Non-Invasive Differentiation of Liver Hemangiomas and Colorectal Metastases: The Role of Apparent Diffusion Coefficient in Reducing Unnecessary Liver Biopsies
Abstract
Diffusion-weighted imaging (DWI) and the calculation of the Apparent Diffusion Coefficient (ADC) provide valuable functional information at the molecular level, which can aid in distinguishing hepatic lesions. This study aims to assess the role of MRI DWI and ADC values in differentiating between hepatic hemangiomas and colorectal liver metastases (CRLMs), focusing on lesion size and potential to reduce reliance on liver biopsy. In this prospective observational study conducted from January 2019 to February 2020 at Hiwa Cancer Hospital, 61 patients with newly diagnosed colorectal cancer (CRC) and suspicious liver lesions underwent abdominal MRI. Lesions were characterized using DWI with two b-values (b=50 and b=800 sec/mm²), and ADC values were calculated for both hemangiomas and metastases. The histopathological diagnosis of CRLM was confirmed for all cases. The study excluded larger or necrotic lesions and focused on lesion size influencing ADC values and ratios. Statistical analysis was performed using SPSS version 25. Hemangiomas demonstrated significantly higher ADC values and ADC ratios than metastases, particularly in smaller lesions (≤21.5 mm), with a P<0.001. In lesions >21.5 mm, while ADC values were less pronounced, ADC ratios remained significantly higher for hemangiomas (P=0.02). ADC values in left lobe lesions were slightly higher than those in the right lobe, although this difference did not reach statistical significance. MRI DWI with ADC measurement is valuable for differentiating hepatic hemangiomas from colorectal liver metastases, especially in smaller lesions. The significantly higher ADC values and ratios in hemangiomas can help avoid unnecessary biopsies and reduce the risk of metastasis seeding, which is particularly crucial in patients with resectable liver metastases.
1. Chow FC, Chok KS. Colorectal liver metastases: An update on multidisciplinary approach. World J Hepatol 2019;11:150.
2. Owen JW, Fowler KJ, Doyle MB, Saad NE, Linehan DC, Chapman WC. Colorectal liver metastases: disappearing lesions in the era of Eovist hepatobiliary magnetic resonance imaging. Hpb 2016 ;18:296-303.
3. Adam R, de Gramont A, Figueras J, Kokudo N, Kunstlinger F, Loyer E, et al. Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus. Cancer Treat Rev 2015;41:729-41.
4. Aziz H, Brown ZJ, Baghdadi A, Kamel IR, Pawlik TM. A comprehensive review of hepatic hemangioma management. J Gastrointest Surg 2022;26:1998-2007.
5. Mahmood KA, Rashid RJ, Fateh SM, Mohammed NA. Evaluation of the Effect of Patient Preparation Using Castor Oil on ADC Value of Focal Liver Lesion. Int J Gen Med 2021:469-74.
6. Yılmaz FG, Yıldırım AE. Relative contribution of Apparent Diffusion Coefficient (ADC) values and ADC ratios of focal hepatic lesions in the characterization of benign and malignant lesions. Eur J Ther 2018;24:150-7.
7. Testa ML, Chojniak R, Sene LS, Damascena AS, Guimaraes MD, Szklaruk J, et al. Is DWI/ADC a useful tool in the characterization of focal hepatic lesions suspected of malignancy?. PloS one 2014;9:e101944.
8. Varigonda M, Yarlagadda J, Sai TC, Patnaik S, Bhrugumalla S, Gunturi SR. The Role of Diffusion-Weighted MRI in Correlation with Contrast-Enhanced MRI and Histopathology in the Evaluation of Focal Liver Lesions. Cureus 2024;16:e71261.
9. Jahic E, Sofic A, Selimovic AH. DWI/ADC in differentiation of benign from malignant focal liver lesion. Acta Informatica Medica 2016;24:244.
10. Piskunowicz M, Fang C, Deganello A, Sellars ME, Sidhu PS. Contrast-Enhanced Ultrasound of Pediatric Focal Liver Lesions. Contrast-Enhanced Ultrasound in Pediatric Imaging 2021:63-84.
11. Liu Z, Yi L, Chen J, Li R, Liang K, Chen X, et al. Comparison of the clinical and MRI features of patients with hepatic hemangioma, epithelioid hemangioendothelioma, or angiosarcoma. BMC Med Imaging 2020;20:1-9.
12. Takayama Y, Nishie A, Okamoto D, Fujita N, Asayama Y, Ushijima Y, et al. Differentiating liver hemangioma from metastatic tumor using T2-enhanced spin-echo imaging with a time-reversed gradient-echo sequence in the hepatobiliary phase of gadoxetic acid-enhanced MR imaging. Magn Reson Med Sci 2022;21:445-57.
13. Cresswell AB, Welsh FK, Rees M. A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy? Hpb 2009;11:533-40.
14. Misiakos EP, Karidis NP, Kouraklis G. Current treatment for colorectal liver metastases. World J Gastroenterol 2011;17:4067.
15. Kahraman G, Haberal KM, Dilek ON. Imaging features and management of focal liver lesions. World J Radiol 2024;16:139.
16. Doblas S, Garteiser P, Van Beers BE. Diffuse Liver Diseases. Diffusion Weighted Imaging of the Hepatobiliary System. Techniques and Clinical Applications 2021:69-97.
17. Drevelegas K, Nikiforaki K, Constantinides M, Papanikolaou N, Papalavrentios L, Stoikou I, ET AL. Apparent diffusion coefficient quantification in determining the histological diagnosis of malignant liver lesions. J Cancer 2016;7:730.
18. Chen I, Lorentzen T, Linnemann D, Nolsøe CP, Skjoldbye B, Jensen BV, Nielsen D. Seeding after ultrasound-guided percutaneous biopsy of liver metastases in patients with colorectal or breast cancer. Acta Oncologica 2016;55:638-43.
19. Ohlsson B, Nilsson J, Stenram U, Åkerman M, Tranberg KG. Percutaneous fine‐needle aspiration cytology in the diagnosis and management of liver tumours. Br J Surg 2002;89:757-62.
20. Jones OM, Rees M, John TG, Bygrave S, Plant G. Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection. Br J Surg 2005;92:1165-8.
21. Kim H, Folks KD, Guo L, Sellers JC, Fineberg NS, Stockard CR, et al. Early therapy evaluation of combined cetuximab and irinotecan in orthotopic pancreatic tumor xenografts by dynamic contrast-enhanced magnetic resonance imaging. Mol Imaging 2011;10:153-67.
22. Karaoğlan BB, Öz DK, Araz MS, Akyol C, Utkan G. Advancements in the Management of Synchronous Colorectal Liver Metastases: A Comprehensive Review of Surgical, Systemic, and Local Treatment Modalities. Curr Oncol Rep 2024;26:791-803.
23. Ma J, Nie X, Kong X, Xiao L, Liu H, Shi S, et al. MRI T2WI-based radiomics combined with KRAS gene mutation constructed models for predicting liver metastasis in rectal cancer. BMC Medi Imaging 2024;24:262.
24. Sheth KR, Clary BM. Management of hepatic metastases from colorectal cancer. Clin Colon Rectal Surg 2005;18:215-23.
25. Bruegel M, Holzapfel K, Gaa J, Woertler K, Waldt S, Kiefer B, et al. Characterization of focal liver lesions by ADC measurements using a respiratory triggered diffusion-weighted single-shot echo-planar MR imaging technique. Eur Radiol 2008; 18:477-85.
26. Cieszanowski A, Anysz-Grodzicka A, Szeszkowski W, Kaczynski B, Maj E, Gornicka B, et al. Characterization of focal liver lesions using quantitative techniques: comparison of apparent diffusion coefficient values and T2 relaxation times. Eur Radiol 2012; 22:2514-24.
27. Ergelen R, Sahın C, Bal H, Tuney D. Diffusion-weighted MRI: In differential diagnosis of liver masses. Marmara Med J 2016;29:145-51.
28. Pena-Nogales O, Hernando D, Aja-Fernandez S, de Luis-Garcia R. Determination of optimized set of b-values for apparent diffusion coefficient mapping in liver diffusion-weighted MRI. J Magn Reson 2020; 310:106634.
29. Galea N, Cantisani V, Taouli B. Liver lesion detection and characterization: role of diffusion‐weighted imaging. J Magn Reson Imaging 2013;37:1260-76.
30. Mürtz P, Flacke S, Träber F, van den Brink JS, Gieseke J, Schild HH. Abdomen: diffusion-weighted MR imaging with pulse-triggered single-shot sequences. Radiology 2002;224:258-64.
31. Kaya B, Koc Z. Diffusion-weighted MRI and optimal b-value for characterization of liver lesions. Acta radiol 2014;55:532-42.
32. Luo M, Zhang L, Jiang XH, Zhang WD. Intravoxel incoherent motion diffusion-weighted imaging: evaluation of the differentiation of solid hepatic lesions. Transl Oncol 2017;10:831-8.
33. Taouli B, Koh DM. Diffusion-weighted MR imaging of the liver. Radiology 2010;254:47-66.
34. Parikh T, Drew SJ, Lee VS, Wong S, Hecht EM, Babb JS, et al. Focal liver lesion detection and characterization with diffusion-weighted MR imaging: comparison with standard breath-hold T2-weighted imaging. Radiology 2008;246:812-22.
35. Mamone G, Di Piazza A, Carollo V, Cannataci C, Cortis K, Bartolotta TV, et al. Imaging of hepatic hemangioma: from A to Z. Abdom Radiol 2020; 45:672-91.
36. Darbar A, Waqas M, Enam SF, Mahmood SD. Use of preoperative apparent diffusion coefficients to predict brain tumor grade. Cureus 2018;10.
37. Javadrashid R, Shakeri Bavil Olyaei A, Tarzamni MK, Razzaghi R, Jalili J, Hashemzadeh S, et al. The diagnostic value of diffusion-weighted imaging in differentiating benign from malignant hepatic lesions. Egypt Liver J 2020;10:1-9.
38. Heijmen L, Ter Voert EE, Nagtegaal ID, Span P, Bussink J, Punt CJ, et al. Diffusion-weighted MR imaging in liver metastases of colorectal cancer: reproducibility and biological validation. Eur Radiol 2013; 23:748-56.
39. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. Am J Roentgenol 2007;188:1622-35.
40. Caraiani C, Chiorean L, Fenesan DI, Lebovici A, Feier D, Gersak M, et al. Diffusion weighted magnetic resonance imaging for the classification of focal liver lesions as benign or malignant. J Gastrointestin Liver Dis 2015;24:309-17.
41. Colagrande S, Pasquinelli F, Mazzoni LN, Belli G, Virgili G. MR‐diffusion weighted imaging of healthy liver parenchyma: repeatability and reproducibility of apparent diffusion coefficient measurement. J Magn Reson Imaging 2010;31:912-20.
42. Kanematsu M, Goshima S, Watanabe H, Kondo H, Kawada H, Noda Y, et al. Detection and characterization of focal hepatic lesions with diffusion-weighted MR imaging: a pictorial review. Abdom Imaging 2013;38:297-308.
43. Girometti R, Furlan A, Esposito G, Bazzocchi M, Como G, Soldano F, et al. Relevance of b‐values in evaluating liver fibrosis: a study in healthy and cirrhotic subjects using two single‐shot spin‐echo echo‐planar diffusion‐weighted sequences. J Magn Reson Imaging 2008;28:411-9.
2. Owen JW, Fowler KJ, Doyle MB, Saad NE, Linehan DC, Chapman WC. Colorectal liver metastases: disappearing lesions in the era of Eovist hepatobiliary magnetic resonance imaging. Hpb 2016 ;18:296-303.
3. Adam R, de Gramont A, Figueras J, Kokudo N, Kunstlinger F, Loyer E, et al. Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus. Cancer Treat Rev 2015;41:729-41.
4. Aziz H, Brown ZJ, Baghdadi A, Kamel IR, Pawlik TM. A comprehensive review of hepatic hemangioma management. J Gastrointest Surg 2022;26:1998-2007.
5. Mahmood KA, Rashid RJ, Fateh SM, Mohammed NA. Evaluation of the Effect of Patient Preparation Using Castor Oil on ADC Value of Focal Liver Lesion. Int J Gen Med 2021:469-74.
6. Yılmaz FG, Yıldırım AE. Relative contribution of Apparent Diffusion Coefficient (ADC) values and ADC ratios of focal hepatic lesions in the characterization of benign and malignant lesions. Eur J Ther 2018;24:150-7.
7. Testa ML, Chojniak R, Sene LS, Damascena AS, Guimaraes MD, Szklaruk J, et al. Is DWI/ADC a useful tool in the characterization of focal hepatic lesions suspected of malignancy?. PloS one 2014;9:e101944.
8. Varigonda M, Yarlagadda J, Sai TC, Patnaik S, Bhrugumalla S, Gunturi SR. The Role of Diffusion-Weighted MRI in Correlation with Contrast-Enhanced MRI and Histopathology in the Evaluation of Focal Liver Lesions. Cureus 2024;16:e71261.
9. Jahic E, Sofic A, Selimovic AH. DWI/ADC in differentiation of benign from malignant focal liver lesion. Acta Informatica Medica 2016;24:244.
10. Piskunowicz M, Fang C, Deganello A, Sellars ME, Sidhu PS. Contrast-Enhanced Ultrasound of Pediatric Focal Liver Lesions. Contrast-Enhanced Ultrasound in Pediatric Imaging 2021:63-84.
11. Liu Z, Yi L, Chen J, Li R, Liang K, Chen X, et al. Comparison of the clinical and MRI features of patients with hepatic hemangioma, epithelioid hemangioendothelioma, or angiosarcoma. BMC Med Imaging 2020;20:1-9.
12. Takayama Y, Nishie A, Okamoto D, Fujita N, Asayama Y, Ushijima Y, et al. Differentiating liver hemangioma from metastatic tumor using T2-enhanced spin-echo imaging with a time-reversed gradient-echo sequence in the hepatobiliary phase of gadoxetic acid-enhanced MR imaging. Magn Reson Med Sci 2022;21:445-57.
13. Cresswell AB, Welsh FK, Rees M. A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy? Hpb 2009;11:533-40.
14. Misiakos EP, Karidis NP, Kouraklis G. Current treatment for colorectal liver metastases. World J Gastroenterol 2011;17:4067.
15. Kahraman G, Haberal KM, Dilek ON. Imaging features and management of focal liver lesions. World J Radiol 2024;16:139.
16. Doblas S, Garteiser P, Van Beers BE. Diffuse Liver Diseases. Diffusion Weighted Imaging of the Hepatobiliary System. Techniques and Clinical Applications 2021:69-97.
17. Drevelegas K, Nikiforaki K, Constantinides M, Papanikolaou N, Papalavrentios L, Stoikou I, ET AL. Apparent diffusion coefficient quantification in determining the histological diagnosis of malignant liver lesions. J Cancer 2016;7:730.
18. Chen I, Lorentzen T, Linnemann D, Nolsøe CP, Skjoldbye B, Jensen BV, Nielsen D. Seeding after ultrasound-guided percutaneous biopsy of liver metastases in patients with colorectal or breast cancer. Acta Oncologica 2016;55:638-43.
19. Ohlsson B, Nilsson J, Stenram U, Åkerman M, Tranberg KG. Percutaneous fine‐needle aspiration cytology in the diagnosis and management of liver tumours. Br J Surg 2002;89:757-62.
20. Jones OM, Rees M, John TG, Bygrave S, Plant G. Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection. Br J Surg 2005;92:1165-8.
21. Kim H, Folks KD, Guo L, Sellers JC, Fineberg NS, Stockard CR, et al. Early therapy evaluation of combined cetuximab and irinotecan in orthotopic pancreatic tumor xenografts by dynamic contrast-enhanced magnetic resonance imaging. Mol Imaging 2011;10:153-67.
22. Karaoğlan BB, Öz DK, Araz MS, Akyol C, Utkan G. Advancements in the Management of Synchronous Colorectal Liver Metastases: A Comprehensive Review of Surgical, Systemic, and Local Treatment Modalities. Curr Oncol Rep 2024;26:791-803.
23. Ma J, Nie X, Kong X, Xiao L, Liu H, Shi S, et al. MRI T2WI-based radiomics combined with KRAS gene mutation constructed models for predicting liver metastasis in rectal cancer. BMC Medi Imaging 2024;24:262.
24. Sheth KR, Clary BM. Management of hepatic metastases from colorectal cancer. Clin Colon Rectal Surg 2005;18:215-23.
25. Bruegel M, Holzapfel K, Gaa J, Woertler K, Waldt S, Kiefer B, et al. Characterization of focal liver lesions by ADC measurements using a respiratory triggered diffusion-weighted single-shot echo-planar MR imaging technique. Eur Radiol 2008; 18:477-85.
26. Cieszanowski A, Anysz-Grodzicka A, Szeszkowski W, Kaczynski B, Maj E, Gornicka B, et al. Characterization of focal liver lesions using quantitative techniques: comparison of apparent diffusion coefficient values and T2 relaxation times. Eur Radiol 2012; 22:2514-24.
27. Ergelen R, Sahın C, Bal H, Tuney D. Diffusion-weighted MRI: In differential diagnosis of liver masses. Marmara Med J 2016;29:145-51.
28. Pena-Nogales O, Hernando D, Aja-Fernandez S, de Luis-Garcia R. Determination of optimized set of b-values for apparent diffusion coefficient mapping in liver diffusion-weighted MRI. J Magn Reson 2020; 310:106634.
29. Galea N, Cantisani V, Taouli B. Liver lesion detection and characterization: role of diffusion‐weighted imaging. J Magn Reson Imaging 2013;37:1260-76.
30. Mürtz P, Flacke S, Träber F, van den Brink JS, Gieseke J, Schild HH. Abdomen: diffusion-weighted MR imaging with pulse-triggered single-shot sequences. Radiology 2002;224:258-64.
31. Kaya B, Koc Z. Diffusion-weighted MRI and optimal b-value for characterization of liver lesions. Acta radiol 2014;55:532-42.
32. Luo M, Zhang L, Jiang XH, Zhang WD. Intravoxel incoherent motion diffusion-weighted imaging: evaluation of the differentiation of solid hepatic lesions. Transl Oncol 2017;10:831-8.
33. Taouli B, Koh DM. Diffusion-weighted MR imaging of the liver. Radiology 2010;254:47-66.
34. Parikh T, Drew SJ, Lee VS, Wong S, Hecht EM, Babb JS, et al. Focal liver lesion detection and characterization with diffusion-weighted MR imaging: comparison with standard breath-hold T2-weighted imaging. Radiology 2008;246:812-22.
35. Mamone G, Di Piazza A, Carollo V, Cannataci C, Cortis K, Bartolotta TV, et al. Imaging of hepatic hemangioma: from A to Z. Abdom Radiol 2020; 45:672-91.
36. Darbar A, Waqas M, Enam SF, Mahmood SD. Use of preoperative apparent diffusion coefficients to predict brain tumor grade. Cureus 2018;10.
37. Javadrashid R, Shakeri Bavil Olyaei A, Tarzamni MK, Razzaghi R, Jalili J, Hashemzadeh S, et al. The diagnostic value of diffusion-weighted imaging in differentiating benign from malignant hepatic lesions. Egypt Liver J 2020;10:1-9.
38. Heijmen L, Ter Voert EE, Nagtegaal ID, Span P, Bussink J, Punt CJ, et al. Diffusion-weighted MR imaging in liver metastases of colorectal cancer: reproducibility and biological validation. Eur Radiol 2013; 23:748-56.
39. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. Am J Roentgenol 2007;188:1622-35.
40. Caraiani C, Chiorean L, Fenesan DI, Lebovici A, Feier D, Gersak M, et al. Diffusion weighted magnetic resonance imaging for the classification of focal liver lesions as benign or malignant. J Gastrointestin Liver Dis 2015;24:309-17.
41. Colagrande S, Pasquinelli F, Mazzoni LN, Belli G, Virgili G. MR‐diffusion weighted imaging of healthy liver parenchyma: repeatability and reproducibility of apparent diffusion coefficient measurement. J Magn Reson Imaging 2010;31:912-20.
42. Kanematsu M, Goshima S, Watanabe H, Kondo H, Kawada H, Noda Y, et al. Detection and characterization of focal hepatic lesions with diffusion-weighted MR imaging: a pictorial review. Abdom Imaging 2013;38:297-308.
43. Girometti R, Furlan A, Esposito G, Bazzocchi M, Como G, Soldano F, et al. Relevance of b‐values in evaluating liver fibrosis: a study in healthy and cirrhotic subjects using two single‐shot spin‐echo echo‐planar diffusion‐weighted sequences. J Magn Reson Imaging 2008;28:411-9.
| Files | ||
| Issue | Vol 63 No 2 (2025) | |
| Section | Original Articles | |
| DOI | https://doi.org/10.18502/acta.v63i2.18963 | |
| Keywords | ||
| Diffusion-weighted imaging Apparent diffusion coefficient Hepatic hemangiomas Colorectal liver metastases MRI ADC values Liver lesions Colorectal cancer | ||
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How to Cite
1.
A. Mahmood K. Non-Invasive Differentiation of Liver Hemangiomas and Colorectal Metastases: The Role of Apparent Diffusion Coefficient in Reducing Unnecessary Liver Biopsies. Acta Med Iran. 2025;63(2):98-105.
