Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma: characterization of five cases

Objective

To describe the imaging and histopathology of pseudomyogenic hemangioendothelioma.

Materials and methods

Five cases of pseudomyogenic hemangioendothelioma, which presented over the last 5 years, were retrieved from the files of the Royal National Orthopaedic Hospital. The imaging and histopathology were reviewed in all cases. Magnetic resonance imaging, which was available from all cases, was assessed for the following features: the number of lesions, location in soft tissue (superficial and or deep/subfascial) and bone, and the signal characteristics and morphology of individual lesions. Immunohistochemistry was performed in all cases to characterize the lesions.

Results

Four of the five patients had multiple lesions involving a single limb. Bone was involved in 3 of the 5 individuals. All tumors diffusely expressed ERG and cytokeratins AE1/3, but not MNF116. CD31 was weakly positive in 4 cases. INI-1 expression was retained in all cases. Imaging features included ill-defined, infiltrative lesions in subcutaneous fat with extension to the adjacent skin, poor- to well-defined intramuscular nodules and predominantly intracortical focal bone lesions with rare medullary involvement.

Conclusion

Pseudomyogenic hemangioendothelioma represents a distinct recently characterized tumor type presenting in young adults, with a tendency towards multicentric bone and soft tissue involvement.     

Subfascial involvement in glomuvenous malformation

Objective

Glomuvenous malformation (GVM) is an inherited autosomal dominant trait. The lesions, which appear as bluish nodules or plaque-like cutaneous elevations, are usually tender and more firm than sporadic venous malformations. Conventionally, the lesions are thought to be limited to the cutaneous and subcutaneous tissue planes. The objective was to characterize the depth of involvement of GVM lesions.

Materials and Methods

Magnetic resonance imaging (MRI) findings in GVM were retrospectively evaluated by two radiologists. The signal characteristics, tissue distribution, pattern of contrast enhancement of the lesions in GVM were documented.

Results

Thirty patients (19 female) aged 1–35 years (mean 18 years) were diagnosed with GVM based on clinical features (n?=?20) and/or histopathological findings (n?=?10). The lesions were present in the lower extremity (n?=?15), upper extremity (n?=?6), cervico-facial region (n?=?6), pelvis (n?=?2), and chest wall (n?=?1). All patients had skin and subcutaneous lesions. Fifty percent of the patients (n?=?15) demonstrated subfascial intramuscular (n?=?15), intra-osseous (n?=?1), and intra-articular involvement (n?=?1).

Conclusion

Contrary to the conventional belief that GVMs are generally limited to the skin and subcutaneous tissue, deep subfascial extension of the lesions is common.     

Miofibromatosis infantil. Un caso estudiado con ecografía y resonancia magnética de cuerpo entero

Infantile myofibromatosis, despite being considered a rare condition, is the most common fibrous tumour in infancy. It is characterised by the presence of benign fibroblastic-myofibroblastic lesions. It usually occurs in children under two years-old, but it can appear at any age. The solitary form (myofibromas) may affect the skin, subcutaneous cellular tissue, muscle or bone. In the multi-centred form (myofibromatosis), there may also be visceral lesions. The lesions usually regress spontaneously in one or two years, with the prognosis being excellent in these cases. However, when there is visceral involvement, the prognosis is poor and treatment with chemotherapy is indicated. Lung involvement is more associated with a poor prognosis. Although the definitive diagnosis is by histopathology, diagnostic imaging tests are essential for characterising the lesions, establishing the extent of the disease, assessing visceral involvement, and following up the progression of the lesions.     

Infantile myofibromatosis

 Infantile myofibromatosis is a mesenchymal tumor most commonly seen in infancy. The tumors have a variable appearance on CT/MR and often simulate a more aggressive neoplasm. This report describes CT/MR findings in cases of infantile myofibromatosis with pathologic correlation. Discussion into the success of imaging in suggesting the correct diagnosis is also addressed. Infantile myofibromatosis is a mesenchymal disorder of infancy characterized by the presence of tumorous nodules in the skin, subcutaneous tissue, muscle, viscera, and bone. Cases of solitary and multiple lesions have been described. We present the clinical, histologic, and radiographic findings of one case of the solitary form of infantile myofibromatosis that was recently diagnosed at our hospital.     

Ultrasonographic assessment of lipodystrophy in HIV-1-infected patients

Purpose

We performed a cross-sectional study of physical changes in HIV-infected adults to evaluate the role of ultrasonography for the diagnosis of lipodystrophy.

Materials and methods

Sixty HIV-infected patients were recruited from 1 June to 31 December 2006. A total of 34 patients were included in the lipodystrophy group and 26 in no lipodystrophy group. Thickness of subcutaneous fat was measured twice with a high-frequency (15 MHz) transducer by transverse scans at four skin-based reference points: the periumbilical region, the brachial region, the crural region and the malar region. Visceral fat thickness was determined with a low-frequency (3.75 MHz) transducer at two skin reference points: perirenal fat diameter and visceral abdominal fat.

Results

Compared with HIV-infected patients without lipodystrophy, those with lipoatrophy or mixed lipodystrophy had thinner facial, arm and leg fat, whereas patients with lipodystrophy showed thicker intra-abdominal fat. The median of the ratio between intra-abdominal fat and subcutaneous fat and between perirenal fat diameter and body mass index in the lipodystrophy group was higher than in the no lipodystrophy group. The measurements of brachial, malar and crural fat were significantly lower in patients with lipodystrophy.

Conclusions

We consider the ratio between visceral adipose tissue and subcutaneous adipose tissue and the thickness of malar fat to be the most useful ultrasonographic parameters for the early diagnosis of lipodystrophy in HIV-infected patients on highly active antiretroviral therapy.     

Small nodular hepatocellular carcinoma treated by laser thermal ablation in high risk locations: preliminary results

Objectives

To demonstrate the effectiveness and the safety of laser thermal ablation (LTA) in patients with unresectable hepatocellular carcinoma (HCC) deemed not accessible for other percutaneous procedures (radiofrequency ablation, sclerotherapy).

Methods

From September 2003 to August 2008, 140 patients with HCC nodules were treated. In 49 patients, the lesions were localized in “critical sites”. A total of 29 men and 20 women (age range 51–79 years; Child–Pugh score A = 75.51%, B = 24.49%) with 52 nodules (mean diameter 2.0?±?1.2 cm) were treated in 95 percutaneous LTA sessions. We compared major and minor complications observed in the two groups of patients. Effectiveness was defined as the percentage of HCCs completely ablated after percutaneous LTA. Follow-up was carried out with computed tomography (CT) at 1, 3, 6, 9, and 12 months.

Results

No major complications or deaths were registered. In a few patients (8.16%), minor complications were observed. No substantial differences were observed on comparing the percentage of minor and major complications in these patients with the remaining patients. A difference in terms of effectiveness was found.

Conclusion

LTA can be considered a safe treatment in “critical nodules”.     

Shear wave elastography of thyroid nodules in routine clinical practice: preliminary observations and utility for detecting malignancy

Objective

To evaluate real-time shear wave ultrasound elastography (SWE) for characterizing focal thyroid lesions in routine clinical practice.

Methods

Seventy-four patients with 81 focal thyroid lesions undergoing conventional US with needle cytology also underwent SWE. Absolute and relative SWE stiffness measurements on colour-coded elastograms were correlated with cytology and their discriminatory performances assessed.

Results

Seventeen nodules were malignant (13 papillary, 4 other cancers), 45 benign (43 hyperplastic nodules, 2 focal thyroiditis), 5 indeterminate (“follicular lesions”), and 5 had inadequate cytology. SWE results were higher in malignant than benign nodules (P values 0.02–0.05) although their discriminatory performances were mediocre (AUCs 0.58–0.74). The most accurate SWE cut-off, 34.5 kPa for a 2-mm region of interest, achieved 76.9?% sensitivity and 71.1?% specificity for discriminating papillary cancer from benign nodules. No thresholds produced high sensitivity without lowering specificity appreciably, and vice versa. Nodule size correlated with SWE for benign nodules (P?<?0.01). Intranodular cystic change or calcification did not influence SWE. Qualitatively, elastographic artefacts and foci lacking colour elasticity signal occurred in some solid nodules.

Conclusion

Although malignant nodules are generally stiffer than benign nodules, the precision results do not suggest a definitive role for SWE, at present, in identifying or excluding thyroid malignancy.

Key Points

? Shear wave ultrasound elastography (SWE) offers new insight into thyroid disease. ? Papillary cancers have higher SWE indices (equating to higher stiffness) than benign nodules. ? SWE appears limited in terms of identifying or excluding thyroid malignancy accurately. ? Vertically aligned elastographic artefacts can occur in thyroid SWE. ? Areas lacking SWE colour signal can occur in some solid thyroid nodules.     

MR imaging findings of vertebral involvement in Gorham–Stout disease,generalized lymphatic anomaly,and kaposiform lymphangiomatosis

Purpose

To assess the MR imaging findings of vertebral involvement in Gorham–Stout disease (GSD), generalized lymphatic anomaly (GLA), and kaposiform lymphangiomatosis (KLA).

Methods

Nine patients (three patients with GSD, three with GLA, and three with KLA) who underwent whole-spine MR examinations were included. MR findings of fatty marrow replacement and prolonged T1 and T2 lesions of the vertebrae were retrospectively assessed. Prolonged T1 and T2 lesions were defined as well-defined and round-, oval-, or geographic-shaped areas.

Results

Six patients [one (33%) patient with GSD, two (67%) with GLA, and three (100%) with KLA] showed both fatty marrow replacement and prolonged T1 and T2 lesions. Fatty marrow replacement was seen in the cervical spine of two (33%) patients, thoracic spine of six (100%), lumbar spine of six (100%), and sacral spine of two (33%). Prolonged T1 and T2 lesions were seen in the cervical spine of three (50%) patients, thoracic spine of three (50%), lumbar spine of six (100%), and sacral spine of three (50%).

Conclusion

Both fatty marrow replacement and prolonged T1 and T2 lesions of the vertebrae could be observed in GSD, GLA, and KLA. The most commonly affected site was the lumbar spine, followed by the thoracic spine.

     

Invasive Verfahren zur Abklärung pulmonaler Rundherde

Clinical/methodical issue

The management of solitary lung nodules poses a common clinical problem and biopsy is oftten required. Several guidelines provide slightly different recommendations and there are no uniform recommendations regarding the ideal technique of puncture guidance (e.g. percutaneous versus bronchoscopic or thoracoscopic).

Standard radiological methods

Fine needle aspiration biopsy (FNA) and core biopsy are well established techniques. Both can be performed under CT and to some extent ultrasound guidance.

Performance

Diagnostic accuracies of FNA and core biopsy for malignant lesions are around 95?%. Core biopsy is superior to FNA for establishing a specific diagnosis with a diagnostic yield of 81–88?% versus 17–21?%.

Achievements

In clinical routine practice core biopsy is the superior tool when compared to FNA.

Practical recommendations

Central lesions in close proximity to bronchi may be biopsied with endobronchial ultrasound (EBUS)-guided bronchoscopy. In all other lesions percutaneous, ideally CT-guided biopsy should be the method of first choice.     

Dynamic 4D MR angiography versus multislice CT angiography in the evaluation of vascular hepatic involvement in hereditary haemorrhagic telangiectasia

Purpose

Hereditary haemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber disease, is a rare autosomal dominant disorder characterised by mucocutaneous or visceral vascular abnormalities that may be widely distributed throughout the cardiovascular system. The purpose of this study was to compare multislice computed tomography angiography (MSCTA) and 4D dynamic contrast-enhanced magnetic resonance angiography (D-MRA) for evaluating vascular hepatic involvement in patients with HHT.

Materials and methods

Fifty-two consecutive HHT patients underwent MSCTA and D-MRA examinations for systematic analysis of vascular visceral involvement. The images from the two techniques were reviewed independently by two expert radiologists to identify the following vascular abnormalities: telangiectases or large vascular masses; perfusion disorders [transient hepatic attenuation differences (THADs)]; hepatic arteriovenous malformations (HAVMs). Data, as well as diameters of the common hepatic artery and portal vein, were compared with Cohen??s kappa statistic, Student??s t test and receiver operating characteristic (ROC) curve analysis, as appropriate.

Results

Both MSCTA and D-MRA detected one or more of the following hepatic vascular abnormalities in 36/52 cases (telangiectases in 29/52, THADs in 23/52 and HAVMs in 25/52[CE1]). A good concordance was found between the two techniques when determining the type of hepatic shunt (??=0.9). No statistically significant differences were found when comparing mean common hepatic artery and portal vein diameters (p=0.09 and 0.22, respectively) and their accuracy in predicting HAVMs.

Conclusions

D-MRA has the same diagnostic accuracy as MSCTA and has the advantage of being less invasive due to the absence of ionising radiation.     

Identifying the most infectious lesions in pulmonary tuberculosis by high-resolution multi-detector computed tomography

Objective:

This study aimed to determine whether characteristics detected by multi-detector computed tomography (MDCT) were predictive of highly infectious, smear-positive, active pulmonary tuberculosis (PTB).

Methods:

Among 124 patients with active PTB, 84 had positive (group 1) and 40 had negative (group 2) smear results for acid-fast bacilli. Multiplanar MDCT, axial conventional CT and chest X-ray images were analysed retrospectively for morphology, number, and segmental (lobe) distribution of lesions.

Results:

By multivariate analysis, consolidation over any segment of the upper, middle, or lingual lobes, cavitations, and clusters of nodules were associated with group 1, while centrilobular nodules were predictive of group 2. Using five independent variables associated with risk in group 1, a prediction model was created to distinguish between group 1 and group 2. ROC curve analysis showed an area under the curve of 0.951?±?0.021 for this prediction model. With the ideal cutoff point score of 1, the sensitivity, specificity, and positive predictive values were 84.5%, 97.5%, and 98.0%, respectively.

Conclusions:

A model to predict smear-positive active PTB on the basis of findings from MDCT may be a useful tool for clinical decisions about isolating patients pending sputum smear results.     

MRI characteristics of nodular fasciitis of the musculoskeletal system

Objective

To evaluate MRI imaging appearances of nodular fasciitis in a pathologic-proven series of 29 patients.

Materials and methods

Review of the orthopedic oncology and pathology databases yielded 51 cases of histologically proven nodular fasciitis. MR imaging was available in 29 patients. Three musculoskeletal radiologists retrospectively reviewed all cases in consensus. Imaging features evaluated included location in the body, size, compartmental localization, relationship to fascia, signal characteristics, enhancement pattern, transcompartmental extension, and osseous and intra-articular involvement.

Results

There were 15 male and 14 female patients. Mean age was 33 years (range, 16–59 years). Lesions ranged in size from 1.6 to 9 cm with 84 % of lesions measuring less than 4 cm. Twenty-three lesions were located in the upper arm or shoulder girdle. Nine lesions were subcutaneous in location, nine were intra-muscular, and 11 were inter-muscular. Lesions were consistently ovoid in shape with broad fascial contact. They exhibited internal homogenous low T1 and heterogeneous intermediate T2 signal with surrounding edema and slightly inhomogeneous enhancement. Twelve lesions exhibited central non-enhancing areas. Trans-compartmental spread was demonstrated in nine lesions. Osseous changes were seen in five cases and included extrinsic cortical saucerization, medullary edema, and transcortical osseous invasion. Two lesions demonstrated intra-articular extension.

Conclusions

MR imaging features of nodular fasciitis are generally non-specific and can be mistaken for a soft tissue sarcoma. This series, the largest MRI series of musculoskeletal cases in the literature, confirms the predilection of nodular fasciitis for the upper extremity in young adults but also demonstrates that aggressive imaging features such as transcompartmental spread, and osseous and intra-articular involvement may be seen in association with this benign soft tissue lesion.     

Prospective evaluation in 123 patients of strain ratio as provided by quantitative elastosonography and multiparametric ultrasound evaluation (ultrasound score) for the characterisation of thyroid nodules

Purpose

This study was done to compare quantitative elastosonography and ultrasound analysis in the characterisation of thyroid nodules.

Materials and methods

From July 2009 to September 2011, 123 patients with 147 thyroid nodules were included in our study. All patients enrolled had to undergo thyroidectomy because of nodular thyroid disease (goitre or nodules). After preliminary examination with conventional ultrasound (US) and colour Doppler US, the patients were examined with elastosonography, using high-level equipment (Toshiba Aplio XG) and quantitative software (Elasto-Q). Each lesion was characterised using an US score (echogenicity, borders, microcalcifications and colour Doppler pattern), and then by elastosonographic strain ratio. Each patient subsequently underwent thyroidectomy. Histological results were used as the gold standard.

Results

Histological examination demonstrated 89 benign and 58 malignant lesions. On average, the strain ratio value was 2.84±2.69 (range, 0.05–14.5; p=0.001). Sensitivity and specificity of the US score were about 56% and 72%, respectively, whereas those of the strain ratio were 93% and 89%, using a cut-off of 2 obtained with receiver operating characteristic (ROC) curve analysis. Elastosonography was more accurate than US and colour Doppler US in characterising thyroid nodules (p=0.002).

Conclusions

Quantitative elastosonography is a useful diagnostic tool in the evaluation of thyroid lesions, and can be used to limit fine-needle aspiration cytology and improve the selection of patients for thyroidectomy.     

Erdheim-Chester disease: clinical and radiological findings

Purpose

The authors retrospectively reviewed six cases of histologically proven Erdheim-Chester disease (ECD) to evaluate organ involvement and clinical and radiological findings.

Materials and methods

Through a search of the pathology databases of four Italian hospitals, we identified six men (mean age, 56 years) with a histological diagnosis of ECD. Histology was performed on retroperitoneal or pulmonary biopsy, depending on disease involvement on imaging. Patients underwent plain radiography of the lower limbs and chest, total-body computed tomography (CT) and bone scintigraphy. Magnetic resonance (MR) imaging was performed in two patients to evaluate the lower limbs and in one patient to study the brain, the chest and the abdomen.

Results

Clinical manifestations included dyspnoea (n=2), hydronephrosis (n=2) and bone pain (n=1). Bilateral symmetrical osteosclerosis of the metaphyseal and diaphyseal portions of the lower-limb long bones was present in five patients. Imaging studies revealed extraskeletal manifestations in all patients, including involvement of the retroperitoneal space (n=4), the lung (n=4) and the heart (n=2).

Conclusions

ECD is a multiorgan disease that displays constant involvement of the bones and retroperitoneum; in particular, of the perirenal fat. Although the diagnosis of ECD is histological, imaging can raise suspicion and help to establish a presumptive diagnosis.     

Assessment of pulmonary melanoma metastases with 18F-FDG PET/CT: which PET-negative patients require additional tests for definitive staging?

Objectives

To determine, in patients with melanoma, the dependence of PET sensitivity on pulmonary metastasis size, and to determine patients who require further evaluation for definite staging.

Methods

Of 183 melanoma patients who underwent ¹⁸F-fluorodeoxyglucose PET/computed tomography (CT) for staging or follow-up between January 2008 and June 2011, 38 patients (18 women and 20 men; mean age 62.0?±?14.7?years) with one or more pulmonary metastases visible on CT were included in the retrospective study. Each pulmonary metastasis was rated as positive or negative on PET, and lesion size (maximum transverse diameter) was assessed on CT. PET sensitivity was calculated according to the lesions’ size, in 2-mm steps.

Results

A total of 181 pulmonary metastases were analysed. PET sensitivity was 7.9?% for lesions of 4–5?mm; 33.3?% for lesions of 6–7?mm; 56.8?% for lesions of 8–9?mm; 63.6?% for lesions of 10–11?mm; 100?% for lesions of 12–14?mm; and 100?% for lesions of at least 15?mm. The differences in sensitivity between the size groups were significant (P?<?0.001)

Conclusions

With current state-of-the-art PET/CT technology, additional tests are necessary for definitive staging of melanoma patients who have one or more PET-negative lung nodules less than 12?mm in diameter on expiratory CT.

Key Points

? PET cannot rule out malignancy in pulmonary nodules less than 12?mm on expiratory CT. ? Melanoma patients with PET-negative pulmonary nodules less than 12?mm require additional tests. ? Knowledge of these factors can help interpretation of PET and PET/CT findings.     

Bias, underestimation of risk, and loss of statistical power in patient-level analyses of lesion detection

Purpose

Sensitivity and the false positive rate are usually defined with the patient as the unit of observation, i.e., the diagnostic test detects or does not detect disease in a patient. For tests designed to find and diagnose lesions, e.g., lung nodules, the usual definitions of sensitivity and specificity may be misleading. In this paper we describe and compare five measures of accuracy of lesion detection.

Methods

The five levels of evaluation considered were patient level without localization, patient level with localization, region of interest (ROI) level without localization, ROI level with localization, and lesion level.

Results

We found that estimators of sensitivity that do not require the reader to correctly locate the lesion overstate sensitivity. Patient-level estimators of sensitivity can be misleading when there is more than one lesion per patient and they reduce study power. Patient-level estimators of the false positive rate can conceal important differences between techniques. Referring clinicians rely on a test’s reported accuracy to both choose the appropriate test and plan management for their patients. If reported sensitivity is overstated, the clinician could choose the test for disease screening, and have false confidence that a negative test represents the true absence of lesions. Similarly, the lower false positive rate associated with patient-level estimators can mislead clinicians about the diagnostic value of the test and consequently that a positive finding is real.

Conclusion

We present clear recommendations for studies assessing and comparing the accuracy of tests tasked with the detection and interpretation of lesions...     

Intraosseous hibernoma: characterization of five cases and literature review

Objective

To describe the imaging and histopathological findings and provide an overview of a recently described and rare cause of bone sclerosis.

Materials and methods

Five cases of intra-osseous hibernoma of bone that presented over the last year. The imaging and histopathology is reviewed.

Results

All cases were identified in asymptomatic middle-aged to elderly adults as incidental findings with bone sclerosis in the axial skeleton. MRI showed lesions that were T1 hypointense to subcutaneous fat and hyperintense to skeletal muscle and one showed contrast enhancement. Glucose avidity was demonstrated on FDGPET in both cases tested and isotope bone scan performed in three cases showed strong positivity in two, but uptake was inconspicuous in one case.

Conclusions

Intra-osseous hibernoma is a rare cause of sclerotic bone lesions, predominating in the axial skeleton of middle-aged and elderly adults. They have a non-aggressive appearance on CT and on MRI are T1 hypointense to subcutaneous fat and hyperintense to skeletal muscle. They are usually T2 hyperintense and may show peripheral contrast enhancement. They may show increased glucose avidity on FDGPET and may or may not be positive on isotope bone scans. We suspect that with ever-increasing use of a variety of imaging techniques, particularly in a setting of staging for malignant disease, more such cases will come to light. This diagnosis should be added to the differential diagnosis of sclerotic bone lesions.     

Magnetic resonance imaging features of the spinal cord in pediatric multiple sclerosis: a preliminary study

Introduction

Spinal cord lesions in adults with multiple sclerosis (MS) are thought to contribute to disability. The magnetic resonance imaging (MRI) appearance and clinical correlates of spinal cord lesions in children with MS have not been reported.

Methods

T1-weighted pre- and post-gadolinium and T2-weighted TSE/FSE spine MR images of 36 children (age, 14.3?±?3.3) with relapsing–remitting MS (annualized relapse rate, 0.7; disease duration, 7.5?±?3.3 years) were analyzed for total lesion count, lesion location and length, intramedullary extent, and gadolinium enhancement. Clinical, demographic, laboratory, and MRI data were correlated.

Results

Lesions preferentially involved the cervical region, were predominantly focal, and involved only a portion of the transverse cord diameter. However, ten of 36 patients demonstrated longitudinally extensive lesions. Children with the highest clinical relapse rate also tended to have more spinal cord lesions and were more likely to accrue new lesions on serial spinal scans.

Conclusion

These preliminary data suggest that MS lesions of the spinal cord in children are radiographically similar to that of adult-onset MS—supporting a common biology of pediatric- and adult-onset disease. However, children with relapsing–remitting MS can also develop longitudinally extensive lesions, suggesting that such lesions may be less specific for diseases such as neuromyelitis optica in pediatric patients. All patients recovered well from spinal cord attacks, and the presence of spinal cord lesions in the first few years of disease did not correlate with physical disability. Measures of spinal cord atrophy and longer periods of observation are required to determine the impact of spinal cord involvement in pediatric-onset MS.     

Hepatocellular carcinoma (HCC) in non-cirrhotic liver: clinical,radiological and pathological findings

Objectives

Our aim was to evaluate the clinical and pathological findings, mutidetector-row computed tomography (MDCT) and magnetic resonance imaging (MRI) appearances, treatment and 1-year survival of patients with HCC in non-cirrhotic liver.

Methods

Histopathological and laboratory findings of 30 non-cirrhotic patients with 32 HCCs were reviewed retrospectively. MDCT and gadobenate dimeglumine-enhanced MR images were evaluated in consensus by two radiologists in terms of HCC size, presence of tumour capsule, necrosis, haemorrhage, fat and calcification, and vascular involvement. Imaging patterns were compared directly with HCC findings in a matched group of cirrhotic patients.

Results

No differences between non-cirrhotic and cirrhotic patients were noted in terms of serum α-fetoprotein levels (elevated in 11 [36.7 %] and 21 [35 %] patients, respectively). The imaging appearance at CT and contrast-enhanced MRI was typical in 27 (84.3 %) and 28 (87.5 %) cases respectively. Most lesions presented as a well-differentiated large solitary mass, with well-defined margins, areas of necrosis and peripheral capsule. No significant differences in HCC pattern were observed between cirrhotic and non-cirrhotic liver.

Conclusions

In non-cirrhotic patients, HCC is more likely to manifest as an asymptomatic mass with elevation of serum tumour markers similar to that seen in cirrhotic patients. HCC in cirrhotic and non-cirrhotic livers show similar enhancement patterns.

Key Points

• HCC shows similar CT/MRI pattern in cirrhotic and non-cirrhotic livers.
• Non-invasive diagnostic criteria for HCC should also be extended to non-cirrhotic livers.
• No differences were found between α-fetoprotein levels in non-cirrhotic and cirrhotic patients.

     

Hepatocellular carcinoma in cirrhotic patients: prospective comparison of US, CT and MR imaging

Objectives

To prospectively compare the diagnostic performance of ultrasound (US), multidetector computed tomography (MDCT) and contrast-enhanced magnetic resonance imaging (MRI) in cirrhotic patients who were candidates for liver transplantation.

Methods

One hundred and forty consecutive patients with 163 hepatocellular carcinoma (HCC) nodules underwent US, MRI and MDCT. Diagnosis of HCC was based on pathological findings or substantial growth at 12-month follow-up. Four different image datasets were evaluated: US, MDCT, MRI unenhanced and dynamic phases, MRI unenhanced dynamic and hepatobiliary phase. Diagnostic accuracy, sensitivity, specificity, PPV and NPV, with corresponding 95 % confidence intervals, were determined. Statistical analysis was performed for all lesions and for three lesion subgroups (<1 cm, 1-2 cm, >2 cm).

Results

Significantly higher diagnostic accuracy, sensitivity and NPV was achieved on dynamic + hepatobiliary phase MRI compared with US, MDCT and dynamic phase MRI alone. The specificity and PPV of US was significantly lower than that of MDCT, dynamic phase MRI and dynamic + hepatobiliary phase MRI. Similar results were obtained for all sub-group analyses, with particular benefit for the diagnosis of smaller lesions between 1 and 2 cm.

Conclusions

Dynamic + hepatobiliary phase MRI improved detection and characterisation of HCC in cirrhotic patients. The greatest benefit is for diagnosing lesions between 1 and 2 cm.

Key Points

? US, CT and MRI can all identify HCC in cirrhotic patients ? US has good sensitivity but suffers from false-positive findings ? Dynamic CT and MR have similar diagnostic performance for diagnosing HCC ? Dynamic + hepatobiliary phase MRI significantly improves detection and characterisation of HCC ? The greatest benefit is for the diagnosis of lesions between 1 and 2 cm