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Original Article Re-assessing the diagnostic value of the enhancing “capsule” in hepatocellular carcinoma imaging
Jae Seok Bae1,2orcid , Jeong Min Lee1,2,3orcid , Bo Yun Hur4orcid , Jeongin Yoo1,2orcid , Sae-Jin Park5orcid

DOI: [Accepted]
Published online: May 8, 2024
1Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
2Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
3Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
4Department of Radiology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
5G&E Alphadom Medical Center, Gyeonggi-do, Republic of Korea
Corresponding author:  Jeong Min Lee,
Received: 8 March 2024   • Revised: 18 April 2024   • Accepted: 1 May 2024
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The enhancing “capsule” (EC) in hepatocellular carcinoma (HCC) diagnosis has received varying degrees of recognition across major guidelines. This study aimed to assess the diagnostic utility of EC in HCC detection.
We retrospectively analyzed patients who underwent pre-surgical computed tomography (CT) and hepatobiliary agent-enhanced magnetic resonance imaging (HBA-MRI) between January 2016 and December 2019. A single hepatic tumor was confirmed based on the pathology of each patient. Three radiologists independently reviewed the images according to the Liver Imaging Reporting and Data System (LIRADS) v2018 criteria and reached a consensus. Interobserver agreement for EC before reaching a consensus was quantified using Fleiss κ statistics. The impact of EC on the LI-RADS classification was assessed by comparing the positive predictive values for HCC detection in the presence and absence of EC.
In total, 237 patients (median age, 60 years; 184 men) with 237 observations were included. The interobserver agreement for EC detection was notably low for CT (κ=0.169) and HBA-MRI (κ=0.138). The presence of EC did not significantly alter the positive predictive value for HCC detection in LI-RADS category 5 observations on CT (94.1% [80/85] vs. 94.6% [88/93], P=0.886) or HBA-MRI (95.7% [88/92] vs. 90.6% [77/85], P=0.178).
The diagnostic value of EC in HCC diagnosis remains questionable, given its poor interobserver agreement and negligible impact on positive predictive values for HCC detection. This study challenges the emphasis on EC in certain diagnostic guidelines and suggests the need to re-evaluate its role in HCC imaging.

JLC : Journal of Liver Cancer