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Can absolute arterial phase hyperenhancement improve sensitivity of detection of hepatocellular carcinoma in indeterminate nodules on CT?

  • Hepatobiliary-Pancreas
  • Published:
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Abstract

Objectives

To determine if quantitative assessment of relative (R) and absolute (A) arterial phase hyperenhancement (APHE) and washout (WO) applied to indeterminate nodules on CT would improve the overall sensitivity of detection of hepatocellular carcinoma (HCC).

Methods

One-hundred and fourteen patients (90 male; mean age, 65 years) with 210 treatment-naïve HCC nodules (190 HCCs, 20 benign) who underwent 4-phase CT were included in this retrospective study. Four radiologists independently assigned a qualitative LR (LI-RADS) category per nodule. LR-3/4 nodules were then quantitatively analyzed by the 4 readers, placing ROIs within nodules and adjacent liver parenchyma. A/R-APHE and WO were calculated, and per-reader sensitivity and specificity updated. Interobserver agreement and AUCs were calculated per reader.

Results

Qualitative readers 1–4 categorized 57, 69, 57, and 63 nodules as LR-3/4 respectively with moderate to substantial agreement in LR category (kappa 0.56–0.69, p < 0.0001); their diagnostic performances in the detection of HCC were 80%, 73.2%, 77.4%, and 77.4% sensitivity, and 100%, 95%, 70%, and 100% specificity, respectively. A threshold of ≥ 20 HU for A-APHE increased overall sensitivity of HCC detection by 0.5–3.1% without changing specificity for the subset of nodules APHE − /WO + on qualitative read, with 2, 6, 6, and 1 additional HCC detected by readers 1–4. Relative and various A-WO formulae and thresholds all increased sensitivity, but with a drop in specificity for some/all readers.

Conclusion

Quantitatively assessed A-APHE showed potential to increase sensitivity and maintain specificity of HCC diagnosis when selectively applied to indeterminate nodules demonstrating WO without subjective APHE. Quantitatively assessed R and A-WO increased sensitivity, however reduced specificity.

Clinical relevance statement

A workflow using selective quantification of absolute arterial enhancement is routinely employed in the CT assessment of renal and adrenal nodules. Quantitatively assessed absolute arterial enhancement is a simple tool which may be used as an adjunct to help increase sensitivity and maintain specificity of HCC diagnosis in indeterminate nodules demonstrating WO without subjective APHE.

Key Points

• In indeterminate nodules categorized as LI-RADS 3/4 due to absent subjective arterial phase hyperenhancement, a cut-off for absolute arterial phase hyperenhancement of ≥ 20 HU may increase the overall sensitivity of detection of HCC by 0.5–3.1% without affecting specificity.

• Relative and various absolute washout formulae and cut-offs increased sensitivity of HCC detection, but with a drop in specificity for some/all readers.

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Abbreviations

A-:

Absolute

AUC:

Area under the ROC curve

AP:

Arterial phase

APHE:

Arterial phase hyperenhancement

APHE − /WO + :

Nodule without arterial phase hyperenhancement demonstrating washout

APHE + /WO − :

Nodule with arterial phase hyperenhancement but no washout

CI:

Confidence interval

CEUS:

Contrast enhanced ultrasound

CT:

Computed tomography

DP:

Delayed phase

FN:

False negative

FP:

False positive

HCC:

Hepatocellular carcinoma

HU:

Hounsfield units

ICC:

Intraclass correlation coefficient

Κ:

Cohen’s kappa

LI-RADS:

Liver Imaging Reporting and Data System (LI-RADS v. 2018)

LR:

LI-RADS

MRI:

Magnetic resonance imaging

MAHU:

Mean attenuation in Hounsfield units

PV:

Portal venous phase

PRE:

Unenhanced phase

R-:

Relative

ROI:

Region of interest

ROC curve:

Receiver operating characteristic curve

SD:

Standard deviation

TAE:

Trans-arterial embolization

TIV:

Tumor in vein

TN:

True negative

TP:

True positive

WO:

Washout

US:

Ultrasound

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Funding

This study was supported through protected research time provided by University Medical Imaging Toronto for Dr. Korosh Khalili.

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Authors and Affiliations

  1. Department of Medical Imaging, University of Toronto Joint Department of Medical Imaging, University Health Network, Princess Margaret Hospital, 610 University Avenue, Room 3-964, Toronto, Ontario, M5G 2M9, Canada

    Sara Zafar, Khaled Y Elbanna, Andrew W M Todd, Luis Guimaraes, Ciara O’Brien, Ankur Goel, Tae Kyoung Kim & Korosh Khalili

Authors
  1. Sara Zafar
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  2. Khaled Y Elbanna
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  3. Andrew W M Todd
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  4. Luis Guimaraes
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  6. Ankur Goel
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  7. Tae Kyoung Kim
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  8. Korosh Khalili
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Corresponding author

Correspondence to Korosh Khalili.

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Guarantor

The scientific guarantor of this publication is Dr. Korosh Khalili.

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

Pascal Tyrell, PhD Statistics and Epidemiology, and Sylvia Li, Masters, kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained (Health Sciences Research Ethics Board, University of Toronto).

Study subjects or cohorts overlap

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Methodology

• Retrospective

• Observational

• Performed at one institution

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Zafar, S., Elbanna, K.Y., Todd, A.W.M. et al. Can absolute arterial phase hyperenhancement improve sensitivity of detection of hepatocellular carcinoma in indeterminate nodules on CT?. Eur Radiol 34, 2256–2268 (2024). https://doi.org/10.1007/s00330-023-10237-7

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  • DOI: https://doi.org/10.1007/s00330-023-10237-7

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