Abdominal Radiology

, Volume 44, Issue 9, pp 3209–3209 | Cite as

Reply to “Letter to the editor”

  • Roberto Cannella
  • Kathryn J. Fowler
  • Alessandro FurlanEmail author
Letter to the Editor

We thank Madhusudhan and Srivastava [1] for their interest in our manuscript [2] and for sharing their experience. We reported on five pitfalls that, in our opinion, are commonly encountered when applying the Liver Imaging Reporting and Data System (LI-RADS) [2]. However, we recognize that there are many more challenges related to the diagnosis of hepatocellular carcinoma (HCC) on CT and MR imaging studies of cirrhotic livers, including the scenarios mentioned in this letter.

The presence of significant fat deposition may be problematic for both detection and characterization of liver lesions. Two recent studies investigated the performance of LI-RADS in this scenario. Kim et al. [3] showed that the performance of major features on contrast-enhanced CT was not significantly different between patients with and those without severe steatosis. On the other hand, Thompson et al [4] reported that the lack of visualization of washout and capsule on MRI was associated with increasing histologic steatosis grade. The reduced conspicuity of washout in a steatotic liver is likely due to the decreased T1-weighted signal intensity in the perilesional liver. When the observation appears hyperintense on pre-contrast T1-weighted images, subtraction imaging (e.g., extracellular phase—pre-contrast) may be useful to detect washout although care is needed to ensure the images are well registered [5].

In Fig. 2 [1], Madhusudhan and Srivastava report a case of LR-TIV (tumor-in-vein) contiguous with an infiltrative mass with minimal APHE and washout, suggesting a LR-M observation. Although we agree with the authors that the presence of portal vein thrombosis may affect the enhancement pattern of a liver mass/tumor, to our knowledge, no study has evaluated it in the context of LI-RADS. We would like to add that it is possible that the decreased conspicuity of APHE and washout in HCC presenting with a diffuse/infiltrative appearance may be due to the macroscopic growth pattern characterized by minute tumor nodules spread among cirrhotic nodules, regardless of the presence of tumor-in-vein [6].

We welcome further conversation on the current status of LI-RADS with the overarching goal of further improving the system and promoting its use in clinical practice.


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Madhusudhan KS, Srivastava DN (2019) Letter to the Editor, Abdom Radiol (NY). CrossRefGoogle Scholar
  2. 2.
    Cannella R, Fowler KJ, Borhani AA, et al. (2019) Common pitfalls when using the Liver Imaging Reporting and Data System (LI-RADS): lessons learned from a multi-year experience. Abdom Radiol (NY) 44:43–53CrossRefGoogle Scholar
  3. 3.
    Kim SS, Hwang JA, Shin HC, et al. (2019) LI-RADS v2017 categorisation of HCC using CT: Does moderate to severe fatty liver affect accuracy? Eur Radiol 29:186–194CrossRefPubMedGoogle Scholar
  4. 4.
    Thompson SM, Garg I, Ehman EC, et al. (2018) Non-alcoholic fatty liver disease-associated hepatocellular carcinoma: effect of hepatic steatosis on major hepatocellular carcinoma features at MRI. Br J Radiol 91:20180345CrossRefPubMedGoogle Scholar
  5. 5.
  6. 6.
    Reynolds AR, Furlan A, Fetzer DT, et al. (2015) Infiltrative hepatocellular carcinoma: what radiologists need to know. Radiographics 35:371–386CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Roberto Cannella
    • 1
    • 2
  • Kathryn J. Fowler
    • 3
  • Alessandro Furlan
    • 1
    Email author
  1. 1.Abdominal Imaging Division, Department of RadiologyUniversity of PittsburghPittsburghUSA
  2. 2.Section of Radiology - BiNDUniversity Hospital “Paolo Giaccone”PalermoItaly
  3. 3.Department of RadiologyUniversity of California San DiegoLa JollaUSA

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