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The Value of Diffusion-Weighted Imaging in Characterizing Focal Liver Masses

Posted Sep 30, 2009 Updated Apr 7, 2023
By Kumaresan Srasegaran MD , Fatih M. Akisik MD , Chen Lin PhD , Bilal Tahir MD , Janaki Rajan MD , Alex M. Aisen MD
7 min read

Rationale and Objectives

To determine if focal liver masses could be differentiated as benign or malignant on the basis of diffusion-weighted imaging (DWI).

Methods and Materials

A total of 104 patients with focal liver masses were scanned using 1.5 T magnetic resonance imaging (MRI). DWI was performed with b values of 0, 50, and 400 s/mm 2 . Of these, 76 patients had lesions larger than 2 cm diameter, radiologic or pathologic characterization of the lesion, and diagnostic quality DWI. The apparent diffusion coefficient (ADC) of the largest liver lesion was measured. The liver masses were diagnosed on histology or had characteristic computed tomography/MRI findings and follow up of more than 6 months. The analyzed lesions were hemangioma ( n = 17), cysts ( n = 5), hepatocellular cancer (HCC) ( n = 41), adenoma ( n = 3), focal nodular hyperplasia (FNH) ( n = 6), and metastases ( n = 4).

Results

The mean (standard deviation) ADC values (10 −5 mm 2 /second) of hemangiomas, cysts, FNH, and HCC were 156.8 (54.1), 190.2 (43.0), 130.1 (81.9), and 107.6 (32.7). The ADC of cysts and hemangiomas were significantly higher than that of other lesions ( P = .0003, t -test). There was no significant difference between ADC values of solid, benign liver lesions (FNH, adenoma) and malignant lesions (HCC, metastases) ( P = .62).

Conclusion

Solid liver lesions have a lower ADC than cysts and hemangiomas. However, there is no significant difference in ADC between solid benign and malignant lesions. DWI appears to have only minimal additional value over currently used MRI sequences in characterizing liver masses.

With the increasing use of computed tomography (CT) and magnetic resonance imaging (MRI), incidental liver lesions are increasingly identified. Even in patients undergoing staging for known malignancy, liver lesions may be identified that cannot be characterized with reasonable certainty. The ability to definitely diagnose liver lesions has many clinical benefits, including obviating the need for invasive techniques such as biopsy or resection surgery. An indeterminate diagnosis often requires follow-up imaging in several months, and may result in considerable anxiety to the patient and cost to the health system. In the last few years, progress has been made in imaging characterization of liver lesions. Delayed scanning with gadobenate dimeglumine (MultiHance, Bracco Diagnostics, Princeton, NJ) has been reported to help in differentiating focal nodular hyperplasia from other hypervascular lesions, including hepatic adenomas . Studies have indicated the usefulness of MRI studies performed using protocols involving two contrast agents, superparamagnetic iron oxide particles and conventional gadolinium, in improving accuracy for hepatocellular carcinoma in cirrhotic patients . Microbubble-enhanced sonography is being evaluated for its use in characterizing liver lesions .

Diffusion is the random, thermally induced movement of water molecules. Diffusion of intracellular water molecules is reduced due to the presence of the membranes that encase the cell and its organelles. Conversely, diffusion is less restricted in the normal extracellular space. In general, malignant lesions are more cellular than benign lesions. Therefore, diffusion would be expected to be lower in malignant than in benign lesions, and diffusion-weighted MRI (DWI) potentially may be a robust method for differentiating malignant and benign lesions. In this study, we investigated whether DWI can help differentiate benign from malignant liver lesions.

Methods

Patients

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MRI Examination

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Confirmation of Liver Lesions

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Statistical Analysis

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Results

Lesion Characteristics

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Interobserver Correlation

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ADC Values of Lesions

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Figure 1, Box-and-whisker plots of apparent diffusion coefficient (ADC) values of various liver lesions. In these plots, the central box represents the values from the 25th to 75th percentiles. The middle line represents the mean. A line extends from the minimum to the maximum value, excluding “far out” values which are displayed as separate points (small squares). HEM, hemangioma; METS, metastases.

Figure 2, A 61-year-old male on follow-up 7 years after orthotopic liver transplantation. (a) T2-weighted magnetic resonance imaging (MRI) sequence (repetition time/echo time [TR/TE] [ms], flip angle, echo train length: 5301/104, 150, 13) shows very high signal lesion in lateral right lobe (arrow) . (b) There is no contrast enhancement in the lesion (arrow) on three-dimensional T1-weighted image (TR/TE [ms], flip angle: 4.85/2.48, 12°) after 20 mL of gadobenate dimeglumine (MultiHance, Bracco Diagnostics, Princeton, NJ). The lesion is radiologically diagnosed as a cyst. (c) ADC map shows the lesion to be very bright. The mean ADC value is 234 × 10 −5 mm 2second.

Figure 3, A 27-year-old female had a magnetic resonance imaging scan to characterize a low-density lesion seen on computed tomography. (a,b) T1-weighted sequence (repetition time/echo time [TR/TE] (ms), flip angle: 4.85/2.48, 12°) obtained in arterial (a) and venous (b) phases after 17 mL of gadobenate dimeglumine shows progressive puddling of contrast within the lesion (arrow) consistent with a hemangioma. (c,d) Diffusion-weighted images performed with b value of 50 (c) and 400 (d) s/mm 2 show that the lesion (arrows) has high signal on both sequences. (e) Apparent diffusion coefficient (ADC) maps also indicates high signal within the lesion. The ADC value was measured at 205 × 10 −5 mm 2second.

Figure 4, A 40-year-old female with known liver mass, proven at subsequent surgery to be focal nodular hyperplasia. (a) Arterial phase magnetic resonance imaging scan performed after 17 mL of gadobenate dimeglumine shows a lobulated partially hypervascular mass with central nonenhancing “scar.” (b,c) Diffusion-weighted images with b values of 50 (b) and 400 (c) s/mm 2 show variable signal within lesion (arrow) . The apparent diffusion coefficient (ADC) values of this mass had a large variation with a mean of 127 × 10 −5 mm 2second that was similar to adjacent liver.

Figure 5, A 69-year-old female with cirrhosis and hypervascular liver mass, which was biopsy proven to be hepatocellular cancer. Patient has ascites. (a) Arterial phase images after 18 mL of gadobenate dimeglumine shows a homogenous hypervascular mass (arrow) . (b,c) Diffusion-weighted sequences with b values of 50 and 400 s/mm 2 show mildly hyperintense lesion (arrow). (d) The apparent diffusion coefficient (ADC) map shows a lesion with higher diffusion than surrounding cirrhotic liver. The mean ADC value was 146 × 10 −5 mm 2second, which was in the same range of ADC values as benign solid liver lesions.

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Figure 6, Box-and-whisker plots of apparent diffusion coefficient (ADC) lesion-to-liver ratios of various liver lesions. In these plots, the central box represents the values from the 25th to 75th percentiles. The middle line represents the mean. A line extends from the minimum to the maximum value, excluding “far out” values which are displayed as separate points (small squares). HEM, hemangioma; METS, metastases.

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Figure 7, Receiver-operating characteristic curve of apparent diffusion coefficient (ADC) lesion-to-liver ratios in determining benign vs. malignant solid liver lesions. Cysts and hemangioma were excluded. See Table 1 for further details. The area under the curve was 0.50, indicating that it was not possible to use ADC values to reliably differentiate solid benign from malignant lesions.

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Discussion

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Table 1

Prediction of Benignity vs. Malignancy using ADC and ADC Lesion-to-liver Ratios

AUC Best Value Sensitivity (%) Specificity (%) ADC 0.50 104 ∗ 54 44 ADC liver-to-lesion ratio 0.58 1.0 0.67 0.67

ADC, apparent diffusion coefficient.

The table gives the area under the receiver operating characteristic curve (AUC) and the value of ADC or ADC lesion-to-liver ratio that is associated with maximized sensitivity and specificity for differentiating solid benign lesions from malignant lesions.

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Academic Radiology, Volume 16, Issue 10
Journals General Radiology
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