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To depict treatment response to chemoradiotherapy by comparing tumor growth rate between treated and untreated patients and to compare depicted response with objective response according to the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 guideline.This Health Insurance Portability and Accountability Act-compliant, retrospective study was approved by the institutional review board. Volume doubling time (DT) of histologically confirmed locally advanced pancreatic adenocarcinoma was calculated in 16 patients treated with chemoradiotherapy and 10 untreated patients by incorporating interscan interval (Δt) and tumor volume at baseline (V0) and follow-up (V1) obtained by semiautomated segmentation into the following equation: DT = Δt · log 2/log (V1/V0). Reciprocal of doubling time (RDT), which is the linear representation of tumor growth rate, was calculated by use of the following equation: RDT = 365/DT. The lowest RDT value of 2.42 in untreated patients was considered as the cutoff value for depiction of treatment response. Depicted response rate was defined as the proportion of patients with an RDT value of less than 2.42. Depicted response was compared with objective response according to the RECIST 1.1 guideline. The significance level was set at p0.05.There was a significant difference in mean RDT between treated (range, -7.12 to 3.27; mean, -1.27; median, -1.30) and untreated (range, 2.42 to 10.74; mean, 5.33; median, 4.26) patients (p0.05). Reciprocal of doubling time was less than 2.42 in 14 treated patients, which corresponded to a depicted response rate of 87.50% as opposed to the objective response rate of 18.75% according to the RECIST 1.1 guideline (p0.05) and carbohydrate antigen 19-9 response rate of 62.50% (p0.05). Carbohydrate antigen 19-9 response was concordant with RDT and RECIST response in 12 patients (75.00%) (κ, 0.38) and 9 patients (56.25%) (κ, 0.24), respectively.There was a significant difference between depicted response according to RDT and objective response according to RECIST. Reciprocal of doubling time might serve as a valuable biomarker for evaluation of treatment response when depiction of small changes in tumor size is concerned.

Comprehensive training in cardiac imaging during radiology residency is imperative if radiologists are to maintain a significant role in this rapidly growing field. In this study, radiology chief residents were surveyed to assess the current status of cardiac imaging training in radiology residency programs. The responses to this survey may be helpful in understanding current trends in cardiac imaging training and how such training can be improved in the future.Chief residents at accredited radiology residency programs were sent an e-mail with a link to a 17-question Web-based survey. The survey assessed the organization of cardiac imaging training in each residency program, imaging modalities incorporated into cardiac imaging training, the role of residents on cardiac imaging rotations, and attitudes of residents about their cardiac imaging training and the future of cardiac imaging.Responses were obtained from 52 of 112 (46%) programs. Seventy-one percent had at least one dedicated cardiac imaging rotation during their residencies. Fifty-two percent and 62% of respondents reported5 hours of cardiac imaging-related case conferences and didactic lectures per year, respectively. Most had cardiac computed tomography or magnetic resonance imaging incorporated into their cardiac imaging training. Although 92% felt that cardiac imaging training is important, only 17% felt that they currently received adequate training in cardiac imaging.The majority of residency programs represented in this survey had at least one dedicated cardiac imaging rotation for their residents. Most of these programs had few cardiac imaging-related conferences and lectures per year. Although most chief residents believed that cardiac imaging training is important, only a minority felt that they currently received adequate training in cardiac imaging.

Response Evaluation Criteria in Solid Tumors (RECIST) guidelines assume spherical shape of tumors. Morphology of pancreatic adenocarcinoma (PAC) on multidetector row computed tomography was investigated to evaluate the applicability of RECIST guidelines.Study population comprised 16 patients with histologically confirmed localized PAC enrolled in a phase II clinical trial of chemoradiation. Pancreatic adenocarcinomas were segmented on baseline and follow-up multidetector row computed tomography with commercially available software. Tumor volumes (mL), RECIST diameter (mm), volume equivalent sphere diameter (VESD, mm), maximum 3-dimensional diameter (M3DD, mm), and elongation value were obtained. RECIST diameter, VESD and M3DD of the tumors at baseline and follow-up were compared to determine differences. Elongation values were analyzed. The significance level was set at P less than 0.05.Mean volume, RECIST diameter, VESD, M3DD, and elongation for baseline versus follow-up studies were 23.12 mL versus 19.43 mL (P0.05), 41.86 mm versus 39.35 mm (P0.05), 33.14 mm versus 32.1 mm (P0.05), 51.76 mm versus 51.73 mm (P0.05), and 0.67 versus 0.76 (P0.05), respectively. There was a significant difference at baseline and follow-up between RECIST diameter, VESD, and M3DD (P0.05, in all instances).Our results suggest that PACs are not spherical in shape. Evaluation of PAC treatment response based on RECIST guidelines may not be accurate.

CT enterography is a new imaging modality that has distinct advantages over conventional CT, wireless capsule endoscopy, and barium examination. CT enterography is noninvasive and allows rapid mapping of disease activity before endoscopy and in cases where the endoscope cannot reach the diseased segment. CT enterography is readily available, is operator independent, and allows evaluation of extraenteric complications of small bowel disease. This article describes the latest techniques and applications of CT enterography.

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel or colon. The incidence of bowel ischemia and infarction is on the rise for several reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have greatly contributed to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this article, role of radiology in the detection, differential diagnosis, and management of patients who have intestinal ischemia and infarction is discussed.

We evaluated the ability of 64-slice computed tomography (CT), conventional cine-angiography, and intravascular ultrasound (IVUS) to detect stent fractures under ideal conditions. Coronary stent fracture has been implicated as one of the mechanisms of stent thrombosis and, perhaps, in-stent restenosis. However, the preferred imaging modality in detecting fractures in coronary stents has not been well established.Four different types of commonly used coronary stents (Cypher, Taxus, Vision, Hepacoat) each with three strut fractures (Cypher, 5; Taxus, 5; Vision, 4; Hepacoat, 5) were nominally deployed in polyurethane tubes and imaged with 64-slice CT, conventional cine-angiography, and IVUS. For each stent type, an unfractured control stent was also imaged.Overall accuracy (84.1% vs. 73.9%), sensitivity (80.7 vs. 77.2%), and specificity (100% vs. 58.3%) for stent fracture detection was higher with 64 multislice CT compared to conventional cine-angiography. Stent fractures were not accurately detected by IVUS. Fracture detection by multislice CT was best when the stents were imaged at 45 degrees to the z-axis.Under ideal in vitro conditions, CT has a high accuracy when used to evaluate coronary stent fractures. The overall accuracy, sensitivity, and specificity of detecting stent fractures are lower by conventional cine-angiography. Stent fractures were not detected using IVUS.

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel and/or colon. The incidence of bowel ischemia is increasing for a number of reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have contributed greatly to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this review, advances in multidetector computerized tomography, magnetic resonance, and ultrasound in the detection of intestinal ischemia are highlighted and placed in the context of expeditious patient management.

Radioembolization with yttrium 90 (90Y) microspheres represents an emerging transarterial therapy for the treatment of liver malignancies that continues to generate interest in the medical community. The classic indication of treatment response is a reduction in tumor size; however, parenchymal changes (eg, necrosis, lack of enhancement, specific findings at positron emission tomography and functional magnetic resonance imaging) and other benign findings (pleural effusions, perivascular edema, contralateral hypertrophy, ring enhancement, perihepatic fluid, fibrosis) may occur following treatment, requiring proper image interpretation. With classic imaging findings and surrogates (time to progression, duration of response, disease-free interval), response rates range from 20% to 80% in patients treated for hepatocellular carcinoma or metastatic disease to the liver. Complications of 90Y radioembolization include cholecystitis, abscess, and bilomas and should be recognized early in the imaging follow-up of these patients. Radiologists who are involved in the posttreatment assessment of patients undergoing 90Y radioembolization should be familiar with the imaging findings and potential imaging pitfalls associated with this therapy.

A basic overview of wireless networks and radiology applications of wireless teleradiology networks is given. Also, security of wireless teleradiology networks is scrutinized.

Enteric duplication cysts are rare congenital anomalies that may occur anywhere along the gastrointestinal tract, most commonly involving the small bowel. The distal ileum, jejunum, and duodenum are affected in descending order of frequency. We describe a case of biliary dilatation and duodenal intussusception caused by an enteric duplication cyst in an adult patient. To our knowledge, there are no other reported cases of this entity in an adult in the English literature. Multidetector computed tomography (MDCT) findings are emphasized, and the value of multiplanar reformation (MPR) in forming a correct preoperative differential diagnosis is discussed.

The purpose of this pictorial essay is to describe magnetic resonance (MR) imaging features of acute processes involving the bowel. While computed tomography (CT) is likely to remain the modality of choice in this setting, the advantages of MR include high soft tissue contrast, lack of ionizing radiation, and the ability to administer gadolinium in patients with a history of allergic reaction to iodinated contrast material. With the increasing utilization of abdominal/pelvic MR, radiologists must recognize the MR features of acute bowel pathology. Key MR findings of a variety of causes of acute abdominal pain are illustrated.

Purpose To identify changes in hepatic parenchymal volume, fibrosis, and induction of portal hypertension following radioembolization with glass microspheres for patients with metastatic disease to the liver. Results In our series of sequential bilobar (n = 17) treatments, a mean decrease in liver volume of 11.8% was noted. In this group, a mean splenic volume increase of 27.9% and portal vein diameter increase of 4.8% were noted. For patients receiving unilobar treatments (n = 15), mean ipsilateral lobar volume decrease of 8.9%, contralateral lobar hypertrophy of 21.2%, and a 5.4% increase in portal vein diameter were also noted. These findings were not associated with clinical toxicities. Conclusion90Yttrium radioembolization utilizing glass microspheres in patients with liver metastases results in changes of hepatic parenchymal volume and also induced findings suggestive of fibrosis and portal hypertension. Further studies assessing the long-term effects are warranted.

The feasibility of imaging pulsatility in an aneurysm model with the high-resolution dynamic multiscan technique of 64-slice computed tomography (CT) was studied. A pulsatile aneurysm phantom was constructed and imaged with dynamic multiscan technique. The aneurysm model was filled with iodinated contrast material (250 Hounsfield Units) and was scanned with use of a gantry rotation time of 0.33 seconds, slice thickness of 1.2 mm, effective coverage of 24 mm, and total imaging time of 4 seconds. Images were reconstructed at 50-msec intervals. The visualization of wall motion was qualitatively evaluated by direct comparison of four-dimensional images versus phantom motion. Pulsatility imaging without perceptible artifact or need for cardiac gating was achieved with the use of this technique.

Fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) scanning is useful in evaluating suspicious lesions of the lung. Our patient was a 65-year-old woman with a 45-pack-year smoking history who was referred for further evaluation because of a 3 cm × 3 cm solid lung nodule on computed tomography scan of the chest. FDG-PET scan revealed a standard uptake value of 3.2 suggestive of malignancy. The histology of the lung nodule was consistent with lipoid pneumonia, a benign condition frequently associated with inadvertent aspiration or inhalation of oily substances.

OBJECTIVE. The purpose of this study was to describe the CT diagnosis of chyluria after partial nephrectomy.CONCLUSION. Fat in the bladder can be identified on CT after partial nephrectomy. This finding is caused by chyluria secondary to lymphatic injury and should not be mistaken for other abnormalities. Our study population did not need treatment of chyluria.

Gastrointestinal carcinoid tumours are notoriously difficult to diagnose in the absence of the carcinoid syndrome. The clinical presentation is typically non-specific, and patients often go undiagnosed for years. Recent advances in computed tomography (CT), magnetic resonance (MR), endoscopic ultrasound, and nuclear scintigraphy have combined to improve the diagnosis and staging of this fascinating tumour. In this chapter the applications of cross-sectional imaging in patients with gastrointestinal carcinoid tumours is presented.

m w E EARLY 5 MILLION abdominal and pelvic operations are performed annually in the nited States. The most common types of abdomnal surgery are cesarean section, groin and abdomnal wall herniorrhaphy, hysterectomy, cholecysectomy, appendectomy, large-bowel resection or olostomy, and exploratory laparotomy. While he widespread use of laparoscopic techniques in a ariety of disorders has diminished perioperative orbidity and mortality, postoperative complicaions occur as part of the nature and inherent risk of ny surgical intervention. Cross-sectional imaging lays a crucial role in the diagnosis and manageent of these cases. In this article, we review the pectrum of common postoperative abdominal omplications and illustrate their characteristic feaures on CT.

We describe a simple technique for transmission of a complete set of cranial computed tomography (CT) images to a commercially available wireless personal digital assistant (PDA) for remote teleradiology consultation.A complete set of images from the head CT of a trauma patient with subdural hematoma (19 images) was captured from a picture archiving and communication system and transmitted wirelessly as an e-mail attachment after being compressed. The images were retrieved, decompressed, and reviewed using commercially available software and a PDA with cellular phone capability.A complete head CT was transmitted to a remote radiologist's wireless PDA for consultation. The entire procedure (including image capture, transmission, and review) took approximately 11.5 minutes.Using the technique described in this article the wireless PDA may function as a robust medium for facilitating care of brain trauma patients by allowing rapid access to trauma radiologists or neurosurgeons.

esophageal myotomy Carla B Harmath, Jeanne M Horowitz, Senta M Berggruen, Nancy A Hammond, Paul Nikolaidis, Frank H Miller, Lori A Goodhartz, Ezra N Teitelbaum, Eric S Hungness, Vahid Yaghmai Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 800, Chicago, IL 60614, USA Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

The liver, spleen, pancreas, and biliary tract are commonly affected by opportunistic infections, malignancy, and inflammatory disorders during the course of human immune deficiency virus (HIV) infection (Table 9.1). Clinical manifestations of involvement of these organs are protean and usually nonspecific, but it is important to establish a specific diagnosis promptly in these often critically ill patients (Tshibwabwa et al. 2000). Because of the limitations of physical and laboratory examinations, cross-sectional imaging studies are often obtained to clarify the clinical situation (DeToma et al. 1999; Wu et al. 1998). This chapter reviews the imaging spectrum of HIV-associated hepatosplenic and pancreaticobiliary disease. Table 9.1 Hepatic splenic, biliary, and pancreatic disease associated with HIV infection Infection Bacterial Salmonella Rochalimaea Mycobacterial M. tuberculosis M. avium intracellulan complex M. xenopi Viral Cytomegalovirus Hepatitis B, C, and D Herpesvirus Adenovirus HIV Fungal Candida Cryptococcus Histoplasma Aspergillus Coccidia Sporothrix Protozoal Pneumocystis Cryptosporidia Microsporidia Leishmania Toxoplasma Neoplasms Non-Hodgkin’s lymphoma Kaposi’s sarcoma Metastatic cancer of anal canal Drug-related Trimethoprim-sulfamethoxazole Ketoconazole Isoniazid Rifampin Zidovudine Pentamidine Diphenylhydantoin Prochlorperazine Didanosine Fluconazole Oxacillin Dideoxyinosine

The radiologic imaging and staging of primary and metastatic liver tumors has been revolutionized by advances in ultrasonographic (US) imaging, computed tomography (CT), and magnetic resonance imaging (MRI). In spite of the improved sensitivity in the detection of hepatic malignancies, the ability to differentiate benign from malignant intrahepatic lesions often remains problematic due to extensive overlap in imaging appearances. Additionally, only several liver lesions have a pathognomonic appearance on cross-sectional imaging. As a result, tissue sampling performed with CT or ultrasound guidance is often required to better characterize a hepatic lesion (1–5).

The liver, spleen, biliary tract, pancreas, and kidneys are commonly affected by opportunistic infection, malignancy, and inflammatory disorders during the course of human immunodeficiency virus (HIV) infection. Clinical manifestations of solid abdominal visceral involvement are protean and usually nonspecific, but it is important to establish a specific diagnosis promptly in these often critically ill patients. This presentation reviews the cross-sectional imaging spectrum of HIV-associated lesions of these organs.

Dysphagia is a delayed symptom of esophageal constriction and often appears after the luminal diameter is reduced to less than 10 mm. Earlier diagnosis of benign or malignant strictures while clinically silent would be desirable; hence we investigated the detectability of occult esophageal lesions with the aid of an ingested barium tablet during routine chest radiography. We prospectively examined 300 patients older than 40 years, who were referred for chest films because of indications unrelated to the upper gastrointestinal tract. Each patient was instructed to swallow a 12.5-mm barium tablet with 100 mL of water immediately prior to the exposure of posteroanterior and lateral chest films. Radiographs of 17 patients (5.6%) revealed intraesophageal retention of the tablet, and their prompt evaluation with double-contrast esophagrams confirmed various structural or functional abnormalities in 15 patients. Therefore, the oral administration of a barium tablet during routine chest radiography is a simple efficacious method to assess esophageal patency and detect occult narrowings from structural or functional causes.

It is not clear whether survival times of patients with hepatocellular carcinoma (HCC) are associated with their response to therapy. We analyzed the association between tumor response and survival times of patients with HCC who were treated with locoregional therapies (LRTs) (chemoembolization and radioembolization).Patients received LRTs over a 9-year period (n = 463). Patients with metastases, portal venous thrombosis, or who had received transplants were excluded; 159 patients with Child-Pugh B7 or lower were analyzed. Response (based on European Association for the Study of the Liver [EASL] and World Health Organization [WHO] criteria) was associated with survival times using the landmark, risk-of-death, and Mantel-Byar methodologies. In a subanalysis, survival times of responders were compared with those of patients with stable disease and progressive disease.Based on 6-month data, in landmark analysis, responders survived longer than nonresponders (based on EASL but not WHO criteria: P = .002 and .0694). The risk of death was also lower for responders (based on EASL but not WHO criteria: P = .0463 and .707). Landmark analysis of 12-month data showed that responders survived longer than nonresponders (P.0001 and .004, based on EASL and WHO criteria, respectively). The risk of death was lower for responders (P = .0132 and .010, based on EASL and WHO criteria, respectively). By the Mantel-Byar method, responders had longer survival than nonresponders, based on EASL criteria (P.0001; P = .596 with WHO criteria). In the subanalysis, responders lived longer than patients with stable disease or progressive disease.Radiographic response to LRTs predicts survival time. EASL criteria for response more consistently predicted survival times than WHO criteria. The goal of LRT should be to achieve a radiologic response, rather than to stabilize disease.

Background & Aims Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC. Methods We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed. Results Abdominal pain and increased transaminase activity were more frequent following chemoembolization ( P .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42). Conclusions Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies.

Rationale and objectives The biological effects of iodinated contrast media were examined by using spermatogenesis in mouse testis as the experimental model. Methods Spermhead survival and abnormality assays were used as the biological end points. Diatrizoate meglumine/diatrizoate sodium and iopamidol were administered intravenously at equal rates and concentrations. Testicular uptake and clearance of these contrast agents were examined by high-performance liquid chromatography techniques. Appropriate mannitol solutions were employed as osmolality controls. Results Intravenous administration of the contrast agent or its respective mannitol control resulted in approximately a 30% decrease in spermhead count. A dose-related experiment with mannitol demonstrated that the spermhead count decreased rapidly until 600 mOsm/kg was reached, beyond which this decrease was minimal. Clearance of both contrast media was complete in approximately 4 hours. No significant increase in the induction of spermhead abnormalities was observed. Conclusion Osmotic substances, such as iodinated contrast agents, affect the process of spermatogenesis.

A new buffer system is reported for the analysis of radiographic contrast agents (RCAs) sodium meglumine diatrizoate, iohexol, and iopamidol in mice plasma and testes, on a reversed-phase HPLC with UV detection. The buffer consisting of 0.1 M NaH2PO4, 0.2 mM Na2EDTA adjusted to pH 3.1 with orthophosphoric acid and 2.5-5.0% acetonitrile (v/v) resolved RCA peaks for clear quantitation. The main advantages of this system are the ambient temperature of operation and direct sample injection without prior sample purification as required in the earlier procedures. Using this procedure, uptake and clearance kinetics of these RCAs were studied in mice plasma and testes, following iv injections via tail veins. The plasma levels of all the RCAs reached maxima between 5 and 15 min and dropped down sharply. At the end of 12 h they were virtually undetected (detection limits 0.64-0.71 micrograms/mL). The testicular levels also showed a similar trend and reached undetectable levels after 4 h. There were no signs of metabolism of these RCAs in plasma or testes. The present clearance kinetics in plasma compares very well with earlier reports of non-HPLC methods of assay.

Context Response Evaluation Criteria in Solid Tumors (RECIST) (unidimensional), World Health Organization (WHO) (bidimensional), and European Association for Study of the Liver (EASL) (necrosis) guidelines are commonly used to assess response following therapy for hepatocellular carcinoma (HCC). No universally accepted standard exists. Objectives To evaluate intermethod agreement between these 3 imaging guidelines and to introduce the concept of the "primary index lesion" as a biomarker for response. Design, setting, and participants Single-center comprehensive imaging analysis including 245 consecutive patients with HCC who were treated with chemoembolization or radioembolization between January 2000 and December 2008. Computed tomography and magnetic resonance imaging scans (N = 1065) were reviewed to assess response in the "primary index lesion," defined as the largest tumor targeted during first treatment. Main outcome measures Intermethod agreement (kappa statistics) between RECIST, WHO, and EASL guidelines response; correlation of WHO and EASL response in the primary index lesion with time to progression and survival. Results Kappa coefficients were 0.86 (95% confidence interval [CI], 0.80-0.92) between the WHO and RECIST guidelines, 0.24 (95% CI, 0.16-0.33) between RECIST and EASL, and 0.28 (95% CI, 0.19-0.36) between WHO and EASL. Disease progressed in 96 patients; 113 died. The hazard ratio for time to progression in responders compared with nonresponders was 0.36 (95% CI, 0.23-0.57) for WHO, 0.38 (95% CI, 0.24-0.58) for RECIST, and 0.38 (95% CI, 0.22-0.64) for EASL. Hazard ratios for survival in responders compared with nonresponders in univariate and multivariate analyses were 0.46 (95% CI, 0.32-0.67) and 0.55 (95% CI, 0.35-0.84) for WHO and 0.36 (95% CI, 0.22-0.57) and 0.54 (95% CI, 0.34-0.85) for EASL. Hazard ratios for survival in responders vs nonresponders in patients with solitary and multifocal HCC were 0.39 (95% CI, 0.19-0.77) and 0.51 (95% CI, 0.32-0.82) for WHO and 0.26 (95% CI, 0.10-0.67) and 0.47 (95% CI, 0.28-0.79) for EASL. Conclusions Among a group of patients with HCC, agreement for classification of therapeutic response was high between the RECIST and WHO guidelines but low between each of these and EASL. Application of these methods to measure response in a primary index lesion resulted in statistically significant correlations with disease progression and survival.