCs with MVI showed typical dynamic pattern and hyperintensity on T2-weighted and diffusion-weighted images, while atypical dynamic pattern and size of less than 1cm in diameter may suggest absence of MVI. [Copyright &y& Elsevier]

Aim: To compare clinical and radiological findings of newly diagnosed hepatocellular carcinomas (HCCs) in patients with chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infections. Materials and Methods: Dynamic contrast-enhanced CT images in 532 patients with newly diagnosed HCC were retrospectively reviewed. Of these patients, 418 had chronic HBV infections and 114 had chronic HCV infections. The number, size, shape (nodular vs. non-nodular) and enhancement pattern (typical vs. atypical) of hepatic lesions were assessed. The presence of portal vein thrombosis and bile duct invasion were determined. Results: The mean age of the HBV group (54.31 [range 27-85], median 54) was younger than that of the HCV group (64.21 [range 30-86], median 64) ( P < 0.001). Lesions in patients with HBV were more likely to be multifocal (>5; P < 0.001); larger than 5 cm ( P = 0.023); non-nodular shape ( P < 0.001); atypical enhancement pattern ( P = 0.047), association with portal vein thrombosis ( P = 0.004); association with bile duct invasion ( P < 0.001). Conclusions: Clinical and radiological findings of HCC differ between patients with HBV and HCV infections. [ABSTRACT FROM AUTHOR]

Abstract: Background: To evaluate hepatocellular carcinoma (HCC) that developed in patients with no evidence of a tumor during a prior ultrasound (US) performed within 1 year of the diagnosis. Methods: We retrospectively analyzed data for 100 consecutive patients with liver cirrhosis who had undergone US within 1 year prior to HCC diagnosis and who showed no liver lesions on the previous US. Size and T stage of HCC were assessed as well as whether patients met surgical criteria for liver transplantation as HCC treatment [Milan or University of California at San Francisco (UCSF) criteria]. Results: The mean interval between the negative and diagnostic scans was 5 months, 13 days. HCC presented as a single nodule in 69 patients (size, 0.8–8.0cm), as two or more nodules in 18 patients, and as the diffuse form of HCC in 13 patients. HCC presented as a small tumor (<3cm) in 48 patients. T stages were: T1 in 26 patients, T2 in 45, T3 in 18, and T4 in 11. The Milan criteria were met in 79 patients. Eighty-five patients fulfilled the UCSF. Conclusion: Patients may present with advanced HCC, even if sonographic findings were negative within 1 year prior to diagnosis. [Copyright &y& Elsevier]

Detection, characterization, staging, and treatment monitoring are major roles in imaging diagnosis in liver cancers. Contrast-enhanced ultrasonography (CEUS) using microbubble contrast agents has expanded the role of US in the detection and diagnosis of liver nodules in patients at high risk of hepatocellular carcinoma (HCC). CEUS provides an accurate differentiation between benign and malignant liver nodules, which is critical for adequate management of HCC and is also useful for guidance of percutaneous local therapy of HCC and postprocedure monitoring of the therapeutic response. The technology of multidetector-row computed tomography (MDCT) has increased spatial and temporal resolutions of computed tomography (CT). It has made possible a more precise evaluation of the hemodynamics of liver tumor, and the diagnostic accuracy of dynamic MDCT has improved. Perfusion CT can measure tissue perfusion parameters quantitatively and can assess segmental hepatic function. Dynamic MDCT with high spatial and temporal resolution enables us to reconstruct 3- and 4-dimensional imaging, which is very useful for pretreatment evaluation. Dual-energy CT makes possible the differentiation of materials and tissues in images obtained based on the differences in iodine and water densities. Monochromatic images, which can be reconstructed by dual-energy CT data, provide some improvement in contrast and show a higher contrast-to-noise ratio for hypervascular HCCs. Dynamic magnetic resonance imaging with fast imaging sequence of 3-dimensional Fourier transformation T1-weighted gradient echo and nonspecific contrast medium can show high detection sensitivity of hypervascular HCC. However, the hepatic tissue-specific contrast medium, gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid, has become an essential contrast medium for liver imaging because of its higher diagnostic ability. It may replace CT during hepatic arteriography and during arterioportography. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Despite the clinical and genetic significance of macrotrabecular-massive hepatocellular carcinoma (MTM-HCC), its characteristics on imaging have not been described. This study aimed to characterise MTM-HCC on gadoxetic acid-enhanced MRI and to evaluate the diagnostic accuracy and prognostic value of these imaging characteristics. We enrolled 3 independent cohorts from 2 tertiary care centres. The 3 cohorts consisted of a total of 476 patients who underwent gadoxetic acid-enhanced MRI and surgical resection for treatment-naïve single HCCs. Independent review of histopathology and MRI by 2 reviewers was performed for each cohort, and inter-reader agreement was evaluated. Based on the result of MRI review in the training cohort (cohort 1), we developed 2 diagnostic criteria for MTM-HCC and evaluated their prognostic significance. The diagnostic performance and prognostic significance were validated in 2 validation cohorts (cohorts 2 and 3). We developed 2 diagnostic MRI criteria (MRIC) for MTM-HCC: MRIC-1, ≥20% arterial phase hypovascular component; MRIC-2, ≥50% hypovascular component and 2 or more ancillary findings (intratumoural artery, arterial phase peritumoural enhancement, and non-smooth tumour margin). MRIC-1 showed high sensitivity and negative predictive value (88% and 95% in the training cohort, and 88% and 97% in the pooled validation cohorts, respectively), whereas MRIC-2 demonstrated moderate sensitivity and high specificity (47% and 94% in the training cohort, and 46% and 96% in the pooled validation cohorts, respectively). MRIC-2 was an independent poor prognostic factor for overall survival in both training and pooled validation cohorts. Using gadoxetic acid-enhanced MRI findings, including an arterial phase hypovascular component, we could stratify the probability of MTM-HCC and non-invasively obtain prognostic information. Macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) is a histopathologic subtype of HCC characterised by aggressive biological behaviour and poor prognosis. We developed imaging criteria based on liver MRI that could be used for the non-invasive diagnosis of MTM-HCC. HCCs showing imaging findings of MTM-HCC were associated with poor outcomes after hepatic resection. • Macrotrabecular-massive hepatocellular carcinoma (MTM-HCC) is an aggressive subtype of HCC. • We revealed gadoxetic acid-enhanced MRI findings related to MTM-HCC. • Using MRI findings, we could non-invasively stratify the probability of MTM-HCC. • HCC without an arterial phase hypovascular component is highly unlikely to be MTM-HCC. • MRI findings of MTM-HCC could be a useful prognostic factor after surgical resection. [ABSTRACT FROM AUTHOR]

Backgrounds & Aims The aim of this study is to evaluate the prognostic significances of not only the initial and the best response during repeated transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), but if eligible, also the time point of achieving treatment responses. Methods Three hundred and fourteen treatment-naïve patients with well-preserved liver function undergoing TACE were recruited. Treatment responses were assessed using modified Response Evaluation Criteria in Solid Tumors. Overall survival (OS) was analyzed using Kaplan–Meier methods, and Cox regression analysis was performed for multivariate analysis. Results After adjusting other variables, objective response (complete response [CR] and partial response [PR]) as the initial response (adjusted hazard ratio [HR] 0.410) and the best response (adjusted HR 0.335) had independent prognostic significances for OS, respectively (both p <0.001). Objective responders as the initial response had the longest OS, followed by patients who subsequently achieved objective response after at least two sessions and those who did not achieve objective response during treatment course eventually (52.6, 27.0, and 10.8 months, respectively; log-rank test, p <0.001). Likewise, patients with CR as the initial response had the longest OS, followed by those who subsequently achieved CR after at least two sessions and those who achieved PR as the best response (70.2, 40.6, and 23.0 months, respectively; log-rank test, p <0.001). Large (>5 cm) and multiple (⩾4) tumors were independently associated with failure to achieve CR after the initial TACE (both p <0.05). Conclusion Both the initial and the best response predicts OS effectively. However, achievement of treatment response at an early time point is still the most robust predictor for favorable outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Backgrounds: European Association for the Study of the Liver (EASL) and modified Response Evaluation Criteria in Solid Tumours (mRECIST) guidelines, which measure changes in arterialised hepatocellular carcinoma (HCC), differ in terms of number of target lesions (all versus ⩽2) and calculation method (bidimensional versus unidimensional). We compared prognostic values of mRECIST for predicting overall survival (OS) with reference to EASL criteria in treatment-naïve HCC undergoing trans-arterial chemoembolisation (TACE). Methods: The ability to predict OS during longitudinal follow-up was expressed as C-index, and a sample size of 292 patients was required to validate its equivalence between each criteria. Treatment responses were assessed using both guidelines 4weeks after the first TACE, using dynamic computed tomography or magnetic resonance imaging. Kaplan–Meier and Cox regression analyses were used to explore differences in OS between responders (complete or partial) and non-responders (stable or progressive disease), defined by each method. Results: C-index for EASL and mRECIST guidelines was 0.753 and 0.759, respectively, demonstrating equivalence between two methods. Differences in median OS between responders and non-responders were statistically significant for both EASL (30.1 versus 18.7months, p <0.001) and mRECIST (33.8 versus 17.1months, p <0.001) guidelines. In addition to radiological response, α-fetoprotein (p <0.001), tumour number (p <0.001) and tumour size (p =0.048) were significant predictors of OS. In multivariate analysis, radiological criteria, tumour number and α-fetoprotein were identified as independent predictors (all p <0.05). Conclusion: mRECIST, a simpler method, provided prognostic values for predicting OS equivalent to EASL criteria in patients with HCC undergoing TACE as an initial treatment modality. [Copyright &y& Elsevier]

Abstract: Liver fibrosis determines the functional liver reserve. Several studies have reported that the apparent diffusion coefficient (ADC) values of diffusion-weighted magnetic resonance imaging (DW-MRI) can assess liver fibrosis. We investigated whether DW-MRI predicts postoperative hepatic insufficiency and liver fibrosis in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). Twenty-six patients with HBV-related HCC who received preoperative DW-MRI on a 3-T MRI system were enrolled between July and December 2008. ADC values were measured twice by two observers. Three “b values” were used: 50, 400 and 800 s/mm2. Postoperative hepatic insufficiency was defined as persistent hyperbilirubinemia (total bilirubin level >5 mg/dl for more than 5 days after surgery) or postoperative death without other causes. The mean age (21 men and 5 women) was 51.4 years. Three patients experienced postoperative hepatic insufficiency. liver stiffness measurement predicted postoperative hepatic insufficiency, advanced fibrosis (F3–4), and cirrhosis significantly [area under the receiving operator characteristic curve (AUROC)=0.942, 0.771 and 0.818, respectively, with P=.047, 0.048 and 0.006, respectively]; ADC values of DW-MRI, however, did not (AUROC=0.797, 0.648 and 0.491, respectively, with P=.100, 0.313 and 0.938, respectively). Reliability of ADC values between right and left hepatic lobes (ρ=0.868 and ρ=0.910 in the first and second measures of Observer A; ρ=0.865 and ρ=0.831 in the first and second measures of Observer B) was high and the intra- and interobserver reliability (ρ=0.958 in observer A and ρ=0.977 in observer B; ρ=0.929 in the first measure and ρ=0.978 in the second measure between the two observers) were high. All reliability was significant (P<.001). Our results suggest that DW-MRI on a 3-T MRI system is not suitable for predicting postoperative hepatic insufficiency, advanced liver fibrosis, and cirrhosis in patients with HBV-related HCC, despite significantly high reliability. [Copyright &y& Elsevier]