Objectives
To evaluate the diagnostic performance of the LI-RADS (v2014) on gadoxetate-enhanced MRI prospectively applied in actual practice.
Methods
We retrospectively reviewed the prospectively ...written radiology reports of 143 treatment-naïve at-risk patients who underwent gadoxetate-enhanced liver MRI from January to December 2014, and identified 202 hepatic observations categorized using the LI-RADS. The diagnostic performances of LI-RADS categories for hepatocellular carcinoma (HCC) and hepatic malignancy were calculated.
Results
Twenty (69.0 %) of 29 LR-4, 73 (97.3 %) of 75 LR-5, and all of five (100 %) LR-5V observations were HCCs. The remaining two (2.7 %) LR-5 observations were combined hepatocellular-cholangiocarcinomas, while 10 (76.9 %) of 13 LR-M observations were HCCs. The sensitivity and specificity of LR-5/5V for HCC were 60.5 % and 97.3 %, respectively. Including LR-M in the diagnostic criteria for HCC increased sensitivity (68.2 %,
p
= 0.002) but decreased specificity without statistical significance (93.2 %,
p
= 0.154). LR-5/5V/M yielded sensitivity of 68.9 % and specificity of 100.0 % for hepatic malignancy.
Conclusions
LI-RADS v2014 was successfully applied on gadoxetate-enhanced MRI in clinical practice. LR-5/5V was the most specific diagnostic measure for HCC, but most LR-M observations were HCCs and a considerable portion of non-HCC malignancies were categorized as LR-4 or LR-5.
Key Points
•
LR-5/5V provided a highly specific diagnosis for HCC
.
•
Half of non-HCC malignancies were categorized as LR-4 or LR-5
.
•
The majority of LR-M observations were finally diagnosed as HCCs
.
•
More sensitive diagnosis of HCC was feasible with LR-5/5V/M on gadoxetate-enhanced MRI
.
•
Observations in either LR-5/5V or LR-M categories were definitely malignant
.
Background
Sarcopenia has been underscored as a significant predictor of poor prognosis in cancer patients undergoing immunotherapy with programmed death-1 (PD-1) inhibitors. We aimed to investigate ...the prognostic significance of computed tomography (CT)-determined sarcopenia in patients with microsatellite-stable (MSS) gastric cancer (GC) treated with PD-1 inhibitors.
Methods
We retrospectively assessed patients with MSS GC who had been treated with PD-1 inhibitors from March 2016 to June 2019. Pre-treatment sarcopenic status was determined by analyzing L3 skeletal muscle index with abdominal CT. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan–Meier method, and the differences in survival probability according to sarcopenic status were compared using the log-rank test. Cox proportional hazards regression analyses were performed to identify predictors of PFS and OS.
Results
Of 149 patients with MSS GC (mean age, 57.0 ± 12.3 years; 93 men), 79 (53.0%) had sarcopenia. Patients with sarcopenia had significantly shorter PFS than patients without sarcopenia (median, 1.4 months vs. 2.6 months;
P
= 0.026). Sarcopenia was independently associated with shorter PFS (adjusted hazard ratio HR, 1.79; 95% confidence interval CI, 1.10−2.93;
P
= 0.020). Patients with sarcopenia had shorter OS than patients without sarcopenia (median, 3.6 months vs. 4.9 months;
P
= 0.052), but sarcopenia itself was not a significant prognostic factor for OS (adjusted HR, 1.01; 95% CI, 0.58−1.75;
P
= 0.974).
Conclusions
CT-determined sarcopenia is an independent prognostic factor for PFS in patients with MSS GC treated with PD-1 inhibitors.
Programmed cell death-1 (PD-1) inhibitor treatment can cause hyperprogressive disease (HPD), but the incidence, outcome, and predictive factors of HPD are unknown in patients with hepatocellular ...carcinoma (HCC). Herein, we assessed the existence and factors predictive of HPD in patients with advanced HCC treated with nivolumab.
We enrolled 189 patients with advanced HCC treated with nivolumab. Occurrence of HPD was investigated using tumour growth dynamics based on tumour growth kinetics (TGK) and tumour growth rate (TGR) before and after treatment, or time to treatment failure. We additionally analysed patients treated with regorafenib (n = 95) or best supportive care (BSC)/placebo (n = 103) after progression on sorafenib to compare tumour growth dynamics.
Flare-up of tumour growth was observed in a fraction of patients upon PD-1 blockade, indicating the occurrence of HPD. Based on distinct patterns of disease progression exclusively observed in the nivolumab-treated cohort, but not in the regorafenib- or BSC/placebo-treated cohorts, 4-fold increases in TGK and TGR ratios as well as a 40% increase in TGR were the cut-off values used to define HPD; 12.7% of the patients (24/189) treated with nivolumab met all these criteria. Patients with HPD had worse progression-free survival (hazard ratio HR 2.194; 95% CI 1.214–3.964) and overall survival (HR 2.238; 95% CI 1.233–4.062) compared to patients with progressive disease without HPD. More than 90% of patients with HPD missed the opportunity for subsequent treatment because of rapid clinical deterioration. An elevated neutrophil-to-lymphocyte ratio (>4.125) was associated with HPD and an inferior survival rate.
HPD occurs in a fraction of patients with HCC who receive PD-1 inhibitor treatment. Analyses of the baseline immune profile and on-treatment tumour growth dynamics could enable optimal patient selection and earlier identification of HPD.
Hyperprogressive disease is an unexpected response pattern observed in patients treated with an immune checkpoint inhibitor. This study revealed that hyperprogressive disease occurs in a fraction of patients with advanced hepatocellular carcinoma treated with an anti-PD-1 antibody, providing evidence to encourage careful monitoring of patients to prevent clinical deterioration induced by PD-1 blockade.
Display omitted
•HPD occurs in a fraction of patients with HCC treated with PD-1 inhibitors.•HPD is associated with worse PFS and OS, depriving patients of the chance to receive subsequent treatments.•Elevated neutrophil-to-lymphocyte ratio predicts the occurrence of HPD and inferior survival rate after PD-1 blockade.
Background
The Liver Imaging Reporting and Data System (LI‐RADS) is a comprehensive system for standardizing liver imaging in patients at risk for hepatocellular carcinoma (HCC).
Purpose
To ...systematically compare the performance of computed tomography (CT)/MRI LI‐RADS category 5 (LR‐5) for diagnosing HCC between versions 2017 and 2018.
Study Type
Systematic review and meta‐analysis.
Subjects
Six articles with 1181 lesions.
Field Strength/Sequence
1.5 T and 3.0 T.
Assessment
Data extraction was independently performed by two reviewers who identified and reviewed articles comparing the performance of LR‐5 for diagnosing HCC between CT/MRI LI‐RADS versions 2017 and 2018. Study and patient characteristics, index test characteristics, reference standards, and study outcomes were extracted from included studies. Risk of bias and concerns regarding applicability were evaluated using the Quality Assessment of Diagnostic Accuracy Studies‐2 tool.
Statistical Tests
Bivariate random‐effects models were used to calculate the pooled per‐observation sensitivity and specificity of LR‐5 using both versions. The summary receiver operating characteristic curves were plotted. Meta‐regression analysis was performed to explore heterogeneity. A P‐value <0.05 was considered to be statistically significant for all analyses other than heterogeneity, where the significance threshold was 0.1.
Results
The pooled per‐observation sensitivity of LR‐5 for diagnosing HCC did not show statistically significant difference between versions 2017 (60%; 95% confidence interval CI, 49%–70%) and 2018 (67%; 95% CI, 56%–76%; P = 0.381). The pooled per‐observation specificities of LR‐5 were not significantly different between versions 2017 (92%; 95% CI, 90%–95%) and 2018 (91%; 95% CI, 88%–93%; P = 0.332). Meta‐regression analyses revealed that the most common underlying liver disease (hepatitis B or hepatitis C) was a significant factor contributing to the heterogeneity of sensitivities among studies for both versions.
Data Conclusion
In this meta‐analysis using intraindividual paired comparisons, the pooled sensitivity and pooled specificity of LR‐5 were not significantly different between 2017 and 2018 LI‐RADS versions.
Level of Evidence
3
Technical Efficacy
Stage 2
The aim of this study was to evaluate the association of contrast-enhanced ultrasound (CEUS) features using Sonazoid for liver nodules with Liver Imaging Reporting and Data System (LI-RADS) ...categories and to identify the usefulness of Kupffer-phase images.
This retrospective study was conducted in 203 patients at high risk of hepatocellular carcinoma (HCC) who underwent CEUS with Sonazoid from 2013 to 2016. Nodule enhancement in the arterial, portal venous, late, and Kupffer phases; CEUS LI-RADS major features; and Kupffer-phase defects were evaluated. According to the computed tomography/magnetic resonance imaging (CT/MRI) LI-RADS v2018, all nodules were assigned an LR category (n=4/33/99/67 for LR-M/3/4/5) and comparisons across LR categories were made. We defined modified CEUS LI-RADS as using Kupffer-phase defects as an alternative to late and mild washout in CEUS LI-RADS and compared the diagnostic performance for HCC.
On CEUS of 203 nodules, 89.6% of CT/MRI LR-5 and 85.9% of LR-4 nodules showed hyperenhancement in the arterial phase, while 57.6% of LR-3 nodules showed hyperenhancement. Among the CT/MRI LR-5 nodules that showed arterial phase hyperenhancement or isoenhancement, 59.7% showed hypoenhancing changes from the portal venous phase, 23.9% from the late phase, and 13.4% additionally in the Kupffer phase. The modified CEUS LI-RADS showed higher sensitivity than CEUS LI-RADS (83.2% vs. 74.2%, P=0.008) without compromising specificity (63.6% vs. 69.7%, P=0.500).
The Kupffer phase best shows hypoenhancing changes in LR-5 lesions and is expected to improve the sensitivity for HCC in high-risk patients.
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.
The LI-RADS treatment response algorithm may lack sufficient sensitivity for viable tumor after locoregional treatment (LRT) for hepatocellular carcinoma (HCC).
The purpose of our study was to ...evaluate the impact of incorporation of ancillary MRI features on the diagnostic performance of the LI-RADS treatment response algorithm after LRT for HCC.
This retrospective study included 141 patients (114 men, 27 women; median age, 56 years) who underwent gadoxetic acid-enhanced MRI after LRT for HCC between October 2005 and January 2020 and subsequent liver surgery. Two readers assessed lesions for LI-RADS features of viability for ancillary MRI features (transitional phase TP hypointensity, hepatobiliary phase HBP hypointensity, DWI hyperintensity or low ADC, and mild-to-moderate T2 hyperintensity). Interobserver agreement was assessed before reaching consensus. Significant ancillary features were identified using random forest analysis. The impact of incorporation of significant ancillary features on diagnostic performance for incomplete pathologic necrosis (IPN; pathologically viable tumor > 0 mm) was assessed using McNemar tests.
Complete pathologic necrosis (CPN) was observed in 88 of 181 (48.6%) lesions. Interreader agreement was almost perfect for LI-RADS features of viability (κ = 0.92-0.97) and was substantial to almost perfect for ancillary features (κ = 0.73-0.94). Random forest analysis identified TP hypointensity (present in 8.0%, 25.0%, and 75.3% of lesions with CPN, viable tumor < 10 mm, and viable tumor ≥ 10 mm, respectively) and HBP hypointensity (9.2%, 25.0%, and 74.0%, respectively) as significant ancillary features. For detecting IPN, LR-TR (treatment response) Viable or LR-TR Equivocal had higher sensitivity than LR-TR Viable (71.0% vs 57.0%, respectively;
= .001) but had lower specificity (86.4% vs 94.3%,
= .02). However, LR-TR Viable or LR-TR Equivocal and TP hypointensity showed higher sensitivity than LR-TR Viable (64.5% vs 57.0%,
= .02) without a significantly different specificity (90.9% vs 94.3%,
= .25). LR-TR Viable or LR-TR Equivocal and HBP hypointensity also showed higher sensitivity than LR-TR Viable (65.6% vs 57.0%,
= .01) without a significantly different specificity (90.8% vs 94.3%,
= .25).
TP hypointensity and HBP hypointensity increase the sensitivity of LI-RADS treatment response algorithm for viable tumor without lowering specificity.
The two identified ancillary features may improve tumor viability assessment and planning of additional therapies after LRT for HCC.
•Multi-shot DWI of the liver was clinically feasible using MUSE reconstruction.•MUSE-DWI showed less image noise and distortions, and sharper liver contours.•Lesion detectability in MUSE-DWI was ...enhanced in terms of lesion conspicuity.•Solid lesion characterization was accurate in MUSE-DWI.
To compare multiplexed sensitivity encoding (MUSE) and conventional diffusion-weighted magnetic resonance imaging (cDWI) techniques in liver MRI.
Fifty-nine patients who underwent both two-shot echo-planar DWI using MUSE and single-shot echo-planar cDWI at a 3.0-T MRI system were included. Qualitative parameters were independently evaluated by three radiologists, and quantitative parameters were calculated on the basis of region of interest measurements. Receiver operating characteristic curve analysis and McNemar’s test were used to compare solid lesion characterization results and lesion detectability, respectively.
All reviewers found less image noise, sharper liver contours, milder susceptibility artifacts, and better lesion conspicuity in MUSE-DWI than in cDWI (reader average mean, 4.1–4.5 vs. 3.5–4.0; p < 0.05). The signal-to-noise ratio (SNR) of the liver was significantly higher in MUSE-DWI than in cDWI (right lobe: mean, 9.39 vs. 8.10, p < 0.001; left lobe: mean, 8.34 vs. 7.19, p < 0.001), while the SNR of the lesion (mean, 23.72 vs. 23.88, p = 0.911) and lesion-to-liver contrast-to-noise ratio (mean, 14.65 vs. 15.41, p = 0.527) were comparable between MUSE-DWI and cDWI. Solid lesion characterization results were comparably accurate between MUSE-DWI and cDWI (reader average area under the receiver operating characteristic curve, 0.985 vs. 0.986, p = 0.480). The detectability of lesions was better in MUSE-DWI than in cDWI (reader consensus, 83.7 % 41/49 vs. 67.3 % 33/49, p = 0.021).
MUSE-DWI can provide multi-shot liver DWI with less noise, fewer distortions, improved SNR of the liver, and better lesion detectability.
Objective
We performed an updated meta-analysis to determine the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS, LR) 5 category for hepatocellular carcinoma (HCC) using ...LI-RADS version 2018 (v2018), and to evaluate differences by imaging modalities and type of MRI contrast material.
Methods
The MEDLINE and Embase databases were searched for studies reporting the performance of LR-5 using v2018 for diagnosing HCC. A bivariate random-effects model was used to calculate the pooled per-observation sensitivity and specificity. Subgroup analysis was performed based on imaging modalities and type of MRI contrast material.
Results
Forty-eight studies qualified for the meta-analysis, comprising 9031 patients, 10,547 observations, and 7216 HCCs. The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC were 66% (95% CI, 61–70%) and 91% (95% CI, 89–93%), respectively. In the subgroup analysis, MRI with extracellular agent (ECA-MRI) showed significantly higher pooled sensitivity (77% 95% CI, 70–82%) than CT (66% 95% CI, 58–73%;
p
= 0.023) or MRI with gadoxetate (Gx-MRI) (65% 95% CI, 60–70%;
p
= 0.001), but there was no significant difference between ECA-MRI and MRI with gadobenate (gadobenate-MRI) (73% 95% CI, 61–82%;
p
= 0.495). Pooled specificities were 88% (95% CI, 80–93%) for CT, 92% (95% CI, 86–95%) for ECA-MRI, 93% (95% CI, 91–95%) for Gx-MRI, and 91% (95% CI, 84–95%) for gadobenate-MRI without significant differences (
p
= 0.084–0.803).
Conclusions
LI-RADS v2018 LR-5 provides high specificity for HCC diagnosis regardless of modality or contrast material, while ECA-MRI showed higher sensitivity than CT or Gx-MRI.
Clinical relevance statement
Refinement of the criteria for improving sensitivity while maintaining high specificity of LR-5 for HCC diagnosis may be an essential future direction.
Key Points
•
The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC using LI-RADSv2018 were 66% and 91%, respectively
.
•
ECA-MRI showed higher sensitivity than CT (77% vs 66%, p = 0.023) or Gx-MRI (77% vs 65%, p = 0.001)
.
•
LI-RADS v2018 LR-5 provides high specificity (88–93%) for HCC diagnosis regardless of modality or contrast material type
.
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