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DOI:10.2214/AJR.07.3066
AJR 2008; 190:W223
© American Roentgen Ray Society

Letters

Reply

Stephanie R. Wilson

Foothills Medical Center Calgary, AB, Canada

WEB—This is a Web exclusive article.

We thank Drs. Francica and Lapiccirella [1] for their interest in our article [2]. They clearly share our enthusiasm for this most interesting topic. Their cited case of lymphoma in a cirrhotic liver does undoubtedly reflect a discordance due to timing, similar to the examples that we described whereby CT arterial phase imaging is performed later than the arterial phase hypervascularity as shown on contrast-enhanced sonography.

Regarding their specific questions [1], the authors are correct that in our article [2] we did not have a consistent confirmation of diagnosis for all of our cases, although in each and every case, we used a combination of clinical information, including biopsy, to establish the final diagnosis. Partly because of this issue, we wrote this retrospective effort as a Clinical Observations article rather than as clinical research (i.e., as an Original Research article), two of the distinct types of manuscripts possible for publication in the AJR.

We have no impression that the discordance described in our article is related in any way to the type or age of the sonography, CT, and MR equipment. Nor do we think that the type of equipment used might have influenced the results.

We do believe that the third question [1] very cleverly addresses the potential explanation for the discordance that we describe for some types of lesions—in particular, for focal nodular hyperplasia and adenoma. We remain keenly interested in this potential, although at this point in time, we have been unable to document any relationship of discordance either to vascular architecture or to histomorphology. Regarding lesion size, we have tried to look at this characteristic also. To date, size does not seem to have a unique association with discordance.

The fourth question [1] relates to discordance of enhancement of nodules seen in cirrhotic livers. We recognize this issue as a very complex one, and since the submission of this article [2], we also have documented more examples in this population. We agree with Drs. Francica and Lapiccirella and also with Bolondi et al. [3] that discordance is very frequent for small nodules. In our article, written as a Clinical Observations paper, we did document three unexplained examples of clear discordance for hepatoma. Our effort, however, was focused on shedding light on discordance and the importance of its recognition and also explaining why this discordance might occur. The groups of discordance that we identified—those due to the diffusion of contrast agent, those due to timing, and those due to the presence of fat—were clear categories. We are grateful to the authors of the Letter to the Editor for highlighting the important issue of cirrhotic nodules, which we are sure will attract further attention from investigators in the future.

Discordance of imaging results will continue to happen, and the sharing of personal experiences will enhance the ability for all of us to adequately address the problems when they occur. Thank you Drs. Francica and Lapiccirella for shedding further light on this topic.

References

  1. Francica G, Lapiccirella G. Focal liver lesions: one more example of discordance between contrast-enhanced sonography and CT pattern of enhancement. (letter) AJR 2008;190 : W222[Free Full Text]
  2. Wilson SR, Kim TK, Jang HJ, Burns PN. Enhancement patterns of focal liver masses: discordance between contrast-enhanced sonography and contrast-enhanced CT and MRI. AJR 2007;189 : W7–W12[Abstract/Free Full Text]
  3. Bolondi L, Gaiani S, Celli N, et al. Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma. Hepatology2005; 42:27 –34[CrossRef][Medline]

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This Article
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