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

Primary liver cancer is the fourth leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) comprising the vast majority of primary liver malignancies. Imaging plays a central role in HCC diagnosis and management. As a result, the content and structure of radiology reports are of utmost importance in guiding clinical management. The Liver Imaging Reporting and Data System (LI-RADS) provides guidance for standardized reporting of liver observations in patients who are at risk for HCC. LI-RADS standardized reporting intends to inform patient treatment and facilitate multidisciplinary communication and decisions, taking into consideration individual clinical factors. Depending on the context, observations may be reported individually, in aggregate, or as a combination of both. LI-RADS provides two templates for reporting liver observations: in a single continuous paragraph or in a structured format with keywords and imaging findings. The authors clarify terminology that is pertinent to reporting, highlight the benefits of structured reports, discuss the applicability of LI-RADS for liver CT and MRI, review the elements of a standardized LI-RADS report, provide guidance on the description of LI-RADS observations exemplified with two case-based reporting templates, illustrate relevant imaging findings and components to be included when reporting specific clinical scenarios, and discuss future directions. An invited commentary by Yano is available online. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

Over the past 16 years, several scientific organizations have proposed systems that incorporate imaging for surveillance, diagnosis, staging, treatment, and monitoring of treatment response of hepatocellular carcinoma (HCC). These systems are needed to standardize the acquisition, interpretation, and reporting of liver imaging examinations; help differentiate benign from malignant observations; improve consistency between radiologists; and provide guidance for management of HCC. This review article discusses the historical evolution of HCC imaging systems. We indicate the features differentiating these systems, including target population, screening and surveillance algorithm, diagnostic imaging modalities, diagnostic scope, expertise and technical requirements, terminology, major and ancillary imaging features, staging and transplant eligibility, and assessment of treatment response. We highlight the potential benefits of unifying the systems, which we anticipate will enable sharing, pooling, and meta-analysis of data; facilitate multi-center trials; and accelerate dissemination of knowledge.

OBJECTIVE. In this article, we describe the concepts of ventilation-perfusion planar, SPECT, and SPECT/CT and outline the advantages of integrated ventilation-perfusion SPECT/CT over planar imaging. We present an overview of the traditional and new applications of ventilation-perfusion scintigraphy. CONCLUSION. SPECT/CT has improved the diagnostic accuracy of ventilation-perfusion imaging and opened the door for a new spectrum of applications.

© 2018, Springer Science+Business Media, LLC, part of Springer Nature. The Liver Imaging and Reporting Data System (LI-RADS) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver imaging with the overarching goal of improving communication, clinical care, education, and research relating to patients at risk for or diagnosed with hepatocellular carcinoma (HCC). In 2018, the American Association for the Study of Liver Diseases (AASLD) integrated LI-RADS into its clinical practice guidance for the imaging-based diagnosis of HCC. The harmonization between the AASLD and LI-RADS diagnostic imaging criteria required minor modifications to the recently released LI-RADS v2017 guidelines, necessitating a LI-RADS v2018 update. This article provides an overview of the key changes included in LI-RADS v2018 as well as a look at the LI-RADS v2018 diagnostic algorithm and criteria, technical recommendations, and management suggestions. Substantive changes in LI-RADS v2018 are the removal of the requirement for visibility on antecedent surveillance ultrasound for LI-RADS 5 (LR-5) categorization of 10-19 mm observations with nonrim arterial phase hyper-enhancement and nonperipheral “washout”, and adoption of the Organ Procurement and Transplantation Network definition of threshold growth (≥ 50% size increase of a mass in ≤ 6 months). Nomenclatural changes in LI-RADS v2018 are the removal of -us and -g as LR-5 qualifiers.

The Liver Imaging Reporting and Data System (LI-RADS) standardizes the interpretation, reporting, and data collection for imaging examinations in patients at risk for hepatocellular carcinoma (HCC). It assigns category codes reflecting relative probability of HCC to imaging-detected liver observations based on major and ancillary imaging features. LI-RADS also includes imaging features suggesting malignancy other than HCC. Supported and endorsed by the American College of Radiology (ACR), the system has been developed by a committee of radiologists, hepatologists, pathologists, surgeons, lexicon experts, and ACR staff, with input from the American Association for the Study of Liver Diseases and the Organ Procurement Transplantation Network/United Network for Organ Sharing. Development of LI-RADS has been based on literature review, expert opinion, rounds of testing and iteration, and feedback from users. This article summarizes and assesses the quality of evidence supporting each LI-RADS major feature for diagnosis of HCC, as well as of the LI-RADS imaging features suggesting malignancy other than HCC. Based on the evidence, recommendations are provided for or against their continued inclusion in LI-RADS. (©) RSNA, 2017 Online supplemental material is available for this article.

To determine per-lesion sensitivity and positive predictive value (PPV) of gadoxetic acid-enhanced 3-T magnetic resonance (MR) imaging for the diagnosis of malignant lesions by using matched (spatially correlated) hepatectomy pathologic findings as the reference standard. Materials andIn this prospective, institutional review board-approved, HIPAA-compliant study, 20 patients (nine men, 11 women; mean age, 59 years) with malignant liver lesions who gave written informed consent underwent preoperative gadoxetic acid-enhanced 3-T MR imaging for surgical planning. Two image sets were independently analyzed by three readers to detect liver lesions (set 1 without and set 2 with hepatobiliary phase [HBP] images). Hepatectomy specimen ex vivo MR imaging assisted in matching gadoxetic acid-enhanced 3-T MR imaging findings with pathologic findings. Interreader agreement was assessed by using the Cohen κ coefficient. Per-lesion sensitivity and PPV were calculated.Cohen κ values were 0.64-0.76 and 0.57-0.84, and overall per-lesion sensitivity was 45% (42 of 94 lesions) to 56% (53 of 94 lesions) and 58% (55 of 94 lesions) to 64% (60 of 94 lesions) for sets 1 and 2, respectively. The addition of HBP imaging did not affect interreader agreement but significantly improved overall sensitivity for one reader (P.05) and almost for another (P = .05). Sensitivity for 0.2-0.5-cm lesions was 0% (0 of 26 lesions) to 8% (two of 26 lesions) for set 1 and 4% (one of 26 lesions) to 12% (three of 26 lesions) for set 2. Sensitivity for 0.6-1.0-cm lesions was 28% (nine of 32 lesions) to 59% (19 of 32 lesions) for set 1 and 66% (21 of 32 lesions) to 69% (22 of 32 lesions) for set 2. Sensitivity for lesions at least 1.0 cm in diameter was at least 81% (13 of 16 lesions) for set 1 and was not improved for set 2. PPV was 98% (56 of 57 lesions) to 100% (60 of 60 lesions) for all readers without differences between image sets or lesion size.Gadoxetic acid-enhanced 3-T MR imaging provides high per-lesion sensitivity and PPV for preoperative malignant liver lesion detection overall, although sensitivity for 0.2-0.5-cm malignant lesions is poor.

Postsurgical bile leaks can be associated with significant morbidity and even mortality, if not identified and treated at an early phase. Hepatobiliary iminodiacetic acid (HIDA) scan is an important test for detection of bile leaks in the postoperative abdomen. However, the lack of anatomical details on planar images can make interpretation difficult, especially in the setting of altered postsurgical anatomy. Familiarity with the expected postoperative appearance on HIDA scan and correlation with SPECT/CT or other imaging modalities when available are very important. The purpose of this review is to describe the expected findings on HIDA scan after common major abdominal surgeries that involve a change in biliary tree anatomy, and illustrate how to identify biliary leaks and avoid interpretation pitfalls.

The Liver Imaging-Reporting and Data System (LI-RADS) is a comprehensive system for standardized interpretation and reporting of computed tomography and magnetic resonance examinations performed in patients at risk for hepatocellular carcinoma. LI-RADS includes a diagnostic algorithm, lexicon, and atlas as well as suggestions for reporting, management, and imaging techniques. This primer provides an introduction to LI-RADS for radiologists including an explanation of the diagnostic algorithm, descriptions of the categories, and definitions of the major imaging features used to categorize observations with case examples.

Author(s): Smorodinsky, Emmanuil; Ansdell, David S; Foster, Zeke W; Mazhar, Sameer M; Cruite, Irene; Wolfson, Tanya; Sugay, Sebastian B; Iussich, Gabriella; Shiehmorteza, Masoud; Kono, Yuko; Kuo, Alexander; Sirlin, Claude B | Abstract: PurposeTo determine the risk of nephrogenic systemic fibrosis (NSF) in a cohort of patients with chronic liver disease.Materials and methodsThis retrospective, Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study was performed at a single tertiary liver center. The study cohort comprised 1167 patients with chronic liver disease followed in a liver clinic and exposed to gadolinium-based contrast agents (GBCAs) between February 2004 and October 2007. A retrospective review of medical records was performed. For each patient, data were collected on demographics, history of GBCA exposure, presence of purported risk factors for NSF, and histopathological evidence of NSF.ResultsOf the 1167 patients with chronic liver disease, 58% (n = 678) had cirrhosis. The patients had a total of 2421 separate GBCA exposures. Fifty-five percent (n = 646) had a single exposure, 19% (n = 218) had two exposures, and 26% (n = 303) had three or more exposures. Seventy-two percent (n = 843) of patients had renal insufficiency, 25 patients (2.1%) had hepatorenal syndrome, 80 patients (6.8%) were in the perioperative liver transplant period, and 49 patients (4.2%) had one or more additional risk factors for NSF. None of the 1167 patients developed NSF.ConclusionChronic liver disease does not appear to be a significant risk factor for NSF.

Standardized tumor response criteria have been developed over time since the advent of cytotoxic anticancer therapies. The criteria have evolved and continue to do so as the understanding of the therapeutic basis of various anticancer agents increases and as novel therapeutic agents are developed. Currently, the criteria can be divided into the following main categories: anatomical-based criteria; tumor- and therapy-specific criteria; metabolic-based criteria; and response assessment of lymphomas. The standardized criteria are critical to the successful conduct of clinical trials during the development of cancer therapeutic agents as they offer uniform end points that facilitate comparison of therapeutic agents and interpretation of studies. The criteria are also relevant in clinical practice as they standardize how radiologists select, measure, and report lesions in oncology patients, and they provide standardized definitions for tumor response categories. To remain relevant in a rapidly evolving oncology field and provide up-to-date imaging information that meets the needs of oncologists in both research trials and clinical practice, radiologists need to familiarize themselves with the various standardized tumor response criteria.

Contrast-enhanced computed tomography and MRI are frequently used for the noninvasive diagnosis of hepatocellular carcinoma (HCC). Despite their important role in diagnosis and management of HCC, until recently, there has been no standardized system for their interpretation, reporting and data collection. In 2008, the American College of Radiology convened a committee to develop such a standardized system. This article reviews the role of computed tomography and MRI in the diagnosis and management of HCC; the need for a standardized imaging interpretation system; current HCC imaging criteria included in management guidelines endorsed by the European Association for the Study of Liver, American Association for Study of Liver Diseases, United Network for Organ Sharing and Asian Pacific Association for the Study of the Liver; and the limitations of these criteria. The article then provides an overview of the Liver Imaging Reporting and Data System and discusses future directions.

The American College of Radiology supported Liver Imaging Reporting And Data System (LI-RADS) is a comprehensive system for standardized interpretation and reporting of imaging examinations performed in patients at risk for hepatocellular carcinoma (HCC). As reviewed in the first article of a two-part series, LI-RADS uses 5 major imaging features to categorize LR-3, LR-4, and LR-5 observations. The major features are arterial phase enhancement, washout appearance, capsule appearance, diameter, and threshold growth. In addition to the major imaging features, LI-RADS uses ancillary imaging features to adjust the LI-RADS category to increase or decrease the suspicion for HCC. In this second article of a two-part series, we would discuss and illustrate a selection of LI-RADS ancillary imaging features.

The purpose of this article is to review and illustrate the Liver Imaging Reporting and Data System (LI-RADS) major features for interpretation and reporting of liver imaging examinations performed in patients at risk for hepatocellular carcinoma (HCC).

Hepatic Fibrosis, the progressive deposition of collagen in the extracellular matrix of the liver, is a fundamental alteration of liver parenchyma in many chronic liver diseases. It impairs liver function, may lead to cirrhosis and hepatocellular carcinoma, and constitutes an important cause of morbidity, mortality, and health care costs (1–4). Early diagnosis is important to initiate treatment and halt progression. Biopsy is the current gold standard for diagnosis, but it is expensive and invasive—factors that limit utility in longitudinal assessments (5–16). The limitations of biopsy for longitudinal assessment have impeded progress in clinical care and research of diffuse liver diseases associated with hepatic fibrosis. There is a need to develop noninvasive imaging techniques that can safely diagnose fibrosis. Conventional ultrasound, computed tomography, and magnetic resonance imaging (MRI) can assess gross liver morphology, or contour, to confirm cirrhosis in patients with advanced liver disease, but such an assessment is insensitive to the early stages of fibrosis and cirrhosis (6,17–19). An alternative imaging-based approach to evaluate hepatic fibrosis is to assess internal liver architecture, or texture. Texture can be defined as a complex visual pattern within an image that consists of simpler subpatterns with characteristic features (20). These features can be assessed objectively by quantitative texture analysis (TA). Quantitative TA has been used to noninvasively classify the liver in a dichotomous fashion as normal or cirrhotic on unenhanced MR images (21,22). In a study with 13 healthy volunteers and 5 cirrhotic patients, quantitative TA of high spatial resolution T2-weighted images provided 100% sensitivity and specificity for discrimination between normal volunteers and cirrhotic patients (21). In another study of 43 cirrhotic patients and 10 normal volunteers, quantitative TA on unenhanced T2-weighted MR images classified patients as cirrhotic or normal with a misclassification rate of 8% (22). Both studies used a publicly available, free software program (MaZda, v. 3.20, Instytut Elektroniki Politechnika, Lodza, Poland) to compute TA parameters from liver images and to generate multivariate predictive models from the parameters (23–25). Because double contrast-enhanced MRI shows fibrosis with greater clarity than unenhanced imaging (26–30), we hypothesized that quantitative TA of double contrast-enhanced MRI may permit accurate dichotomous classification of fibrosis in clinical patients with a spectrum of fibrosis severity, not just discrimination between healthy volunteers versus patients with cirrhosis. The purpose of this pilot, retrospective study was to demonstrate proof of concept that noninvasive quantitative TA on double contrast-enhanced MR liver images can classify liver fibrosis dichotomously in clinical patients, using histology as the reference standard. We used the same software program used in prior studies (MaZda) to compute TA parameters and applied statistical techniques to develop classification models based on the TA parameters.

A theoretical triglyceride model was developed for in vivo human liver fat 1H MRS characterization, using the number of double bonds (–CH=CH–), number of methylene-interrupted double bonds (–CH=CH–CH2–CH=CH–) and average fatty acid chain length. Five 3 T, single-voxel, stimulated echo acquisition mode spectra (STEAM) were acquired consecutively at progressively longer TEs in a fat–water emulsion phantom and in 121 human subjects with known or suspected nonalcoholic fatty liver disease. T2-corrected peak areas were calculated. Phantom data were used to validate the model. Human data were used in the model to determine the complete liver fat spectrum. In the fat–water emulsion phantom, the spectrum predicted by the model (based on known fatty acid chain distribution) agreed closely with spectroscopic measurement. In human subjects, areas of CH2 peaks at 2.1 and 1.3 ppm were linearly correlated (slope, 0.172; r = 0.991), as were the 0.9 ppm CH3 and 1.3 ppm CH2 peaks (slope, 0.125; r = 0.989). The 2.75 ppm CH2 peak represented 0.6% of the total fat signal in high-liver-fat subjects. These values predict that 8.6% ofm the total fat signal overlies the water peak. The triglyceride model can characterize human liver fat spectra. This allows more accurate determination of liver fat fraction from MRI and MRS.

The purpose of this article is to review the use of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (gadoxetate disodium [Gd-EOB-DTPA]) in the cirrhotic liver and illustrate the imaging appearance of lesions commonly encountered in the cirrhotic liver.Gd-EOB-DTPA shows promise as a problem-solving tool in the cirrhotic liver because it provides additional information that may be helpful in lesion detection and characterization. Further research is needed to optimize Gd-EOB-DTPA imaging protocols in cirrhosis and develop diagnostic criteria for liver lesions in the cirrhotic liver.

In this study, we assess the sensitivity and specificity of ultrasound and computed tomography (CT) for pericardial effusion and constrictive pericarditis.This was a retrospective, institutional review board-approved, and health insurance privacy accountability act compliant study performed at a single tertiary center over a 10-year period (2001-2011) for patients who had clinical symptoms of pericarditis and had undergone both cardiac CT imaging and transesophageal echocardiogram (TEE) in a span of 2 weeks.Inclusion criteria included patients with clinical symptoms of pericarditis, pericardial thickness measuring more than 2 mm on CT, and patients who had both cardiac CT imaging and TEE performed within 2 weeks.Exclusion criteria included patients with pericardial thickness measuring 2 mm or less on CT, no TEE, TEE not done within 2 weeks of the thoracic CT, and calcified pericardium on CT.Computed tomographic images were retrospectively reviewed by 2 radiologists who were unaware of the TEE findings. Pericardial effusion on CT was deemed present if there was obliteration of the fat plane in the left pulmonic recess.Statistical analysis was performed using the R statistical environment (Rstat). Intraobserver and interobserver variability was estimated using Cohen κ- statistic (Cohen).Forty-three cases constituted the study population (28 men and 15 women; mean age, 55 years; age range, 22-82 years). Twenty-one patients had pathologic confirmation of pericarditis.The findings for CT and TEE were discrepant in 10 cases. Intraobserver variability Cohen κ statistic was 0.855. Interobserver variability Cohen κ statistics were 0.54 and 0.49.Computed tomography is sensitive to pericardial effusion and pericardial thickening, whereas TEE seems insensitive to isolated pericardial thickening.

The Liver Imaging-Reporting and Data System (LI-RADS) is a comprehensive system for standardized interpretation and reporting of computed tomography and magnetic resonance examinations performed in patients at risk for hepatocellular carcinoma. LI-RADS includes a diagnostic algorithm, lexicon, and atlas as well as suggestions for reporting, management, and imaging techniques. This primer provides an introduction to LI-RADS for radiologists including an explanation of the diagnostic algorithm, descriptions of the categories, and definitions of the major imaging features used to categorize observations with case examples.

A clear understanding of the normal anatomy and pattern of disease spread is important in evaluating many retroperitoneal disorders. Primary retroperitoneal tumors are uncommon, accounting for 0.1%-0.2% of all malignancies in the body; 80%-90% of all primary retroperitoneal tumors are malignant. The primary retroperitoneal neoplasms can be divided into solid or cystic masses. The solid neoplasms can be classified according to their tissue of origin into 3 main categories: mesodermal tumors, neurogenic tumors, and extragonadal germ cell tumors. Computed tomography and magnetic resonance imaging play a vital role in the localization, characterization, evaluation of the extent of local invasion, assessment of metastases, and determination of treatment response for these tumors. The diagnosis of a primary retroperitoneal malignancy is often challenging owing to overlap of imaging findings. A definitive diagnosis can be established only at histopathologic analysis. However, knowledge of the important tumor characteristics, growth pattern, and vascularity can assist in narrowing the differential diagnosis.

Noninvasive imaging plays critical roles in the treatment of patients with cirrhosis or other risk factors for the development of hepatocellular carcinoma. In recognition of the critical roles played by imaging, numerous international scientific organizations and societies have, in the past 12 years, proposed diagnostic systems for the interpretation of liver imaging examinations performed of at-risk patients.Although these imaging-based diagnostic systems represent important advances, they have limitations and they are not perfectly consistent with each other. The limitations and inconsistencies potentially cause confusion and may impair the integration of the systems into clinical practice as well as their utilization in research studies. The purpose of this article is to synthesize and critically appraise the current published imaging-based diagnostic systems endorsed by major societies for the noninvasive diagnosis and staging of hepatocellular carcinoma and to propose future directions that we hope may be helpful in further advancing the field.

Uterine didelphys with obstructed hemivagina and ipsilateral renal agenesis is a rare congenital anomaly of the Müllerian duct system referred to as Herlyn-Werner-Wunderlich syndrome. Because of its rare occurrence, a high level of suspicion is often required for diagnosis. Clinically, these patients usually present after menarche with pelvic pain, dysmenorrhea, and a palpable pelvic mass. We present a case of a 31-year-old female patient with infertility. Imaging findings were consistent with Herlyn-Werner-Wunderlich syndrome, with a congenital defect in the longitudinal vaginal septum resulting in partial spontaneous decompression of right-sided hematocolpos.

OBJECTIVE. The purpose of this article is to review the pharmacokinetic and pharmacodynamic properties of gadoxetate disodium (Gd-EOB-DTPA), to describe a workflow-optimized pulse sequence protocol, and to illustrate the imaging appearance of focal lesions in the noncirrhotic liver.CONCLUSION. Gd-EOB-DTPA allows a comprehensive evaluation of the liver with the acquisition of both dynamic and hepatocyte phase images. This provides potential additional information, especially for the detection and characterization of small liver lesions. However, protocol optimization is necessary for improved image quality and workflow.

Hepatic steatosis is characterized by abnormal and excessive accumulation of lipids within hepatocytes. It is an important feature of diffuse liver disease, and the histological hallmark of non-alcoholic fatty liver disease (NAFLD). Other conditions associated with steatosis include alcoholic liver disease, viral hepatitis, HIV and genetic lipodystrophies, cystic fibrosis liver disease, and hepatotoxicity from various therapeutic agents. Liver biopsy, the current clinical gold standard for assessment of liver fat, is invasive and has sampling errors, and is not optimal for screening, monitoring, clinical decision making, or well-suited for many types of research studies. Non-invasive methods that accurately and objectively quantify liver fat are needed. Ultrasound (US) and computed tomography (CT) can be used to assess liver fat but have limited accuracy as well as other limitations. Magnetic resonance (MR) techniques can decompose the liver signal into its fat and water signal components and therefore assess liver fat more directly than CT or US. Most magnetic resonance (MR) techniques measure the signal fat-fraction (the fraction of the liver MR signal attributable to liver fat), which may be confounded by numerous technical and biological factors and may not reliably reflect fat content. By addressing the factors that confound the signal fat-fraction, advanced MR techniques measure the proton density fat-fraction (the fraction of the liver proton density attributable to liver fat), which is a fundamental tissue property and a direct measure of liver fat content. These advanced techniques show promise for accurate fat quantification and are likely to be commercially available soon.