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Accurate diagnosis and staging of NAFLD is of utmost prognostic importance. The gold standard for diagnosis is histological examination, but growing interest exists in novel noninvasive methods to evaluate NAFLD. This Review describes the advantages and limitations of noninvasive methods for the diagnosis and quantification of steatosis, diagnosis of NASH and staging of hepatic fibrosis in NAFLD. A common clinical concern in patients with NAFLD is whether they have NASH or simple steatosis and, more importantly, what the stage of fibrosis is and whether the level of fibrosis has increased over time. Such concern is based on the fact that patients with NAFLD with advanced fibrosis are at greatest risk of developing complications of end-stage liver disease. Although it lacks sensitivity, ultrasonography is an accepted tool for steatosis screening. The controlled attenuation parameter or CAP seems a promising screening technique, but requires further validation. Cytokeratin-18 has been extensively validated, but it is an imperfect serum marker of NASH. Ultrasonography-based transient elastography can exclude advanced fibrosis and cirrhosis, but its main limitation is its reduced applicability in patients with NAFLD, which is not completely solved by use of the XL probe. Of the noninvasive serum markers, the NAFLD fibrosis score is the most validated and has appropriate accuracy in distinguishing patients with and without advanced fibrosis. Although noninvasive methods require further validation, they could be useful for selecting those patients with NAFLD who require a liver biopsy. This Review discusses the advantages and limitations of noninvasive methods for the management of adults with NAFLD, including diagnosis and quantification of steatosis, diagnosis of NASH and staging of hepatic fibrosis. Key Points Liver biopsy remains the reference standard for diagnosing NASH and staging fibrosis in patients with NAFLD Identifying advanced fibrosis and cirrhosis is paramount as it dictates the need to screen for gastro-oesophageal varices and hepatocellular carcinoma Noninvasive methods for fibrosis assessment rely on two different, but complementary, approaches: the biological approach based on serum biomarker levels and the physical approach based on liver stiffness (measured mainly using transient elastography) The main limitation of ultrasonography-based transient elastography in clinical practice is its failure to obtain reliable liver stiffness measurements (∼20% of cases, mainly obese patients), which diminishes its application in NAFLD The XL probe could be used as second line in the subset of patients in whom the regular (M) probe fails, but appropriate cut-off levels remain to be defined Several biomarkers have been proposed to reliably identify advanced fibrosis and cirrhosis and could be useful to select patients with NAFLD who might benefit most from a liver biopsy

As opposed to most solid cancers, hepatocellular carcinoma (HCC) does not necessarily require histological confirmation. Noninvasive diagnosis is possible and relies on imaging. In cirrhotic patients, the diagnosis can be obtained in tumors displaying typical features that include non-rim arterial phase hyperenhancement followed by washout during the portal venous and/or delayed phases on CT or MR imaging. This pattern is very specific and, as such, has been endorsed by both Western and Asian diagnostic guidelines and systems. However, its sensitivity is not very high, especially for small lesions. Numerous ancillary features favoring the diagnosis of HCC may be depicted, including appearance after injection of hepatobiliary MR imaging contrast agents. These features increase confidence in diagnosis, but cannot be used as substitutes to liver biopsy. Aside from its diagnostic purpose, imaging also helps to assess tumor biology and patient outcome, by identifying features of local invasiveness. The purpose of this review article is to offer an overview of the role of imaging for the diagnosis and prognostication of HCC.

ObjectivesTo prospectively assess the role of the US attenuation imaging coefficient (AC) for the diagnosis and quantification of hepatic steatosis.MethodsOne hundred and one patients underwent liver biopsy and US-AC measurement on the same day. Liver steatosis was graded according to biopsy as absent (S0 < 5%), mild (S1 5–33%), moderate (S2 33–66%), or severe (S3 > 66%); liver fibrosis was graded from F0 to F4. The correlation between AC and steatosis on pathology (%) was calculated using the Pearson correlation coefficient. The Student t or Mann–Whitney U test was used to compare continuous variables and ROC curve analysis was used to assess diagnostic performance of AC in diagnosing steatosis.ResultsOverall, 43 (42%), 35 (35%), 12 (12%), and 11 (11%) patients were classified as S0, S1, S2, and S3, respectively. The AC was positively correlated with steatosis as a continuous variable (%) on pathology (r = 0.58, p < 0.01). Patients with steatosis of any grade had a higher AC than those without steatosis (mean 0.77 ± 0.13 vs. 0.63 ± 0.09 dB/cm/MHz, respectively; p < 0.01, AUROC = 0.805). Patients with S2–S3 had a higher AC than patients with S0–1 (0.85 ± 0.11 vs. 0.67 ± 0.11 dB/cm/MHz, respectively; p < 0.01, AUROC = 0.892). AC > 0.69 dB/cm/MHz had a sensitivity and specificity of 76% and 86%, respectively, for diagnosing any grade of steatosis (S1–S3), and AC > 0.72 dB/cm/MHz had a sensitivity and specificity of 96% and 74%, respectively, for diagnosing S2–S3. The presence of advanced fibrosis (F3–F4) did not affect the calculated AC.ConclusionsThe attenuation imaging coefficient is a promising quantitative technique for the non-invasive diagnosis and quantification of hepatic steatosis.Key Points• Measurement of the attenuation coefficient is achieved with a very high rate of technical success.• We found a significant positive correlation between the attenuation coefficient and the grade of steatosis on pathology.• The attenuation imaging coefficient is a promising quantitative technique for the noninvasive diagnosis and quantification of hepatic steatosis.

ObjectivesTo evaluate gender differences in the authorship of articles published in two major European radiology journals, European Radiology (EurRad) and CardioVascular and Interventional Radiology (CVIR).MethodsA retrospective bibliometric analysis was performed of 2632 papers published in EurRad and CVIR sampled over a period of 14 years (2002–2016). The authors’ gender was determined. The analysis was focused on first and last authors. In addition, the characteristics of the articles (type, origin, radiological subspecialty, and country) were noted.ResultsOverall, 23% of first authors and 10% of the last authors were women. The proportion of women significantly increased over time in EurRad from 22% in 2002 to 35% in 2016 for first authors (p > 0.001), and from 13% in 2002 to 18% in 2016 for last authors (p = 0.05). There was no significant increase in the proportion of female authors in CVIR over time. Female authors were more frequently identified in breast imaging (48%), pediatrics, and gynecological imaging (29%). There were more female authors in articles from Spain (34%), the Netherlands (28%), France, Italy, and South Korea (26%). Forty-one percent and 21% of women were first authors with a woman or man as last author, respectively (p < 0.001).ConclusionThere was a significant increase in female authorship in original diagnostic but not interventional imaging research articles between 2002 and 2016, with a strong influence of the radiological subspecialty. Women were significantly more frequently first authors when the last author was a woman.Key Points• There was a significant increase in female authorship in original diagnostic but not interventional imaging research articles between 2002 and 2016.• There is a strong influence of the radiological subspecialty on the percentage of female authors.• Women are significantly more frequently first authors when the last author is a woman.

Objectives To obtain the diagnostic performance of diffusion-weighted (DW) and gadoxetic-enhanced magnetic resonance (MR) imaging in the detection of liver metastases. Methods A comprehensive search (EMBASE, PubMed, Cochrane) was performed to identify relevant articles up to June 2015. Inclusion criteria were: liver metastases, DW-MR imaging and/or gadoxetic acid-enhanced MR imaging, and per-lesion statistics. The reference standard was histopathology, intraoperative observation and/or follow-up. Sources of bias were assessed using the QUADAS-2 tool. A linear mixed-effect regression model was used to obtain sensitivity estimates. Results Thirty-nine articles were included (1,989 patients, 3,854 metastases). Sensitivity estimates for DW-MR imaging, gadoxetic acid-enhanced MR imaging and the combined sequence for detecting liver metastases on a per-lesion basis was 87.1 %, 90.6 % and 95.5 %, respectively. Sensitivity estimates by gadoxetic acid-enhanced MR imaging and the combined sequence were significantly better than DW-MR imaging ( p  = 0.0001 and p  < 0.0001, respectively), and the combined MR sequence was significantly more sensitive than gadoxetic acid-enhanced MR imaging ( p  < 0.0001). Similar results were observed in articles that compared the three techniques simultaneously, with only colorectal liver metastases and in liver metastases smaller than 1 cm. Conclusions In patients with liver metastases, combined DW-MR and gadoxetic acid-enhanced MR imaging has the highest sensitivity for detecting liver metastases on a per-lesion basis. Key Points • DW-MRI is less sensitive than gadoxetic acid-enhanced MRI for detecting liver metastases • DW-MRI and gadoxetic acid-enhanced MRI is the best combination • Same results are observed in colorectal liver metastases • Same results are observed in liver metastases smaller than 1 cm • Same results are observed when histopathology alone is the reference standard

Women in Focus: Be Inspired was a unique programme held at the 2019 European Congress of Radiology that was structured to address a range of topics related to gender and healthcare, including leadership, mentoring and the generational progression of women in medicine. In most countries, women constitute substantially fewer than half of radiologists in academia or private practice despite frequently accounting for at least half of medical school enrolees. Furthermore, the proportion of women decreases at higher academic ranks and levels of leadership, a phenomenon which has been referred to as a “leaky pipeline”. Gender diversity in the radiologic workplace, including in academic and leadership positions, is important for the present and future success of the field. It is a tool for excellence that helps to optimize patient care and research; moreover, it is essential to overcome the current shortage of radiologists. This article reviews the current state of gender diversity in academic and leadership positions in radiology internationally and explores a wide range of potential reasons for gender disparities, including the lack of role models and mentorship, unconscious bias and generational changes in attitudes about the desirability of leadership positions. Strategies for both individuals and institutions to proactively increase the representation of women in academic and leadership positions are suggested.Key Points• Gender-diverse teams perform better. Thus, gender diversity throughout the radiologic workplace, including in leadership positions, is important for the current and future success of the field.• Though women now make up roughly half of medical students, they remain underrepresented among radiology trainees, faculty and leaders.• Factors leading to the gender gap in academia and leadership positions in Radiology include a lack of role models and mentors, unconscious biases, other societal barriers and generational changes.

Magnetic resonance imaging following injection of hepatobiliary contrast agents improves the detection of hepatocellular carcinomas when contrast agent accumulations in tumours and the surrounding pathological liver differ. However, tissue accumulation is poorly investigated, and this Clinical Outlook article highlights experimental data to understand better contrast agent accumulation in human pathological livers.

ObjectivesHigh radiation dose during CT perfusion (CTp) studies contributes to prevent CTp application in daily clinical practice. This work evaluates the consequences of scan delay on perfusion parameters and provides guidelines to help reducing the radiation dose by choosing the most appropriate delay.MethodsFifty-nine patients (34 men, 25 women; mean age 68 ± 12) with colorectal cancer, without underlying liver disease, underwent liver CTp, with the acquisition starting simultaneously with iodinated contrast agent injection. Blood flow (BF) and hepatic perfusion index (HPI) were computed on the acquired examinations and compared with those of the same examinations when a variable scan delay (τ) is introduced. Dose length product, CT dose index, and effective dose were also computed on original and delayed examinations.ResultsAltogether, three groups of delays (τ ≤ 4 s, 5 s ≤ τ ≤ 9 s, τ ≥ 10 s) were identified, yielding increasing radiation dose saving (RDS) (RDS ≤ 9.5%, 11.9% ≤ RDS ≤ 21.4%, RDS ≥ 23.8%) and decreasing perfusion accuracy (high (τ ≤ 4 s), medium (5 s ≤ τ ≤ 9 s), low (τ ≥ 10 s)). In particular, single-input and arterial BF and HPI were more insensitive to delay as regards the absolute variations (only 1 ml/min/100 g and 1%, respectively, for τ ≤ 9 s), than portal and total BF.ConclusionUsing delays lower than 4 s does not change perfusion accuracy and conveys unnecessary dose to patients. Conversely, starting the acquisition 9 s after contrast agent injection yields a RDS of about 21%, with no significant losses in perfusion accuracy.Key Points• Scan delays lower than 4 s do not alter perfusion accuracy and deliver an unnecessary radiation dose to patients.• Radiation dose delivered to patients can be reduced by 21.4% by introducing a 9-s scan delay, while keeping accurate perfusion values.• Using scan delays higher than 10 s, some perfusion parameters (portal and total BF) were inaccurate.

The purpose of this study was to assess the diagnostic value of multifrequency MR elastography for grading necro-inflammation in the liver. Fifty participants with chronic hepatitis B or C were recruited for this institutional review board-approved study. Their liver was examined with multifrequency MR elastography. The storage, shear and loss moduli, and the damping ratio were measured at 56 Hz. The multifrequency wave dispersion coefficient of the shear modulus was calculated. The measurements were compared to reference markers of necro-inflammation and fibrosis with Spearman correlations and multiple regression analysis. Diagnostic accuracy was assessed. At multiple regression analysis, necro-inflammation was the only determinant of the multifrequency dispersion coefficient, whereas fibrosis was the only determinant of the storage, loss and shear moduli. The multifrequency dispersion coefficient had the largest AUC for necro-inflammatory activity A ≥ 2 [0.84 (0.71–0.93) vs. storage modulus AUC: 0.65 (0.50–0.79), p  = 0.03], whereas the storage modulus had the largest AUC for fibrosis F ≥ 2 [AUC (95% confidence intervals) 0.91 (0.79–0.98)] and cirrhosis F4 [0.97 (0.88–1.00)]. The measurement of the multifrequency dispersion coefficient at three-dimensional MR elastography has the potential to grade liver necro-inflammation in patients with chronic vial hepatitis.