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Multicenter Study
. 2024 Dec;34(12):7661-7672.
doi: 10.1007/s00330-024-10829-x. Epub 2024 Jun 20.

Lesions hyper- to isointense to surrounding liver in the hepatobiliary phase of gadoxetic acid-enhanced MRI

Alicia Furumaya #  1   2 , François E J A Willemssen #  3 , Razvan L Miclea  4 , Martijn P D Haring  5 , Robbert J de Haas  6 , Shirin Feshtali  7 , Inge J S Vanhooymissen  8   9 , Daniel Bos  3   10 , Robert A de Man  11 , Jan N M Ijzermans  12 , Joris I Erdmann  13   8 , Joanne Verheij  8   14 , Michail C Doukas  15 , Otto M van Delden  8   16 , Maarten G J Thomeer  3
Affiliations
Multicenter Study

Lesions hyper- to isointense to surrounding liver in the hepatobiliary phase of gadoxetic acid-enhanced MRI

Alicia Furumaya et al. Eur Radiol. 2024 Dec.

Abstract

Objectives: Hyper- or isointensity in the hepatobiliary phase (HBP) of gadoxetic acid-enhanced MRI has high specificity for focal nodular hyperplasia (FNH) but may be present in hepatocellular adenoma and carcinoma (HCA/HCC). This study aimed to identify imaging characteristics differentiating FNH and HCA/HCC.

Materials and methods: This multicenter retrospective cohort study included patients with pathology-proven FNH or HCA/HCC, hyper-/isointense in the HBP of gadoxetic acid-enhanced MRI between 2010 and 2020. Diagnostic performance of imaging characteristics for the differentiation between FNH and HCA/HCC were reported. Univariable analyses, multivariable logistic regression analyses, and classification and regression tree (CART) analyses were conducted. Sensitivity analyses evaluated imaging characteristics of B-catenin-activated HCA.

Results: In total, 124 patients (mean age 40 years, standard deviation 10 years, 108 female) with 128 hyper-/isointense lesions were included. Pathology diagnoses were FNH and HCA/HCC in 64 lesions (50%) and HCA/HCC in 64 lesions (50%). Imaging characteristics observed exclusively in HCA/HCC were raster and atoll fingerprint patterns in the HBP, sinusoidal dilatation on T2-w, hemosiderin, T1-w in-phase hyperintensity, venous washout, and nodule-in-nodule partification in the HBP and T2-w. Multivariable logistic regression and CART additionally found a T2-w scar indicating FNH, less than 50% fat, and a spherical contour indicating HCA/HCC. In our selected cohort, 14/48 (29%) of HCA were B-catenin activated, most (13/14) showed extensive hyper-/isointensity, and some had a T2-w scar (4/14, 29%).

Conclusion: If the aforementioned characteristics typical for HCA/HCC are encountered in lesions extensively hyper- to isointense, further investigation may be warranted to exclude B-catenin-activated HCA.

Clinical relevance: Hyper- or isointensity in the HBP of gadoxetic acid-enhanced MRI is specific for FNH, but HCA/HCC can also exhibit this feature. Therefore, we described imaging patterns to differentiate these entities.

Key points: FNH and HCA/HCC have similar HBP intensities but have different malignant potentials. Six imaging patterns exclusive to HCA/HCC were identified in this lesion population. These features in liver lesions hyper- to isointense in the HBP warrant further evaluation.

Keywords: Focal nodular hyperplasia; Gadolinium DTPA; Hepatocellular carcinoma; Liver cell adenoma; Magnetic resonance imaging.

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Conflict of interest statement

Compliance with ethical standards Guarantor The scientific guarantor of this publication is Dr. MGJ Thomeer. 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 of the authors has significant statistical expertise. Informed consent Written informed consent was not required for this study because an opt-out procedure was applied. Ethical approval Institutional Review Board approval was not required because the study was beyond the Dutch Medical Research Involving Human Subjects Act (WMO). Methodology RetrospectiveDiagnostic or prognostic studyMulticenter study

Figures

Fig. 1
Fig. 1
Flowchart of the inclusion process
Fig. 2
Fig. 2
CART and multivariable logistic regression analysis. Figure shows imaging characteristics exclusively identified in HCA/HCC (top part of the figure), and combines the results of the multivariable logistic regression and CART analysis (bottom part of the figure, shaded in gray). The tree structure and division of categorical variables are derived from the CART analysis. The odds ratios are derived from multivariable logistic regression. The occurrence of the identified imaging characteristics in the respective groups is shown in the circles on the right part of the figure
Fig. 3
Fig. 3
Case of a patient with imaging features suggestive of FNH occurring in a B-catenin-activated HCA. Large liver mass (B-catenin inflammatory HCA, exon 3, non-S45) in a 21-year-old female using oral contraceptives. On T1-w in-phase and out-of-phase imaging (a, b), we can appreciate a slightly intrinsically hyperintense tumor (226 vs 186 units) which is hypervascular during the arterial and venous phase (c, d). During the HBP (20 min) (e), the tumor is clearly hyper- to isointense to the surrounding liver. Mainly in the center of the lesion, some hypointense lines can be seen, which possibly comprise scar tissue. On T2-w imaging with fat suppression a large rim of hyperintense signal can be visualized and central inhomogeneity (f). This was classified as sinusoidal dilatation with possible atoll configuration. There was no restriction on the apparent diffusion coefficient map (g, h). The combination of extensive hyper- or isointense signal in the HBP (typical for FNH), together with features very typical or unequivocal for HCA/HCC (sinusoidal dilatation and T1-w intrinsic hyperintensity) should prompt a biopsy. The presence of a scar (which is typical for FNH) should not mislead the reader in this situation
See this image and copyright information in PMC

Comment in

References

    1. Fujita N, Nishie A, Asayama Y et al (2020) Hyperintense liver masses at hepatobiliary phase gadoxetic acid-enhanced MRI: imaging appearances and clinical importance. Radiographics 40:72–94. 10.1148/rg.2020190037 - PubMed
    1. Merkle EM, Zech CJ, Bartolozzi C et al (2016) Consensus report from the 7th international forum for liver magnetic resonance imaging. Eur Radiol 26:674–682. 10.1007/s00330-015-3873-2 - PMC - PubMed
    1. Palmucci S (2014) Focal liver lesions detection and characterization: the advantages of gadoxetic acid-enhanced liver MRI. World J Hepatol 6:477–485. 10.4254/wjh.v6.i7.477 - PMC - PubMed
    1. European Association for the Study of the Liver (2016) EASL clinical practice guidelines on the management of benign liver tumours. J Hepatol 65:386–398. 10.1016/j.jhep.2016.04.001 - PubMed
    1. Stoot JH, Coelen RJ, De Jong MC, Dejong CH (2010) Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases. HPB (Oxford) 12:509–522. 10.1111/j.1477-2574.2010.00222.x - PMC - PubMed

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