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Liver Imaging Reporting and Data System

Posted Feb 29, 2016 Updated Apr 10, 2023
By Yu-Dong Zhang MD , Fei-Peng Zhu MD , Xun Xu MM , Qing Wang MM , Chen-Jiang Wu MM , Xi-Sheng Liu MD , Hai-Bin Shi MD
11 min read

Rationale and Objectives

The Liver Imaging Reporting and Data System (LI-RADS) is a newly developed nomogram for standardizing the performance and interpretation of liver imaging. However, it is unclear which imaging technique is optimal to exactly define LI-RADS scale. This study aims to determine the concordance of computed tomography (CT) and magnetic resonance imaging (MRI) for the classification of hepatic nodules (HNs) using a LI-RADS scoring system.

Materials and Methods

Major imaging features (arterial hyper-enhancement, washout, pseudo-capsule, diameter, and tumor embolus) on CT versus MRI for 118 HNs in 84 patients with diffuse liver disease were rated independently using LI-RADS by two groups of readers. Inter-reader agreement (IRA) and intraclass agreement was determined by Fleiss and Cohen’s kappa (κ). Logistic regression for correlated data was used to compare diagnostic ability.

Results

IRA was perfect for determination of nodule size and tumor embolus (κ = 0.94–0.98). IRA was moderate to substantial for determination of arterial hyper-enhancement, washout, and pseudo-capsule (κ = 0.54–0.72). Intraclass agreement between CT and MRI was substantial for determination of washout (0.632 [95% CI: 0.494, 0.771]) and pseudo-capsule (0.670 [95% CI: 0.494, 0.847]), and fair for arterial hyper-enhancement (0.203 [95% CI: 0.051, 0.354]). CT against MR produced false-negative findings of arterial hyper-enhancement by 57.1%, washout by 21.2%, and pseudo-capsule by 42.9%; and underestimated LI-RADS score by 16.9% for LR 3, 37.3% for LR 4, and 8.5% for LR 5. CT produced significantly lower accuracy (54.3% vs 67.8%, P < 0.001) and sensitivity (31.6% vs 71.1%, P < 0.001) than MRI in the prediction of malignancy.

Conclusions

There are substantial discordance between CT and MR for stratification of HNs using LI-RADS. MRI could be better than CT in optimizing the performance of LI-RADS.

Introduction

Hepatocellular carcinoma (HCC) is the most predominant primary malignant hepatic tumor and the third leading cause of cancer death worldwide . The developed imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), have improved the ability of these imaging modalities for lesion detection and malignancy discrimination . Several organizations, including the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, the Organ Procurement and Transplantation Network, the Asian Pacific Association for the Study of the Liver, and the National Comprehensive Cancer Network, have proposed the guidelines for appropriate utilization of imaging for HCC diagnosis and management . Although specific imaging features such as “arterial phase (AP) hyper-enhancement,” “washout,” and “capsule” proposed by these guidelines are widely recognized as important, there is no established consensus yet regarding their exact definitions, and there is no established criteria yet for the standardization of the performance and interpretation of these imaging features.

The Liver Imaging Reporting and Data System (LI-RADS) is a newly developed nomogram to standardize the terminology for reporting, assessing, and recommending action in liver imaging . According to integrative evaluation of classic imaging features of hepatic lesion, for example, enhancement pattern in arterial and/or portal phase, tumor capsule, intravenous tumor embolus, and tumor growth rate, LI-RADS allows radiologists to standardize individual observations by assigning the imaging findings to one of five categories (LR 1–5). As reported currently, LI-RADS exhibited competitive individual features against conventional algorithms, for example, the Organ Procurement and Transplantation Network and the American Association for the Study of Liver Diseases , for screening and surveillance of HCC. The five-point LI-RADS scale, including its fixed criteria, is determined by integrative evaluation of classic imaging features of the observations in cirrhotic liver . However, the definition of these major imaging features and the scoring results of LI-RADS could be technology associated ; for example, arterial hyper-enhancement, one of the important features for the imaging diagnosis of HCC, could be interpreted with great difference between CT and MRI because of the limited tissue contrast for CT imaging. To date, it is yet unclear whether and how the technological difference between CT and MRI will take effect on the imaging observation and the final scoring results of LI-RADS.

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Materials and Methods

Patient Selection, Reference Standard, and CT/MR Technique

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CT and MR Protocols

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Image Interpretation

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Statistical Analysis

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Results

Pathological Findings

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IRA for Major Diagnostic Features of HCC

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Figure 1, Computed tomography (CT) versus magnetic resonance (MR) images of a 0.8-cm hepatic nodule in a 61-year-old man with more than a 20-year history of chronic B viral hepatitis. Images show (a) contrast-enhanced CT at arterial phase, (b) contrast-enhanced CT at portal venous phase (PVP), (c) T2-weighted MRI, (d) diffusion-weighted (DW)-MRI (b = 600 s/mm 2 ), (e) contrast-enhanced MRI at arterial phase, and (f) contrast-enhanced MRI at portal venous phase. The lesion was only shown with slight PVP washout appearance on contrast-enhanced CT imaging, and thus was assigned a preliminary Liver Imaging Reporting and Data System (LI-RADS) score of 3. The lesion was assigned a LI-RADS score of 4A by MRI because of significant arterial phase (AP) hyper-enhancement and PVP washout appearance. Angiography with transcatheter arterial chemoembolization (TACE) treatment was performed 2 weeks after CT/MR examination, tumor was characteristic with rich arterial supply, and a dominant iodized oil uptake was determined at follow-up CT examinations performed at 4-week intervals after TACE (g) .

Figure 2, Computed tomography (CT) versus magnetic resonance (MR) images of a 1.8 × 1.1 cm hepatic nodule in a 52-year-old man with a 10-year history of chronic B viral hepatitis. Images show (a) nonenhanced CT, (b) contrast-enhanced CT at arterial phase, (c) contrast-enhanced CT at portal venous phase, (d) T2-weighted MRI, (e) diffusion-weighted (DW)-MRI (b = 600 s/mm 2 ), (f) precontrast-enhanced MRI, (g) contrast-enhanced MRI at arterial phase, and (h) contrast-enhanced MRI at portal venous phase. The finding was preliminarily considered to be a pseudo-lesion probably because of rib compression on contrast-enhanced CT, and assigned LR 2. The lesion was then assigned a Liver Imaging Reporting and Data System (LI-RADS) score of 3 by MRI because of significant arterial phase (AP) hyper-enhancement. The patient received a local excision 4 weeks later and was pathologically confirmed to have low-grade hepatocellular carcinoma (HCC).

Figure 3, The comparison of computed tomography (CT) to magnetic resonance (MR) images of a 1.9-cm hepatic nodule in a 61-year-old man with a history of chronic B viral hepatitis. Images show (a) nonenhanced CT, (b) arterial phase (AP) contrast-enhanced CT, (c) portal venous phase (PVP) contrast-enhanced CT, (d) T2-weighted MRI, (e) diffusion-weighted (DW)-MRI (b = 600 s/mm 2 ), (f) precontrast-enhanced MRI, (g) contrast-enhanced MRI at AP, (h) contrast-enhanced MRI at PVP, and (i) delayed-phase contrast-enhanced MRI. The lesion was assigned a preliminary LR 3 because of AP hyper-enhancement on contrast-enhanced CT, but was assigned LR 4A because of dominant PVP washout appearance and pseudo-capsule on MRI. The lesion was surgically confirmed to be hepatocellular carcinoma (HCC) grade II.

Figure 4, The comparison of computed tomography (CT) to magnetic resonance (MR) images of a 2.1-cm hepatic nodule in a 66-year-old man with a history of chronic B viral hepatitis. Images show (a) contrast-enhanced CT at arterial phase (AP), (b) contrast-enhanced CT at portal venous phase (PVP), (c) T2-weighted MRI, (d) diffusion-weighted (DW)-MRI (b = 600 s/mm 2 ), (e) contrast-enhanced MRI at AP, and (f) contrast-enhanced MRI at PVP. The lesion was assigned a preliminary LR 3 by CT because of unclearly defined AP hyper-enhancement and additional major features. The lesion was assigned LR 5B by MRI because of the dominant AP hyper-enhancement, PVP washout appearance, and clearly defined pseudo-capsule. The lesion was surgically confirmed to be hepatocellular carcinoma (HCC) grade II.

Table 1

Inter-reader Agreement for Major Diagnostic Features of HCC

Variable κ Coefficients CT MR Tumor size \* 0.95 (0.94, 0.96) 0.98 (0.97, 0.99) Arterial hyper-enhancement 0.54 (0.44, 0.64) 0.63 (0.54, 0.72) Washout appearance 0.61 (0.46, 0.76) 0.72 (0.64, 0.80) Pseudo-capsule 0.56 (0.52, 0.60) 0.65 (0.60, 0.70) Tumor embolus 0.94 (0.91, 0.97) 0.97 (0.95, 0.99)

CT, computed tomography; HCC, hepatocellular carcinoma; MR, magnetic resonance.

Note: Data are mean κ coefficients across all possible combinations of the four readers, and numbers in parentheses are 95% confidence intervals.

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ICA of LR Scores Between CT and MRI

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Table 2

The Intraclass Agreement of Major Imaging Features for HCC Determined by Using CT or MRI

Variable CT MRI Kappa (κ) \* Lesion size (cm) † 1.77 ± 1.82 1.86 ± 1.73 0.995 (0.993, 0.996) Arterial hyper-enhancement 35.6% (42/118) 83.1% (98/118) 0.203 (0.051, 0.354) Washout appearance 44.1% (52/118) 55.9% (66/118) 0.632 (0.494, 0.771) Pseudo-capsule 13.6% (16/118) 23.7% (28/118) 0.670 (0.494, 0.847) Tumor embolus 5.9% (7/118) 5.9% (7/118) 1.000 (1.000, 1.000)

CT, computed tomography; HCC, hepatocellular carcinoma; MRI, magnetic resonance imaging.

Note: Unless otherwise specified, data are percentages, with number of lesions in parentheses.

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Table 3

Comparison of the LI-RADS Scoring Results for 118 Hepatic Lesions by CT and MRI

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CT, computed tomography; LI-RADS, Liver Imaging Reporting and Data System; MRI, magnetic resonance imaging.

Note: Unless otherwise specified, data are number of lesions with the percentages in parentheses.

The blue cell in the table represents overestimate of MRI-based LR score by CT, and green cells represent the underestimate of MRI-based LR scores by CT. (Color version of table is available online.)

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Comparison of Diagnostic Performance by CT and MRI

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Table 4

ROC Analysis for Malignancy Detection at LR Score Thresholds Between CT and MRI

LR Criterion Sensitivity Specificity CT ≥2 100.0 (95.2–100.0) 0.0 (0.0–8.5) >2 89.5 (80.3–95.3) 33.3 (19.6–49.5) >3 \* 31.6 (21.4–43.3) 95.2 (83.8–99.3) >4 10.5 (4.7–19.7) 100.0 (91.5–100.0) >5 0 (0.0–4.8) 100.0 (91.5–100.0) MRI ≥2 100.0 (95.2–100.0) 0.0 (0.0–8.5) >2 100.0 (95.2–100.0) 4.8 (0.7–16.2) >3 \* 71.1 (59.5–80.9) 61.9 (45.6–76.4) >4 21.1 (12.5–31.9) 95.2 (83.8–99.2) >5 0.0 (0.0–4.8) 100.0 (91.5–100.0)

CT, computed tomography; MRI, magnetic resonance imaging; ROC, receiver operating characteristic.

Note: Unless otherwise specified, data are percentages and with ranges in parentheses.

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Table 5

Performance for Determination of HCCs Assessed by CT and MRI at the Optical Scales

Criterion CT MRI_P_ Optical scale >LR 3 >LR 3 – Accuracy 54.3 (64/118) 67.8 (80/118) <0.001 Sensitivity 31.6 (24/76) 71.1 (54/76) <0.001 Specificity 95.2 (40/42) 61.9 (26/42) <0.001 Az 0.701 0.695 0.905

Az, area under the receiver operating characteristic curve; CT, computed tomography; HCC, hepatocellular carcinoma; MRI, magnetic resonance imaging.

Note: Data for accuracy, sensitivity, and specificity are percentages and with raw data in parentheses.

Figure 5, The comparison of diagnostic performance for determination of hepatocellular carcinomas (HCCs) stratified by computed tomography (CT) and magnetic resonance imaging (MRI). (Color version of figure is available online).

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Discussion

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Conclusions

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Acknowledgment

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Appendix

Supplementary material

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Table S1

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Academic Radiology, Volume 23, Issue 3
Journals General Radiology
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