Differentiation of hepatic cysts from hemangiomas:

Contribution of "inversion recovery" single-shot fast spin-

echo sequence

Poster No.: C-2177

Congress: ECR 2014
Type: Scientific Exhibit
Authors: E. Dü#ünceli Atman, A. Erden, C. Uzun, Y. Genç; Ankara/TR
Keywords: Liver, MR, Diagnostic procedure, Cysts, Hemangioma
DOI: 10.1594/ecr2014/C-2177

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Page 1 of 8
Aims and objectives

On standard T2 weighted MR images, since both hepatic hemangiomas and cysts are
typically hyperintense, the differentiation between these benign lesions cannot be made
unless intravenous gadolinium is administered. On the other hand, if an appropriate null
point is chosen, the signal of hepatic hemangiomas will be suppressed, but cysts will
continue to appear hyperintense.

In this study, the additive diagnostic value of "inversion recovery" single-shot fast spin-
echo (IR-SSFSE) sequence using the inversion time (TI) of hepatic hemangioma as a
supplement to standard T2 weighted MR imaging for the differentiation of hemangiomas
and cysts is evaluated.

Methods and materials

A total of 130 lesions (82 hemangiomas, 48 cysts) were evaluated in this study. The study
population consisted of 14 males and 19 females (total 33 patients) aged between 29-78
years (mean 50 years). The study was performed on 1.5 T MR unit using 12-channel
body coil. In addition to routine hepatic MR imaging, IR-SSFSE imaging using TI value
of 600 ms (null point for hepatic hemangiomas) was taken. The parameters of sequence
are shown in table 1.

TR (time to repeat) (ms) 6000

TE (echo time) (ms) 60
IR (inversion time) (ms) 600
Matrix size 320x224
Section thickness (mm) 10
Intersection gap (mm) 2
FOV (field of view) (cm) 40
Plane axial
Bandwidth 62.50
Data collecting time (s) 55
Breath control intermittent breath hold
Table 1: The parameters of IR-SSFSE sequence used to supress the signal of
hemangiomas.

Page 2 of 8
Image Analysis

The segments of the liver were reviewed on T2 weighted images, and the lesions which
were "significantly hyperintense" were recorded. Afterwards, the signal alteration of these
hyperintense lesions was evaluated on IR-SSFSE sequence and the lesions were scored
using a five-point scale independently by two radiologists (1= definitely hemangioma, 2=
probably hemangioma, 3= discrimination cannot be made (equivocal), 4= probably cyst,
5= definitely cyst) (Figures 1-3).

On IR-SSFSE sequence, suppression of the lesion's signal and becoming hypointense

are the diagnostic criteria for hemangioma. Hyperintensity compared with the liver
parenchyma and the presence of a dark rim artifact around the lesion are the
diagnostic criteria for cyst. This artifact forms at the margin between the negative phase
magnetization of the cyst and the positive phase magnetization of liver parenchyma.

As the standard reference method, dynamic contrast-enhanced MRI was used in 31

patients and US was used in 2 patients. Diagnoses of cysts were made if no enhancement
was visible on dynamic MRI. The lesions that showed peripheral nodular enhancement
in the early phase, and enhanced progressively towards centrally were considered as
hemangiomas.

The diagnostic capability of IR-SSFSE sequence to differentiate hemangiomas from cysts

was determined by calculating the area under ROC (receiver operating characteristic)
curve (AUC) (in the ROC curve, the closer the area under the curve to 1, the higher the
correct estimation value of the sequence will be). To assess the interobserver variability,
kappa statistic was calculated (<0.20= poor agreement, 0.21-0.40= mild agreement,
0.41-0.60= moderate, 0.61-0.80= good agreement, 0.81-1.00= excellent agreement).

Images for this section:

Page 3 of 8
Fig. 1: Axial T2W images (a,b) of a 57-year-old female patient show hyperintense lesions
in segment 7 (15 mm) and at the margin of segments 5-6 (6 mm) (arrows). On the IR-
SSFSE image (c,d), the lesion in segment 7 becomes hypointense compared with the
hepatic parenchyma (arrow), however, other lesion remains hyperintense, and in the
periphery of this lesion dark rim artifact is demonstrated (arrow in d). On postcontrast
images (e,d), the lesion in segment 7 is enhanced compatible with a hemangioma,
conversely, the cystic lesion does not show enhancement.

Page 4 of 8
Fig. 2: T2W images of 30-year-old male patient (a,b) indicate 18 mm and 5 mm
hyperintense lesions in segments 7 and 3, respectively (arrows). The lesion in segment
7 is hypointense, and the lesion in segment 3 is hyperintense on IR-SSFSE images
compared with the hepatic parenchyma (c,d). On dynamic contrast-enhanced MR
images (e,g) while the lesion in segment 7 shows "peripheral nodular" enhancement
(hemangioma), other lesion in segment 3 shows no enhancement (cyst).

Fig. 3: On T2W MR image of a 30-year-old male patient (a) a hyperintense lesion in

segment 6 is demonstrated. The lesion becomes hypointense compared with hepatic
parenchyma on IR-SSFSE sequence (b). On dynamic MR image, "peripheral nodular"
enhancement is shown at the periphery of the lesion compatible with a hemangioma.

Page 5 of 8
Results

According to standard reference method, 82 hepatic hemangiomas and 48 hepatic cysts

were evaluated (total 130 lesions) in 33 patients. The lesion diameter was 2-125 mm. The
lesion diameter of the cysts was 2-38 mm (median= 6 mm), and that of the hemangiomas
was 3-125 mm (median= 11 mm).

When 3 scoring (1-3) was used, statistically significant interobserver correlation was
found as #=0.596; p<0.001.

In the ROC analysis for the differentiation of hepatic hemangiomas from cysts, AUC was
0.748 for the first observer, and was 0.867 for the second observer.

Images for this section:

Page 6 of 8
Fig. 4: In the ROC analysis for the differentiation of hepatic hemangiomas from cysts,
AUC was 0.748 for the first observer, and was 0.867 for the second observer.

Page 7 of 8
Conclusion

When a hyperintense lesion is detected on standard T2 weighted images, addition of IR-

SSFSE sequence is useful for distinguishing a hepatic hemangioma from a hepatic cyst.
The sequence technique is based on different relaxation features of hemangiomas and
water in cysts. If inversion time is chosen as 600 ms which represents the null point of
longitudinal magnetization of hemangioma, the spin of protons from the hemangiomas
do not contribute to the MR signal. Consequently, in patients who are unable to
receive intravenous contrast media, in incidental hyperintense lesions encountered on
standard MRCP exams, or when previous ultrasound or dynamic contrast enhanced CT
reports/CD's are unavailable, IR-SSFSE sequence using the inversion time of hepatic
hemangioma as a supplement to standard T2 weighted images is useful for distinguishing
hepatic hemangioma from hepatic cyst.

Personal information

References

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Differentiation between hepatic haemangiomas and cysts with an inversion recovery
single-shot turbo spin-echo (SSTSE) sequence using the TI nulling value of hepatic
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2. Sasaki K, Ito K, Koike S, Fujita T, Okazaki H, Matsunaga N.Differentiation between

hepatic cyst and hemangioma: additive value of breath-hold, multisection fluid-attenuated
inversion-recovery magnetic resonance imaging using half-Fourier acquisition single-
shot turbo-spin-echo sequence. J Magn Reson Imaging 2005;21:29-36.

3. Ohkawa M, Katoh T, Nakano S, Fujiwara N, Mori Y, Hino I, Tanabe M. Use of fluid-

attenuated inversion recovery (FLAIR) pulse sequences for
differential diagnosis of hepatic hemangiomas and hepatic cysts. Acta Med Okayama
1997;51:275-8.

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