Wavelet-Based Hybrid Thresholding Method for Ultrasonic Liver Image Denoising

This paper presents a wavelet-based hybrid threshold method according to the soft- and hard-threshold functions proposed by Donoho. The wavelet-based hybrid threshold method may help doctors to know more details on the liver disease through denoising the ultrasound image of the liver. First of all, an analytical expression for the hybrid threshold function is discussed. The wavelet-based hybrid threshold method is then investigated for ultrasound image of the liver. Finally, we test the influence of this parameter on the proposed method with the real ultrasound image corrupted by speckle noise with different variances. Moreover, we compare the proposed method under the varying parameters with the soft-threshold function and the hard-threshold function. Three metrics, which are correlation coefficient, edge preservation index and structural similarity index, are measured to quantify the denoised results of ultrasound liver image. Experimental results demonstrate the potential of the proposed method for ultrasound liver image denosing.

Diffusion weighted magnetic resonance imaging of liver: Principles, clinical applications and recent updates

Diffusion-weighted imaging(DWI), a functional imaging technique exploiting the Brownian motion of water molecules, is increasingly shown to have value in various oncological and non-oncological applications. Factors such as the ease of acquisition and ability to obtain functional information in the absence of intravenous contrast, especially in patients with abnormal renal function, have contributed to the growing interest in exploring clinical applications of DWI. In the liver, DWI demonstrates a gamut of clinical applications ranging from detecting focal liver lesions to monitoring response in patients undergoing serial follow-up after loco-regional and systemic therapies. DWI is also being applied in the evaluation of diffuse liver diseases such as non-alcoholic fatty liver disease, hepatic fibrosis and cirrhosis. In this review, we intend to review the basic principles, technique, current clinical applications and future trends of DW-MRI in the liver.

Contrast-enhanced ultrasound Liver Imaging Reporting and Data System:Lights and shadows in hepatocellular carcinoma and cholangiocellular carcinoma diagnosis

BACKGROUND Contrast-enhanced ultrasound(CEUS)is considered a secondary examination compared to computed tomography(CT)and magnetic resonance imaging(MRI)in the diagnosis of hepatocellular carcinoma(HCC),due to the risk of misdiagnosing intrahepatic cholangiocarcinoma(ICC).The introduction of CEUS Liver Imaging Reporting and Data System(CEUS LI-RADS)might overcome this limitation.Even though data from the literature seems promising,its reliability in real-life context has not been well-established yet.AIM To test the accuracy of CEUS LI-RADS for correctly diagnosing HCC and ICC in cirrhosis.METHODS CEUS LI-RADS class was retrospectively assigned to 511 nodules identified in 269 patients suffering from liver cirrhosis.The diagnostic standard for all nodules was either biopsy(102 nodules)or CT/MRI(409 nodules).Common diagnostic accuracy indexes such as sensitivity,specificity,positive predictive value(PPV),and negative predictive value(NPV)were assessed for the following associations:CEUS LR-5 and HCC;CEUS LR-4 and 5 merged class and HCC;CEUS LR-M and ICC;and CEUS LR-3 and malignancy.The frequency of malignant lesions in CEUS LR-3 subgroups with different CEUS patterns was also determined.Inter-rater agreement for CEUS LI-RADS class assignment and for major CEUS pattern identification was evaluated.RESULTS CEUS LR-5 predicted HCC with a 67.6%sensitivity,97.7%specificity,and 99.3%PPV(P<0.001).The merging of LR-4 and 5 offered an improved 93.9%sensitivity in HCC diagnosis with a 94.3%specificity and 98.8%PPV(P<0.001).CEUS LR-M predicted ICC with a 91.3%sensitivity,96.7%specificity,and 99.6%NPV(P<0.001).CEUS LR-3 predominantly included benign lesions(only 28.8%of malignancies).In this class,the hypo-hypo pattern showed a much higher rate of malignant lesions(73.3%)than the iso-iso pattern(2.6%).Inter-rater agreement between internal raters for CEUS-LR class assignment was almost perfect(n=511,k=0.94,P<0.001),while the agreement among raters from separate centres was substantial(n=50,k=0.67,P<0.001).Agreement was stronger for arterial phase hyperenhancement(internal k=0.86,P<2.7×10-214;external k=0.8,P<0.001)than washout(internal k=0.79,P<1.6×10-202;external k=0.71,P<0.001).CONCLUSION CEUS LI-RADS is effective but can be improved by merging LR-4 and 5 to diagnose HCC and by splitting LR-3 into two subgroups to differentiate iso-iso nodules from other patterns.

Interobserver agreement for contrast-enhanced ultrasound of liver imaging reporting and data system:A systematic review and metaanalysis

BACKGROUND Hepatocellular carcinoma is the most common primary liver malignancy.From the results of previous studies,Liver Imaging Reporting and Data System(LIRADS)on contrast-enhanced ultrasound(CEUS)has shown satisfactory diagnostic value.However,a unified conclusion on the interobserver stability of this innovative ultrasound imaging has not been determined.The present metaanalysis examined the interobserver agreement of CEUS LI-RADS to provide some reference for subsequent related research.AIM To evaluate the interobserver agreement of LI-RADS on CEUS and analyze the sources of heterogeneity between studies.METHODS Relevant papers on the subject of interobserver agreement on CEUS LI-RADS published before March 1,2020 in China and other countries were analyzed.The studies were filtered,and the diagnostic criteria were evaluated.The selected references were analyzed using the“meta”and“metafor”packages of R software version 3.6.2.RESULTS Eight studies were ultimately included in the present analysis.Meta-analysis results revealed that the summary Kappa value of included studies was 0.76[95%confidence interval,0.67-0.83],which shows substantial agreement.Higgins I2 statistics also confirmed the substantial heterogeneity(I2=91.30%,95%confidence interval,85.3%-94.9%,P<0.01).Meta-regression identified the variables,including the method of patient enrollment,method of consistency testing,and patient race,which explained the substantial study heterogeneity.CONCLUSION CEUS LI-RADS demonstrated overall substantial interobserver agreement,but heterogeneous results between studies were also obvious.Further clinical investigations should consider a modified recommendation about the experimental design.

Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment: Lessons learned and future directions

Hepatocellular carcinoma(HCC)is a leading cause of morbidity and mortality worldwide,with rising clinical and economic burden as incidence increases.There are a multitude of evolving treatment options,including locoregional therapies which can be used alone,in combination with each other,or in combination with systemic therapy.These treatment options have shown to be effective in achieving remission,controlling tumor progression,improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients.Following locoregional therapy(LRT),it is crucial to provide treatment response assessment to guide management and liver transplant candidacy.Therefore,Liver Imaging Reporting and Data Systems(LI-RADS)Treatment Response Algorithm(TRA)was created to provide a standardized assessment of HCC following LRT.LIRADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment.In this review,we provide an overview of different locoregional therapies for HCC,describe the expected post treatment imaging appearance following treatment,and review the LI-RADS TRA with guidance for its application in clinical practice.Unique to other publications,we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.

Differentiating malignant and benign focal liver lesions in children using CEUS LI-RADS combined with serum alpha-fetoprotein

BACKGROUND Contrast-enhanced ultrasound(CEUS)can be used to diagnose focal liver lesions(FLLs)in children.The America College of Radiology developed the CEUS liver imaging reporting and data system(LI-RADS)for standardizing CEUS diagnosis of FLLs in adult patients.Until now,no similar consensus or guidelines have existed for pediatric patients to improve imaging interpretation as adults.AIM To evaluate the performance of CEUS LI-RADS combined with alpha-fetoprotein(AFP)in differentiating benign and malignant FLLs in pediatric patients.METHODS Between January 2011 and January 2021,patients≤18 years old who underwent CEUS for FLLs were retrospectively evaluated.The following criteria for diagnosing malignancy were proposed:Criterion I considered LR-4,LR-5,or LRM lesions as malignancies;criterion II regarded LR-4,LR-5 or LR-M lesions with simultaneously elevated AFP(≥20 ng/mL)as malignancies;criterion III took LR-4 Lesions with elevated AFP or LR-5 or LR-M lesions as malignancies.The sensitivity,specificity,accuracy and area under the receiver operating characteristic curve(AUC)were calculated to determine the diagnostic value of the aforementioned criteria.RESULTS The study included 63 nodules in 60 patients(mean age,11.0±5.2 years;26 male).There were no statistically significant differences between the specificity,accuracy,or AUC of criterion II and criterion III(95.1%vs 80.5%,84.1%vs 87.3%,and 0.794 vs 0.902;all P>0.017).Notably,criterion III showed a higher diagnostic sensitivity than criterion II(100%vs 63.6%;P<0.017).However,both the specificity and accuracy of criterion I was inferior to those of criterion II and criterion III(all P<0.017).For pediatric patients more than 5 years old,the performance of the three criteria was overall similar when patients were subcategorized by age when compared to all patients in aggregate.CONCLUSION CEUS LI-RADS combined with AFP may be a powerful diagnostic tool in pediatric patients.LR-4 with elevated AFP,LR-5 or LR-M lesions is highly suggestive of malignant tumors.

Impact of intra-operative cholangiography and parenchymal resection to donor liver function in living donor liver transplantation

BACKGROUND: Living donor liver transplantation(LDLT)has been widely accepted over the past decade, and hepatic dysfunction often occurs in the donor in the early stage after liver donation. The present study aimed to evaluate the effect of intraoperative cholangiography(IOC) and parenchymal resection on liver function of donors in LDLT, and to assess the role of IOC in influencing the biliary complications and improving the overall outcome.METHODS: Data from 40 patients who had donated their right lobes for LDLT were analyzed. Total bilirubin(TB), alanine aminotransferase(ALT), aspartate aminotransferase(AST),alkaline phosphatase(ALP) and γ-glutamyl transpeptidase(GGT)at different time points were compared, and the follow-up data and the biliary complications were also analyzed.RESULTS: The ALT and AST values were significantly increased after IOC(P<0.001) and parenchymal resection(P<0.001).However, the median values of TB, ALP and GGT were not significantly influenced by IOC(P>0.05) or parenchymal resection(P>0.05). The biochemical changes caused by IOC or parenchymal resection were not correlated with the degree of post-operative liver injury or the recovery of liver function. The liver functions of the donors after operation were stable, and none of the donors suffered from biliary stenosis or leakage during the follow-up.CONCLUSIONS: IOC and parenchymal resection may induce a transient increase in liver enzymes of donors in LDLT, but do not affect the recovery of liver function after operation. Moreover,the routine IOC is helpful to clarify the division line of the hepatic duct, thus reducing the biliary complication rate.

Liver Imaging Reporting and Data System criteria for the diagnosis of hepatocellular carcinoma in clinical practice: A pictorial minireview

Hepatocellular carcinoma(HCC)is the sixth most common cancer.The main risk factors associated with HCC development include hepatitis B virus,hepatitis C virus,alcohol consumption,aflatoxin B1,and nonalcoholic fatty liver disease.However,hepatocarcinogenesis is a complex multistep process.Various factors lead to hepatocyte malignant transformation and HCC development.Diagnosis and surveillance of HCC can be made with the use of liver ultrasound(US)every 6 mo.However,the sensitivity of this imaging method to detect HCC in a cirrhotic liver is limited,due to the abnormal liver parenchyma.Computed tomography(CT)and magnetic resonance imaging(MRI)are considered to be most useful tools for at-risk patients or patients with inadequate US.Liver biopsy is still used for diagnosis and prognosis of HCC in specific nodules that cannot be definitely characterized as HCC by imaging.Recently the American College of Radiology designed the Liver Imaging Reporting and Data System(LI-RADS),which is a comprehensive system for standardized interpretation of CT and MRI liver examinations that was first proposed in 2011.In 2018,it was integrated into the American Association for the Study of Liver Diseases guidance statement for HCC.LI-RADS is designed to ensure high sensitivity,precise categorization,and high positive predictive value for the diagnosis of HCC and is applied to“highrisk populations”according to specific criteria.Most importantly LI-RADS criteria achieved international collaboration and consensus among liver experts around the world on the best practices for caring for patients with or at risk for HCC.

Magnetic resonance-based total liver volume and magnetic resonance-diffusion weighted imaging for staging liver fibrosis in mini-pigs

AIM:To determine whether and how magnetic resonance imaging(MRI)-based total liver volume(TLV) and diffusion weighted imaging(DWI) could predict liver fibrosis.METHODS:Sixteen experimental mature mini-pigs(6 males,10 females),weighing between 20.0 and 24.0 kg were prospectively used to model liver fibrosis induced by intraperitoneal injection of 40% CCl4 dissolved in fat emulsion twice a week for 16 wk,and by feeding 40% CCl4 mixed with maize flour twice daily for the subsequent 5 wk.All the survival animals underwent percutaneous liver biopsy and DWI using b = 300,500 and 800 s/mm2 followed by abdominal gadolinium-enhanced MRI at the 0,5th,9th,16th and 21st weekend after beginning of the modeling.TLV was obtained on enhanced MRI,and apparent diffusion coefficient(ADC) was obtained on DWI.Hepatic tissue specimens were stained with hematoxylin and Masson' s trichrome staining for staging liver fibrosis.Pathological specimens were scored using the human METAVIR classification system.Statistical analyses were performed to determine whether and how the TLV and ADC could be used to predict the stage of liver fibrosis.RESULTS:TLV increased from stage 0 to 2 and decreased from stage 3(r = 0.211;P < 0.001).There was a difference in TLV between stage 0-1 and 2-4(P = 0.03) whereas no difference between stage 0-2 and 3-4(P = 0.71).TLV could predict stage ≥ 2 [area under receiver operating characteristic curve(AUC) = 0.682].There was a decrease in ADC values with increasing stage of fibrosis for b = 300,500 and 800 s/mm2(r =-0.418,-0.535 and-0.622,respectively;all P < 0.001).Differences were found between stage 0-1 and 2-4 in ADC values for b = 300,500 and 800 s/mm2,and between stage 0-2 and 3-4 for b = 500 or 800 s/mm2(all P < 0.05).For predicting stage ≥ 2 and ≥ 3,AUC was 0.803 and 0.847 for b = 500 s/mm2,and 0.848 and 0.887 for b = 800 s/mm2,respectively.CONCLUSION:ADC for b = 500 or 800 s/mm2 could be better than TLV and ADC for b = 300 s/mm2 to pre-dict fibrosis stage ≥ 2 or ≥ 3.

Gd-EOB-DTPA based magnetic resonance imaging for predicting liver response to portal vein embolization

AIM To evaluate the correlation between degree of kinetic growth(k GR) of the liver following portal vein embolization(PVE) liver and the enhancement of the during the hepatobiliary phase of contrast administration and to evaluate if the enhancement can be used to predict response to PVE prior to the procedure.METHODS Seventeen patients were consented for the prospective study.All patients had an MR of the abdomen with GdEOB-DTPA.Fourteen patients underwent PVE.The correlation between the kG R of the liver and the degree of enhancement was evaluated with linear regression(strong assumptions) and Spearman's correlation test(rank based,no assumptions).The correlation was examined for the whole liver,segments I,VIII,VII,VI,V,IV,right liver and left liver.RESULTS There was no correlation between the degree of enhancement during the hepatobiliary phase and kG R for any segment,lobe of the liver or whole liver(P = 0.19 to 0.91 by Spearman's correlation test).CONCLUSION The relative enhancement of the liver during the hepatobiliary phase with Gd-EOB-DTPA cannot be used to predict the liver response to PVE.

Lipid droplets imaging with three-photon microscopy

Lipid droplets(LDs)participate in many physiological processes,the abnormality of which will cause chronic diseases and pathologies such as diabetes and obesity.It is crucial to monitor the distribution of LDs at high spatial resolution and large depth.Herein,we carried three-photon imaging of LDs in fat liver.Owing to the large three-photon absorption cross-section of the luminogen named NAP-CF_(3)(1:67×10^(-79) cm^(6) s^(2)),three-photon fluorescence fat liver imaging reached the largest depth of 80μm.Fat liver diagnosis was successfully carried out with excellent performance,providing great potential for LDs-associated pathologies research.

Magnetic resonance imaging of portal vein invasion in hepatocellular carcinoma:A corroboration of 25 cases

AIMS Pre-operatively to assess tumor thrombus as- sociated with hepatocellular carcinoma in the portal vein. METHEDS Twenty-five patients diagnosed as hav- ing thrombus due to hepatocellular carcinoma were corroborated. MR imaging was perfomed with a 1.0T superconducting magnetic system. Both T1 and T2 weighed images and FLASH sequences were obtained in transverse plane. Additional FLASH images were ob- tained in coronal plane. RESULTS Thrombus in portal vein had a signal in- tensity similar to that of the main tumors. Intrinsic por- tal vein thrombus was in 16 patients. Six cases showed occlusive thrombus. Diffusely narrow portal branches were found in 3 patients. Portal venous thrombus showed an area of signal intensity which was replacing the normal flow void in the portal vein and showed a stumpy portal vein,irregular stenosis of portal vein and the formation of vascular net. CONCLUSION MRI was more sensitive and specific and a noninvasive method in detection of portal tumor thrombus used jointly with spin ech (SE) and gradient echo (GRE) techniques.

Role of diffusion-weighted magnetic resonance imaging in the differential diagnosis of focal hepatic lesions

AIM： To evaluate the utility of diffusion-weighted imaging （DWl） in screening and differential diagnosis of benign and malignant focal hepatic lesions. METHODS： Magnetic resonance imaging （MRI） examinations were performed using the Signa Excite Xl Twin Speed 1.5T system （GE Healthcare, Milwaukee, Wl, USA）. Seventy patients who had undergone MRI of the liver [29 hepatocellular carcinomas （HCC）, four cholangiocarcinomas, 34 metastatic liver cancers, 10 hemangiomas, and eight cysts] between April 2004 and August 2008 were retrospectively evaluated. Visualization of lesions, relative contrast ratio （RCR）, and apparent diffusion coefficient （ADC） were compared between benign and malignant lesions on DWl. Su- perparamagnetic iron oxide （SPIO） was administered to 59 patients, and RCR was compared pre- and postadministration.RESULTS： DWI showed higher contrast between malignant lesions （especially in multiple small metastatic cancers） and surrounding liver parenchyma than did contrast-enhanced computed tomography. ADCs （mean±SD × 10^-3 mm2/s） were significantly lower （P 〈 0.05） in malignant lesions （HCC： 1.31 ± 0.28 and liver metastasis： 1.11 ± 0.22） and were significantly higher in benign lesions （hemangioma： 1.84 ± 0.37 and cyst： 2.61 ± 0.45） than in the surrounding hepatic tissues. RCR between malignant lesions and surrounding he- patic tissues significantly improved after SPIO administration, but RCRs in benign lesions were not improved.CONCLUSION： DWI is a simple and sensitive method for screening focal hepatic lesions and is useful for differential diagnosis.

Contrast-enhanced ultrasound in association with serum biomarkers for differentiating combined hepatocellular-cholangiocarcinoma from hepatocellular carcinoma and intrahepatic cholangiocarcinoma

BACKGROUND Combined hepatocellular-cholangiocarcinoma(CHC)is a rare type of primary liver cancer.Due to its complex histopathological characteristics,the imaging features of CHC can overlap with those of hepatocellular carcinoma(HCC)and intrahepatic cholangiocarcinoma(ICC).AIM To investigate the possibility and efficacy of differentiating CHC from HCC and ICC by using contrast-enhanced ultrasound(CEUS)Liver Imaging Reporting and Data System(LI-RADS)and tumor biomarkers.METHODS Between January 2016 and December 2019,patients with histologically confirmed CHC,ICC and HCC with chronic liver disease were enrolled.The diagnostic formula for CHC was as follows:(1)LR-5 or LR-M with elevated alphafetoprotein(AFP)and carbohydrate antigen 19-9(CA19-9);(2)LR-M with elevated AFP and normal CA19-9;or(3)LR-5 with elevated CA19-9 and normal AFP.The sensitivity,specificity,accuracy and area under the receiver operating characteristic curve were calculated to determine the diagnostic value of the criteria.RESULTS After propensity score matching,134 patients(mean age of 51.4±9.4 years,108 men)were enrolled,including 35 CHC,29 ICC and 70 HCC patients.Based on CEUS LI-RADS classification,74.3%(26/35)and 25.7%(9/35)of CHC lesions were assessed as LR-M and LR-5,respectively.The rates of elevated AFP and CA19-9 in CHC patients were 51.4%and 11.4%,respectively,and simultaneous elevations of AFP and CA19-9 were found in 8.6%(3/35)of CHC patients.The sensitivity,specificity,positive predictive value,negative predictive value,accuracy and area under the receiver operating characteristic curve of the aforementioned diagnostic criteria for discriminating CHC from HCC and ICC were 40.0%,89.9%,58.3%,80.9%,76.9%and 0.649,respectively.When considering the reported prevalence of CHC(0.4%-14.2%),the positive predictive value and NPV were revised to 1.6%-39.6%and 90.1%-99.7%,respectively.CONCLUSION CHCs are more likely to be classified as LR-M than LR-5 by CEUS LI-RADS.The combination of the CEUS LI-RADS classification with serum tumor markers shows high specificity but low sensitivity for the diagnosis of CHC.Moreover,CHC could be confidently excluded with high NPV.

Extended central hepatectomy with preservation of segment 6 for patients with centrally located hepatocellular carcinoma

BACKGROUND： In order to preserve functional liver parenchyma, extended central hepatectomy （segments 4, 5, 7 and 8 resection） was proposed for the management of centrally located hepatocellular carcinoma invading the right and middle hepatic veins, reconstructing segment 6 outflow in the absence of the thick inferior right hepatic vein. The present study was to describe our surgical techniques of extended central hepatectomy.METHODS： Between 2008 and 2012, 5 patients with centrally located hepatocellular carcinoma invading or in the vicinity of the right and middle hepatic veins underwent extended central hepatectomy. The thick inferior right hepatic vein was preserved during dissection. Gore-Tex graft was used for segment 6 outflow reconstruction in the absence of the thick inferior right hepatic vein.RESULTS： The mean future remnant liver volume for segments 2 and 3 was 28% versus 45% on segment 6 preservation. The mean tumor diameter was 7.4 cm. The thick inferior right hepatic vein was found in 1 patient. Outflow reconstruction from segment 6 was performed in 4 patients. Postoperative complications included bile leakage （1 patient）, pleural effusion （2） and liver failure （1）. The rate of graft patency was 75%. There was no perioperative mortality.CONCLUSION： Extended central hepatectomy is a safe alternative for extended hepatic resection in selected patients attempting to preserve the functional liver parenchyma.

Can contrast enhanced ultrasound differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma?

BACKGROUND Hepatocellular carcinoma(HCC)and intrahepatic cholangiocarcinoma(ICC)differ in treatment and prognosis,warranting an effective differential diagnosis between them.The LR-M category in the contrast-enhanced ultrasound(CEUS)liver imaging reporting and data system(LI-RADS)was set up for lesions that are malignant but not specific to HCC.However,a substantial number of HCC cases in this category elevated the diagnostic challenge.AIM To investigate the possibility and efficacy of differentiating ICC from HCC classified in the LR-M category according to the CEUS LI-RADS.METHODS Patients with complete CEUS records together with pathologically confirmed ICC and LR-M HCC(HCC classified in the CEUS LI-RADS LR-M category)between January 2015 and October 2018 were included in this retrospective study.Each ICC was assigned a category as per the CEUS LI-RADS.The enhancement pattern,washout timing,and washout degree between the ICC and LR-M HCC were compared using theχ2 test.Logistic regression analysis was used for prediction of ICC.Receiver operating characteristic(ROC)curve analysis was used to investigate the possibility of LR-M criteria and serum tumor markers in differentiating ICC from LR-M HCC.RESULTS A total of 228 nodules(99 ICCs and 129 LR-M HCCs)in 228 patients were included.The mean sizes of ICC and LR-M HCC were 6.3±2.8 cm and 5.5±3.5 cm,respectively(P=0.03).Peripheral rim-like arterial phase hyperenhancement(APHE)was detected in 50.5%(50/99)of ICCs vs 16.3%(21/129)of LR-M HCCs(P<0.001).Early washout was found in 93.4%(93/99)of ICCs vs 96.1%(124/129)of LR-M HCCs(P>0.05).Marked washout was observed in 23.2%(23/99)of ICCs and 7.8%(10/129)of LR-M HCCs(P=0.002),while this feature did not show up alone either in ICC or LR-M HCC.Homogeneous hyperenhancement was detected in 15.2%(15/99)of ICCs and 37.2%(48/129)of LR-M HCCs(P<0.001).The logistic regression showed that rim APHE,carbohydrate antigen 19-9(CA 19-9),and alpha fetoprotein(AFP)had significant correlations with ICC(r=1.251,3.074,and-2.767,respectively;P<0.01).Rim APHE presented the best enhancement pattern for diagnosing ICC,with an area under the ROC curve(AUC)of 0.70,sensitivity of 70.4%,and specificity of 68.8%.When rim hyperenhancement was coupled with elevated CA 19-9 and normal AFP,the AUC and sensitivity improved to 0.82 and 100%,respectively,with specificity decreasing to 63.9%.CONCLUSION Rim APHE is a key predictor for differentiating ICC from LR-M HCC.Rim APHE plus elevated CA 19-9 and normal AFP is a strong predictor of ICC rather than LR-M HCC.Early washout and marked washout have limited value for the differentiation between the two entities.

Novel model combining contrast-enhanced ultrasound with serology predicts hepatocellular carcinoma recurrence after hepatectomy

BACKGROUND Surgery is the primary curative option in patients with hepatocellular carcinoma(HCC).However,recurrence within 2 years is observed in 30%–50%of patients,being a major cause of mortality.AIM To construct and verify a non-invasive prediction model combining contrastenhanced ultrasound(CEUS)with serology biomarkers to predict the early recurrence of HCC.METHODS Records of 744 consecutive patients undergoing first-line curative surgery for HCC in one institution from 2016–2018 were reviewed,and 292 local patients were selected for analysis.General characteristics including gender and age,CEUS liver imaging reporting and data system(LIRADS)parameters including wash-in time,wash-in type,wash-out time,and wash-out type,and serology biomarkers including alanine aminotransferase,aspartate aminotransferase,platelets,and alpha-fetoprotein(AFP)were collected.Univariate analysis and multivariate Cox proportional hazards regression model were used to evaluate the independent prognostic factors for tumor recurrence.Then a nomogram called CEUS model was constructed.The CEUS model was then used to predict recurrence at 6 mo,12 mo,and 24 mo,the cut-off value was calculate by X-tile,and each C-index was calculated.Then Kaplan-Meier curve was compared by logrank test.The calibration curves of each time were depicted.RESULTS A nomogram predicting early recurrence(ER),named CEUS model,was formulated based on the results of the multivariate Cox regression analysis.This nomogram incorporated tumor diameter,preoperative AFP level,and LIRADS,and the hazard ratio was 1.123(95%confidence interval[CI]:1.041-1.211),1.547(95%CI:1.245-1.922),and 1.428(95%CI:1.059-1.925),respectively.The cut-off value at 6 mo,12 mo,and 24 mo was 100,80,and 50,and the C-index was 0.748(95%CI:0.683-0.813),0.762(95%CI:0.704-0.820),and 0.762(95%CI:0.706-0.819),respectively.The model showed satisfactory results,and the calibration at 6 mo was desirable;however,the calibration at 12 and 24 mo should be improved.CONCLUSION The CEUS model enables the well-calibrated individualized prediction of ER before surgery and may represent a novel tool for biomarker research and individual counseling.

Trapped vessel of abdominal pain with hepatomegaly: A case report

Abdominal pain with elevated transaminases from inferior vena cava(IVC) obstruction is a relatively common reason for referral and further workup by a hepatologist. The differential for the cause of IVC obstruction is extensive, and the most common etiologies include clotting disorders or recent trauma. In some situations the common etiologies have been ruled out, and the underlying process for the patient's symptoms is still not explained. We present one unique case of abdominal pain and hepatomegaly secondary to IVC constriction from extrinsic compression of the diaphragm. Based on this patient's presentation, we urge that physicians be cognizant of the IVC diameter and consider extrinsic compression as a contributor to the patient's symptoms. If IVC compression from the diaphragm is confirmed, early referral to vascular surgery is strongly advised for further surgical intervention.

Application of computer-assisted three-dimensional quantitative assessment and a surgical planning tool for living donor liver transplantation

Background Precise evaluation of the live donor＇s liver is the most important factor for the donor＇s safety and the recipient＇s prognosis in living donor liver transplantation （LDLT）. Our study assessed the clinical value of computer-assisted three-dimensional quantitative assessment and a surgical planning tool for donor evaluation in LDLT. Methods Computer-assisted three-dimensional （3D） quantitative assessment was used to prospectively provide quantitative assessment of the graft volume for 123 consecutive donors of LDLT and its accuracy and efficiency were compared with that of the standard manual-traced method. A case of reduced monosegmental LDLT was also assessed and a surgical planning tool displayed the precise surgical plan to avoid large-for-size syndrome. Results There was no statistically significant difference between the detected graft volumes with computer-assisted 3D quantitative assessment and manual-traced approaches （（856.76±162.18） cm3 vs. （870.64±172.54） cm3, P=0.796）. Estimated volumes by either method had good correlation with the actual graft weight （r-manual-traced method： 0.921, r-3D quantitative assessment method： 0.896, both P 〈0.001）. However, the computer-assisted 3D quantitative assessment approach was significantly more efficient taking half the time of the manual-traced method （（16.91±1.375） minutes vs. （39.27±2.102） minutes, P 〈0.01） to estimate graft volume. We performed the reduced monosegmental LDLT, a pediatric case, with the surgical planning tool （188 g graft in the operation, which was estimated at 208 cm3 pre-operation）. The recipient recovered without large-for-size syndrome. Conclusions Computer-assisted 3D quantitative assessment provided precise evaluation of the graft volume. It also assisted surgeons with a better understanding of the hepatic 3D anatomy and was useful for the individual surgical planning tool.

Systematic Training of Liver Imaging Reporting and Data System Magnetic Resonance Imaging v2018 can Improve the Diagnosis of Hepatocellular Carcinoma for Different Radiologists

Background and Aims:Liver imaging reporting and data system(LI-RADS)provides standardized lexicon and categorization for diagnosing hepatocellular carcinoma(HCC).However,there is limited knowledge about the effect of LI-RADS training.We prospectively explored whether the systematic training of LI-RADS v2018 on magnetic resonance imaging(MRI)can effectively improve the diagnostic performances of different radiologists for HCC.Methods:A total of 20 visiting radiologists and the multiparametric MRI of 70 hepatic observations in 61 patients with high risk of HCC were included in this study.The LI-RADS v2018 training procedure included three times of thematic lectures(each lasting for 2.5 h)given by a professor specialized in imaging diagnosis of liver,with an interval of a month.After each seminar,the radiologists had a month to adopt the algorithm into their daily work.The diagnostic performances and interobserver agreements of these radiologists adopting the algorithm for HCC diagnosis before and after training were compared.Results:A total of 20 radiologists(male/female,12/8;with an average age of 36.75±4.99 years)were enrolled.After training,the interobserver agreements for the LI-RADS category for all radiologists(p=0.005)were increased.The sensitivity,specificity,positive predictive value,negative predictive value,and coincidence rate of all radiologists for HCC diagnosis before and after training were 43%vs.54%,86%vs.88%,74%vs.81%,62%vs.67%,and 65%vs.71%,respectively.The diagnostic performances of all radiologists(p<0.001)showed improvement after training.Conclusions:The systematic training of LI-RADS can effectively improve the diagnostic performances of radiologists with different experiences for HCC.