Abstract
Objective
To elucidate whether the presence of enhancing capsule can be applied to establish a modified Liver Imaging Reporting and Data System (LI-RADS) to differentiate hepatocellular carcinoma (HCC) from non-HCC malignancies in extracellular contrast agent (ECA)–enhanced and hepatobiliary agent (HBA)–enhanced MRI.
Methods
We enrolled 198 participants (161 men; mean age, 56.3 years) with chronic liver disease who underwent ECA-MRI and HBA-MRI before surgery for de novo hepatic nodule(s). Two reviewers assigned LI-RADS categories (v2018). We defined a “modified LR-5 category, which emphasizes enhancing capsule (mLR-5C)” over targetoid features and classifies tumors with both targetoid appearance and enhancing capsule as HCC instead of LR-M. We compared the diagnostic performance of conventional LI-RADS and modified LI-RADS criteria for both MRIs.
Results
A total of 258 hepatic nodules (194 HCCs, 43 benign lesions, and 21 non-HCC malignancies; median size, 19 mm) were analyzed. By conventional LI-RADS, 47 (18.2%) nodules (31 HCCs and 16 non-HCC malignancies) were categorized as LR-M. The mLR-5C criterion showed superior sensitivity (ECA-MRI, 76.6% vs. 67.0%; HBA-MRI, 60.4% vs. 56.3%; both p < 0.05) while maintaining high specificity (ECA-MRI, 93.8% vs. 98.4%; HBA-MRI, 95.3% vs. 98.4%; both p > 0.05) compared with the LR-5 criterion. Using the mLR-5C criterion, ECA-MRI exhibited higher sensitivity than HBA-MRI (76.6% vs. 60.4%, p < 0.001) and similar specificity (93.8% vs. 95.3%, p > 0.99).
Conclusion
Our modified LI-RADS achieved superior sensitivity for diagnosing HCC, without compromising specificity compared with LR-5. ECA-MRI showed higher sensitivity in diagnosing HCC than HBA-MRI by applying the mLR-5C for LR-M lesions.
Key Points
• By conventional LI-RADS, 31 (16.0%) of 194 HCCs were categorized as LR-M.
• Among 31 HCCs categorized as LR-M, 19 HCCs or 8 HCCs were recategorized as HCC on ECA-MRI or HBA-MRI, respectively, after applying the modified LR-5 category, which allocates targetoid lesions with enhancing capsule as mLR-5C instead of LR-M.
• The mLR-5C showed superior sensitivity compared with the LR-5 in both MRIs (ECA-MRI, 76.6% vs. 67.0%; HBA-MRI, 60.4% vs. 56.3%, both p < 0.05), while maintaining high specificity (ECA-MRI, 93.8% vs. 98.4%; HBA-MRI, 95.3% vs. 98.4%; both p > 0.05).
Similar content being viewed by others
Abbreviations
- APHE:
-
Arterial phase hyperenhancement
- cHCC-CC:
-
Combined hepatocellular-cholangiocarcinoma
- ECA:
-
Extracellular contrast agent
- HBA:
-
Hepatobiliary agent
- HBP:
-
Hepatobiliary phase
- HCC:
-
Hepatocellular carcinoma
- ICC:
-
Intrahepatic cholangiocarcinoma
- IQR:
-
Interquartile range
- LI-RADS:
-
Liver Imaging Reporting and Data System
- TP:
-
Transitional phase
References
American College of Radiology. Liver Imaging reporting and data system version 2018. Available via: http://www.acr.org/Quality-Safety/Resources/LIRADS.
Elsayes KM, Hooker JC, Agrons MM et al (2017) 2017 Version of LI-RADS for CT and MR imaging: an update. Radiographics 37:1994–2017
Vasuri F, Golfieri R, Fiorentino M et al (2011) OATP 1B1/1B3 expression in hepatocellular carcinomas treated with orthotopic liver transplantation. Virchows Arch 459:141–146
Granito A, Galassi M, Piscaglia F et al (2013) Impact of gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance on the non-invasive diagnosis of small hepatocellular carcinoma: a prospective study. Aliment Pharmacol Ther 37:355–363
Choi JY, Lee JM, Sirlin CB (2014) CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features. Radiology 273:30–50
European Association for the Study of the Liver (2018) EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 69:182–236
Heimbach JK, Kulik LM, Finn RS et al (2018) AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 67:358–380
Korean Liver Cancer Association, National Cancer Center, Goyang Korea (2019) 2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma. Korean J Radiol 20:1042–1113
Kim TH, Kim SY, Tang A, Lee JM (2019) Comparison of international guidelines for noninvasive diagnosis of hepatocellular carcinoma: 2018 update. Clin Mol Hepatol 25:245–263
Kim YY, Kim MJ, Kim EH, Roh YH, An C (2019) Hepatocellular carcinoma versus other hepatic malignancy in cirrhosis: performance of LI-RADS version 2018. Radiology 291:72–80
van der Pol CB, Lim CS, Sirlin CB et al (2019) Accuracy of the liver imaging reporting and data system in computed tomography and magnetic resonance image analysis of hepatocellular carcinoma or overall malignancy-a systematic review. Gastroenterology 156:976–986
Anis M (2015) Imaging of hepatocellular carcinoma: new approaches to diagnosis. Clin Liver Dis 19:325–340
Rimola J, Forner A, Tremosini S et al (2012) Non-invasive diagnosis of hepatocellular carcinoma </= 2 cm in cirrhosis. Diagnostic accuracy assessing fat, capsule and signal intensity at dynamic MRI. J Hepatol 56:1317–1323
Min JH, Kim JM, Kim YK et al (2018) Prospective intraindividual comparison of magnetic resonance imaging with gadoxetic acid and extracellular contrast for diagnosis of hepatocellular carcinomas using the liver imaging reporting and data system. Hepatology 68:2254–2266
Min JH, Kim JM (2020) Kim YK et al. Magnetic resonance imaging with extracellular contrast detects hepatocellular carcinoma with greater accuracy than with gadoxetic acid or computed tomography Clin Gastroenterol Hepatol 18:2091–2100
Choi SY, Kim SH, Park CK et al (2018) Imaging features of gadoxetic acid-enhanced and diffusion-weighted MR imaging for identifying cytokeratin 19-positive hepatocellular carcinoma: a retrospective observational study. Radiology 286:897–908
Choi SY, Kim YK, Min JH et al (2018) Added value of ancillary imaging features for differentiating scirrhous hepatocellular carcinoma from intrahepatic cholangiocarcinoma on gadoxetic acid-enhanced MR imaging. Eur Radiol 28:2549–2560
Sheng RF, Zeng MS, Rao SX, Ji Y, Chen LL (2014) MRI of small intrahepatic mass-forming cholangiocarcinoma and atypical small hepatocellular carcinoma (</=3 cm) with cirrhosis and chronic viral hepatitis: a comparative study. Clin Imaging 38:265–272
Santillan C, Fowler K, Kono Y, Chernyak V (2018) LI-RADS major features: CT, MRI with extracellular agents, and MRI with hepatobiliary agents. Abdom Radiol (NY) 43:75–81
Joo I, Lee JM, Lee DH, Jeon JH, Han JK, Choi BI (2015) Noninvasive diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced MRI: can hypointensity on the hepatobiliary phase be used as an alternative to washout? Eur Radiol 25:2859–2868
Choi SH, Lee SS, Park SH et al (2019) LI-RADS classification and prognosis of primary liver cancers at gadoxetic acid-enhanced MRI. Radiology 290:388–397
Jeon SK, Joo I, Lee DH et al (2019) Combined hepatocellular cholangiocarcinoma: LI-RADS v2017 categorisation for differential diagnosis and prognostication on gadoxetic acid-enhanced MR imaging. Eur Radiol 29:373–382
Gupta R, Togashi J, Akamatsu N, Sakamoto Y, Kokudo N (2017) Impact of incidental/misdiagnosed intrahepatic cholangiocarcinoma and combined hepatocellular cholangiocarcinoma on the outcomes of liver transplantation: an institutional case series and literature review. Surg Today 47:908–917
Park HJ, Kim YK, Cha DI et al (2020) Targetoid hepatic observations on gadoxetic acid-enhanced MRI using LI-RADS version 2018: emphasis on hepatocellular carcinomas assigned to the LR-M category. Clin Radiol 75:478 e413-478 e423
Pecorelli A, Lenzi B, Gramenzi A et al (2017) Curative therapies are superior to standard of care (transarterial chemoembolization) for intermediate stage hepatocellular carcinoma. Liver Int 37:423–433
An C, Park S, Chung YE et al (2017) Curative resection of single primary hepatic malignancy: liver imaging reporting and data system category LR-M portends a worse prognosis. AJR Am J Roentgenol 209:576–583
Shimizu R, Tamai H, Mori Y et al (2016) The arterial tumor enhancement pattern on contrast-enhanced computed tomography is associated with primary cancer death after radiofrequency ablation for small hepatocellular carcinoma. Hepatol Int 10:328–339
An C, Kim DW, Park YN, Chung YE, Rhee H, Kim MJ (2015) Single hepatocellular carcinoma: preoperative MR imaging to predict early recurrence after curative resection. Radiology 276:433–443
Ariizumi S, Kitagawa K, Kotera Y et al (2011) A non-smooth tumor margin in the hepatobiliary phase of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging predicts microscopic portal vein invasion, intrahepatic metastasis, and early recurrence after hepatectomy in patients with hepatocellular carcinoma. J Hepatobiliary Pancreat Sci 18:575–585
Funding
The authors state that this work has not received any funding.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Guarantor
The scientific guarantor of this publication is Young Kon Kim in the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Conflict of interest
The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Statistics and biometry
One (Soohyun Ahn, PhD) of the authors has significant statistical expertise.
Informed consent
Written informed consent was obtained from each patient before enrollment.
Ethical approval
Institutional Review Board approval was obtained.
Study subjects or cohorts overlap
Among the 198 patients, 91 (46.0%) and 122 (61.6%) have been previously reported in the prior reports from our institution. Previous studies focused on the comparison of the diagnostic performance of ECA-MRI and HBA-MRI based on LI-RADS v2017 (Hepatology. 2018 Dec;68(6):2254-2266), or the diagnostic performance of CT, ECA-MRI, and HBA-MRI alone, and in combination (Clin Gastroenterol Hepatol 2020 Aug;18(9):2091-2100). Our current study focused on the targetoid features and LR-M category of LI-RADS v2018 on each MRI. We defined a modified LR-5 category, which emphasizes enhancing capsule over targetoid features.
Methodology
• prospective
• Diagnostic study
• performed at one institution
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
ESM 1
(PNG 628 kb)
Rights and permissions
About this article
Cite this article
Min, J.H., Kim, J.M., Kim, Y.K. et al. A modified LI-RADS: targetoid tumors with enhancing capsule can be diagnosed as HCC instead of LR-M lesions. Eur Radiol 32, 912–922 (2022). https://doi.org/10.1007/s00330-021-08124-0
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-021-08124-0