May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation 10th Annual International Symposium on MDCT
Detection of HCC: MSCT vs MRI
Background
Detection of Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis: Intraindividual Comparison of Multiphasic 6464-slice CT and Contrast Enhanced MR Imaging and with Explantation Correlation
Carlo Catalano
• HCC is currently the primary indication for OLT in patients with cirrhosis • Different criteria can be used to determine patients' eligibility (Milan, UCSF) • All of which rely on determination of tumor burden at imaging (CEUS, MDCT, MRI) Bruix, Shermann. Hepatology ’05
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Background
• Different studies correlated the diagnostic accuracy of CT or MRI with explanted liver •• Born Born M, M, Rofo. Rofo. 1998 1998 -- CT CT and and MRI MRI are are similar similar (60%) (60%) for for HCC HCC detection. detection. •• Lim Lim JH, JH, AJR AJR 2000 2000 -- CT CT sensitive sensitive (73%) (73%) for for HCC HCC detection detection •• Peterson MS, 2000 Peterson MS, Radiology Radiology 2000 Low accuracy for the detection of -- CT CT has has low low sensitivity sensitivity for for HCC HCC detection detection (60-69%) (60-69%)
MDCT Protocol • Must be MULTIPHASIC: - Noncontrast scan
(detection and characterization of RNs, cysts, focal fat)
- HAP ~ automated bolus tracking (18 s after 100 HU)
HCC
•• Krinsky Krinsky GA, GA, Radiology Radiology 2001 2001 -- MRI MRI has has low low sensitivity sensitivity for for HCC HCC detection detection (58%) (58%) •• Kang Kang BK, BK, Radiology Radiology 2003 2003 -- MRI MRI is is superior superior than than CT CT for for detection detection of of HCC HCC
Detection of HCC: MSCT vs MRI
MRI Protocol
(Sultana S, Radiology ’07)
- PVP ~ 60-70 seconds - EP ~ 180 seconds (Iannaccone R, Catalano C et al, Radiology ’05)
Contrast agent must be rapidly injected (4 or 5 ml/sec)
Detection of HCC: MSCT vs MRI
LiverLiver-specific MR contrast agents
• Requires a state-of-the-art MR imaging technique: - Phased array body multicoil (increased spatial resolution) - T2-w fast spin echo or STIR pulse sequences (HCC frequently shows mild to moderate hyperintensity on T2) T2
- Dynamic gadoliniumgadolinium-enhanced breathbreath-hold imaging
Paramagnetic agents GdGd-BOPTA T1T1-w HepatoHepato-specific phase (120 min)
(most HCC nodules are detected as hypervascular foci on HAP) HAP
moreover,…
Delayed phase
• Due to high tissue-contrast resolution, MRI shows a higher capability in the detection and characterization of cirrhotic nodules (i.e., RNs, DNs, and HCCs)
Stanford Radiology 10th Annual Multidetector CT Symposium
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May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
LiverLiver-specific MR contrast agents
LiverLiver-specific MR contrast agents
T1-w
T1-w
SPIO agents
Paramagnetic agents
T1-w
PostPost-contrast scans
HCC
Poorly differentiated HCC
Well-differentiated HCC
HCC grading
GdGd-EOBEOB-DTPA HepatoHepato-specific phase (20 min)
Detection of HCC: MSCT vs MRI
Forner Forner A, A, Hepatology Hepatology 2008 2008
• The prevalence of malignant HAPE lesions (HCC) is higher (67.4 %) than previously reported in the literature (~7-10%)
• MRI is specific (93.1 %), but non sensitive (61.7 %) for characterizing small HCC
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Kim Kim JI, JI, Invest. Invest. Radiol. Radiol. 2008 2008
• LiverLiver-specific phase may yield a higher sensitivity and accuracy of HCC (due to hypointense signal to the long lasting enhanced surrounding surrounding liver)
• Sensitivity (71.4%) 71.4%) and specificity (92.3%) 92.3%)
Detection of HCC: MSCT vs MRI
Purpose Marin Marin D, D, Catalano Catalano CC Radiology Radiology in in press press
• Gd-BOPTA-enhanced MRI significantly more accurate and sensitive (0.95, 72%) for the detection of HCC compared with 64-slice CT (0.77, 61%)
To intraindividually compare gadobenate dimeglumine (Gd-BOPTA) enhanced MRI and 64slice CT for detection of HCC in patients with cirrhosis with Explanted Liver as Gold Standard
• MRI shows less False Positives than 64-slice CT
Stanford Radiology 10th Annual Multidetector CT Symposium
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May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Material and Methods
CT Technique
250 patients
• Siemens Sensation 64 • Detector configuration,
214 excluded
36 OLT 46 HCC foci
- NO NO OLT OLT (180) (180)
-- NO NO MR MR exam exam (10) (10) -- NO NO CT CT exam exam (5) (5)
- HCV+ HCV+ (23) (23)
-- No No exam exam within within 90 90 days(19) days(19)
-- HBV+ HBV+ (5) (5) -- alcohol alcohol (5) (5)
0.6 mm x 64
• Nonionic highhigh-osmolar c.m. (Iomeron 400) • 2 mL c.m./kg body weight
• Section thickness, 3.0 mm • Effective mAs, 260
• Injection rate, 5 mL/sec • 40 mL saline chaser at 5 mL/sec
• kVp, 120
• Automated bolus tracking
-- cryptogenetic cryptogenetic cirrhosis cirrhosis (2) (2) -- autoimmune autoimmune cirrhosis cirrhosis (1) (1)
technique
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
CT Protocol
MR Technique
• Noncontrast scan • Postcontrast scans: 1) HAP bolus bolus tracking: tracking: 18 18 sec sec after after 150 150 HU HU within within aorta aorta 2) PVP 20 20 sec sec after after HAP HAP 3) EP 180 180 sec sec
• Siemens Avanto 1.5 T
• GdGd-BOPTA (Multihance)
• Slew rate of 200 mTmT-m-s
• 0.2 mM/kg
• Strength 45mT45mT-m
• Injection rate, 2 mL/sec
• Phased array body coil + spine array coil
• 20 mL saline chaser at 2 mL/sec
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
MR Protocol
Pathologic Analysis
•• Noncontrast Noncontrast scan scan •• T2-w T2-w HASTE HASTE w/ w/ and and w/out w/out fs fs •• T1-3D-VIBE T1-3D-VIBE fs fs •• Postcontrast Postcontrast scans scans (T1-3D-VIBE (T1-3D-VIBE fs): fs): 1) 1) HAP HAP 18 18 sec sec after after c.m. c.m. injection injection 2) 2) PVP PVP 60 60 sec sec 3) 3) EP EP 150 150 sec sec
• Prospective imagingimaging-pathologic correlation • 5-8 mm slices thickness (transverse plane) • Lesions sampling based on size, color, texture,
degree of bulging • Hystologic analysis (IWP Terminology)
4) Hepatospecific phase 90 min.
Stanford Radiology 10th Annual Multidetector CT Symposium
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May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Image Analysis
Results: Sensitivity • Three independent radiologists • Two reading sessions (time interval 4 weeks) • Lesion confidence (1 to 4) – Area under the receiver operating characteristic curve (Az)
< 1 cm
1-2 cm
> 2 cm
ALL
28.9
68.7
95.8
65.9
MSCT
12/42
MR
18/42
42.8
33/48
83.3
40/48
46/48
100
48/48
91/138
77.3
106/138
• Sensitivity, Specificity, and PPV
Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Results: Sensitivity
Results: Specificity < 1 cm
1-2 cm
> 2 cm
100
80
91
< 1 cm
1-2 cm
> 2 cm
ALL
28.9
68.7
95.8
66
MSCT
42/42
77
MR
42/42
MSCT
12/42
MR
18/42
42.8
33/48
83.3
40/48
46/48
100
48/48
91/138
106/138
Stanford Radiology 10th Annual Multidetector CT Symposium
100
56/68
80
56/68
26/28
91
26/28
ALL 90
123/138
90
123/138
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May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Results: False Positive
Results: PPV MSCT
MSCT
MR
Average
12
12
Average
< 1 cm
0
0
< 1 cm
1-2 cm
10
10
1-2 cm
> 2 cm
2
2
> 2 cm
Stanford Radiology 10th Annual Multidetector CT Symposium
MR
88.6
90
93/93+12
106/106+12
100
100
12/12
18/18
76.7
80
33/33+10
40/40+10
95.8
96
46/46+2
48/48+2
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May 14, 2008- 8:50 AM
Carlo Catalano, MD: Detection of hepatocellular carcinoma (HCC) in patients with cirrhosis: individual comparison of multiphase 64-slice CT and contrast enhanced MR imaging with explanation correlation Detection of HCC: MSCT vs MRI
Detection of HCC: MSCT vs MRI
Results: Mean (Az) value
Conclusion
Mean (Az) value MSCT
0.84
Gd-BOPTA MRI
0.92
p
< 0.05
Stanford Radiology 10th Annual Multidetector CT Symposium
• CE-MRI is significantly more accurate than 64-slice CT for the diagnosis of HCC
• CE-MRI shows a significantly better sensitivity for the detection of small HCCs (< 2 cm)
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