Rationale and Objectives
To assess the enhancement pattern of focal confluent fibrosis (FCF) on contrast-enhanced hepatic magnetic resonance imaging (MRI) using hepatocyte-specific (Gd-EOB-DTPA) and extracellular (ECA) gadolinium-based contrast agents in patients with primary sclerosing cholangitis (PSC).
Materials and Methods
After institutional review board approval, 10 patients with PSC (6 male, 4 female; 33–61 years) with 13 FCF were included in this retrospective study. All patients had a Gd-EOB-DTPA–enhanced liver MRI exam, and a comparison ECA-enhanced MRI. On each T1-weighted dynamic dataset, the signal intensity (SI) of FCF and the surrounding liver as well as the paraspinal muscle (M) were measured. In the Gd-EOB-DTPA group, hepatocyte phase images were also included. SI FCF/SI M, SI liver/SI M, and [(SI liver − SI FCF)/SI liver] were compared between the different contrast agents for each dynamic phase using the paired Student’s t -test.
Results
There was no significant difference in SI FCF/SI M in all imaging phases. SI liver/SI M was significantly higher for the Gd-EOB-DTPA group in the delayed phase ( P < .001), whereas there was no significant difference in all other imaging phases. In the Gd-EOB-DTPA group, mean [(SI liver − SI FCF)/SI liver] were as follows (values for ECA group in parentheses): unenhanced phase: 0.26 (0.26); arterial phase: 0.01 (−0.31); portal venous phase (PVP): −0.05 (−0.26); delayed phase (DP): 0.14 (−0.54); and hepatocyte phase: 0.26. Differences were significant for the DP ( P < .001).
Conclusions
On delayed phase MR images the FCF-to-liver contrast is reversed with the lesions appearing hyperintense on ECA enhanced images and hypointense on Gd-EOB-DTPA–enhanced images.
Primary sclerosing cholangitis (PSC), a chronic cholestatic liver disease of unknown cause, is characterized by fibrosing inflammatory destruction of the bile ducts, subsequent hepatic fibrosis, and ultimately cirrhosis . In patients with PSC, peripheral wedge-shaped areas of parenchymal atrophy, also called confluent hepatic fibrosis or focal confluent fibrosis (FCF) , have been described in up to 72%; these focal confluent fibrotic lesions typically show hypoenhancement on computed tomography (CT) and magnetic resonance (MR) images obtained immediately after administration of iodinated CT or extracellular gadolinium-based MR contrast agents and hyperenhancement on delayed phase images . Because these FCF are oftentimes mildly hyperintense on T2-weighted (T2w) MR imaging, they are among the most relevant differential considerations for hepatocellular carcinoma and cholangiocarcinoma.
To the best of our knowledge, the enhancement pattern of FCF on fat saturated dynamic T1w MR imaging performed after administration of GD-EOB-DTPA (gadoxetate disodium, Eovist/Primovist, Bayer HealthCare Pharmaceuticals Inc, Wayne, NJ) has not been described yet. Therefore, this study was performed to assess the enhancement pattern of focal confluent fibrosis on contrast-enhanced hepatic MR imaging using hepatocyte-specific (Gd-EOB-DTPA) and extracellular (ECA) gadolinium-based contrast agents in patients with PSC.
Material and methods
Study Population
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Quantitative Analysis
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Results
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Table 1
Onset of the Various Data Acquisition Phases Derived from the DICOM Header
Contrast Phase Arterial
Mean ± SD Portal Venous
Mean ± SD Delayed
Mean ± SD Hepatocyte
Mean ± SD Gd-EOB-DTPA 24 seconds ± 2 seconds 62 seconds ± 19 seconds 7 minutes, 38 seconds ± 2 minutes 20 minutes, 19 seconds ± 6 minutes, 26 seconds Extracellular CA 24 seconds ± 4 seconds 68 seconds ± 14 seconds 7 minutes, 32 seconds ± 2 minutes, 32 seconds_P_ value .78 .41 .89
Values represent the beginning of the pulse sequence data acquisition after the initiation of contrast administration. P values are calculated using a paired Student’s t -test.
CA, contrast agent; mean, average value based on a sample size of ten patients; Gd-EOB-DTPA, hepatocyte-specific gadolinium; SD, standard deviation of the mean.
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Table 2
Ratios of the Signal Intensity Values of Focal Fibrotic Lesions and Surrounding Liver to the Signal Intensity Values of the Paraspinal Muscle, and Focal Fibrotic Lesion-to-liver Ratios for the Various Contrast Phases for the Two Different Contrast Agent Groups
Unenhanced Mean ± SD Min–Max Arterial Mean ± SD Min–Max Portal Venous Mean ± SD Min–Max Delayed
Mean ± SD
Min–Max Hepatocyte
Mean ± SD
Min–Max SI FCF/SI M Gd-EOB-DTPA 0.73 ± 0.27
0.38–1.25 1.06 ± 0.48
0.5–2.07 1.35 ± 0.52
0.75–2.32 1.36 ± 0.41
0.73–1.99 1.18 ± 0.41
0.56–1.87 Extracellular contrast agent 0.65 ± 0.24
0.39–1.24 1.46 ± 0.60
0.70–2.80 1.80 ± 0.92
0.50–3.67 1.59 ± 0.53
1.01–2.51 —P value .42 .07 .14 .23 SI liver/SI M Gd-EOB-DTPA 1.00 ± 0.33
0.47–1.73 1.08 ± 0.32
0.63–1.51 1.28 ± 0.28
0.89–1.75 1.62 ± 0.35
0.94–2.10 1.64 ± 0.46
0.97–2.34 Extracellular contrast agent 0.93 ± 0.45
0.59–1.98 1.28 ± 0.77
0.54–3.31 1.44 ± 0.44
0.78–2.20 1.05 ± 0.33
0.63–1.85 —P Value .67 .40 .28 <.001 [(SI Liver–SI FCF)/SI Liver] Gd-EOB-DTPA 0.26 ± 0.14
0.08–0.59 0.01 ± 0.37
−0.91–0.45 −0.05 ± 0.30
−0.47–0.82 0.14 ± 0.26
−0.50–0.61 0.26 ± 0.24
−0.374–0.70 Extracellular contrast agent 0.26 ± 0.18
0.02–0.68 −0.31 ± 0.49
−0.90–0.65 −0.26 ± 0.50
−0.85–0.70 −0.54 ± 0.35
−1.12–−0.16P value 0.89 0.08 0.21 <0.001
P values are derived from the paired Student’s t -test.
FCF, focal fibrotic lesion; M, paraspinal muscle; mean, average value based on a sample size of 13 focal fibrotic lesions; max, maximum value of the 13 focal fibrotic lesions; SD, standard deviation of the mean; min, minimum value of the 13 focal fibrotic lesions; SI, signal intensity.
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![Figure 1, A 34-year-old male patient with known primary sclerosing cholangitis and normal liver function tests (total bilirubin 0.9 mg/dL [0.1–1.5 mg/dL]). Focal liver lesion is stable over the time course of 2 years. Hepatocyte-specific gadolinium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging. (a) On the axial three-dimensional (3D) gradient echo fat-suppressed Ti-weighted (T1w) image, the focal fibrotic lesion (FCF, arrow ) appears hypointense to the surrounding liver. Axial fat-suppressed 3D T1w gradient echo dynamic datasets acquired after the administration of 10 mL Gd-EOB-DTPA, demonstrate (b) the initial increase of the contrast-to-noise ratio (CNR) of the FCF ( arrow ) and the surrounding liver in the arterial phase, (c) and the portal venous phase, followed by (d) a decrease of the CNR in the delayed and (e) hepatocyte-specific phase. The corresponding (gadobenate dimeglumine) Gd-BOPTA enhanced comparison study was performed 14 months before the Gd-EOB-DTPA study. (f) On the axial 3D gradient echo fat suppressed T1w image, the FCF ( arrow ) again appears hypointense to the surrounding liver. After the administration of 20 mL of Gd-BOPTA, axial fat suppressed 3D T1w gradient echo dynamic datasets were acquired. (g) The FCF ( arrow ) enhances in the arterial phase, and the CNR continues to raise in (h) the portal venous phase, and (i) the delayed phase.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/ContrastEnhancedLiverMRIinPatientswithPrimarySclerosingCholangitis/0_1s20S1076633211003941.jpg)
![Figure 2, A 54-year-old female patient with primary sclerosing cholangitis and normal liver function tests (total bilirubin 0.7 mg/dL [0.1–1.5 mg/dL]). Focal liver lesion is stable over the time course of 6 years; percutaneous biopsy revealed focal fibrosis. Hepatocyte-specific gadolinium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging. (a) On the axial three-dimensional (3D) gradient echo fat suppressed T1-weighted (T1w) image, the focal fibrotic lesion (FCF, arrow ) appears hypointense to the surrounding liver. Axial fat suppressed 3D T1w gradient echo dynamic datasets acquired after the administration of 10 mL Gd-EOB-DTPA during the arterial phase (b) , the portal venous phase (c) , the delayed phase (d) , and the hepatocyte-specific phase (e) . Note the hypointense appearance of the FCF ( arrow ) during all contrast-enhanced phases. (The corresponding Gd-BOPTA enhanced comparison study was performed 12 months before the Gd-EOB-DTPA study. (f) On the axial 3D gradient echo fat suppressed T1w image, the FCF ( arrow ) again appears hypointense to the surrounding liver. After the administration of 13 mL of Gd-BOPTA, axial fat suppressed 3D T1w gradient echo dynamic datasets were acquired: arterial phase (g) , portal venous phase (h) , and delayed phase (i) . Note the hyperintense appearance of the FCF ( arrow ) on the delayed phase.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/ContrastEnhancedLiverMRIinPatientswithPrimarySclerosingCholangitis/1_1s20S1076633211003941.jpg)
![Figure 3, A 52-year-old female patient with known primary sclerosing cholangitis and impaired liver function (total bilirubin 4.9 mg/dL [0.1–1.5 mg/dL]). (a) Fat-suppressed three-dimensional T1-weighted (T1w) gradient echo image acquired in the hepatocyte specific phase after administration of 10 mL hepatocyte-specific gadolinium (Gd-EOB-DTPA) demonstrates hyperintense signal of the focal fibrotic lesion (FCF; arrow ) compared to the surrounding liver. (b) The corresponding comparison study was performed 4 months prior to the Gd-EOB-DTPA study. The axial T1w gradient echo image acquired in the delayed phase after administration of 20 mL Gd-DTPA-BMA also demonstrates hyperintense signal of the FCF ( arrow ) compared to the surrounding liver. Note that chemical fat suppression failed in this comparison study.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/ContrastEnhancedLiverMRIinPatientswithPrimarySclerosingCholangitis/2_1s20S1076633211003941.jpg)
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Discussion
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Limitations
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Conclusion
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