Quantitative Assessment of Benign and Malignant Liver Lesions Using Hepatic Artery Resistive Indices (Assessment of Liver Lesions Using Resistive Indices)

Quantitative Assessment of Benign and Malignant Liver Lesions Using Hepatic Artery Resistive Indices (Assessment of Liver Lesions Using Resistive Indices) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quantitative Assessment of Benign and Malignant Liver Lesions Using Hepatic Artery Resistive Indices (Assessment of Liver Lesions Using Resistive Indices) Suat Keskin, Zeynep Keskin, Ahmet Yeşildağ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8749023/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background The present study aimed to determine whether any distinction can be acquired between the benign and malignant lesions of the liver by calculating the difference between the resistive index (RI) values obtained from the branch of the hepatic artery in focal liver lesions (FLLs), the branch of the hepatic artery in the parenchyma adjacent to the lesion and proper hepatic artery. Methods A total of 96 patients (55 female and 41 male) were admitted to the ultrasonography unit of the radiology department. The values of diagnostic mass/parenchymal RI difference rates were determined to differentiate the benign and malignant lesions one another by performing the receiver operating characteristic (ROC) curve analysis in 68 patients whose RI values obtained from the branch of the hepatic artery in the mass were lower than the RI values obtained from the branch of the hepatic artery adjacent to the lesion. Results In the ROC curve analysis, the cut-off value was calculated as 11.3 in the differentiation of benign liver lesions from malignant liver lesions. The levels of sensitivity, specificity, positive predictive value and negative predictive value were calculated as 68.8, 58.3, 59.5, and 67.7%, respectively. Conclusion In this prospective study, the RI values were obtained from proper hepatic artery, the intra parenchymal branch of the hepatic artery, and the branch of the hepatic artery in the mass in different liver lesions, and whether there was a significant relationship between those RI values was investigated. Liver mass Ultrasonography Resistive index Hepatic artery Liver parenchyma Figures Figure 1 Figure 2 Figure 3 INTRODUCTION As an abdominal imaging method, ultrasonography (USG) is of widespread use and facilitates the detection of multiple focal liver lesions (FLLs) in patients’ groups undergoing routine screening or being admitted for diagnostic abdominal examination. However, performing different imaging methods in the differential diagnosis of benign and malignant liver lesions and even the addition of biochemical and clinical findings to those methods may be insufficient to achieve a definitive diagnosis ( 1 ). The color and power Doppler imaging (CDI, PDI) are non-invasive radiological imaging methods working based on the calculation of the mean Doppler frequency shift; in addition, CDI or PDI are performed percutaneously and provides much different vascularization information for the clinical diagnosis. Many healthcare professionals utilize the spectral Doppler USG, CDI and PDI methods in the evaluation of FLLs ( 2 , 3 ). In recent studies, it has been revealed that the CDI or PDI methods provide beneficial information in determining tumor vascularization ( 4 ). Therefore, the present study aimed to determine whether any distinction can be acquired between the benign and malignant lesions of the liver by calculating the difference between the resistive index (RI) values obtained from the branch of hepatic artery in FLLs, the branch of the hepatic artery in the parenchyma adjacent to the lesion and proper hepatic artery. MATERIALS AND METHODS Study population A total of 96 patients (55 female and 41 male) were admitted to the USG unit of the radiology department referred to from the other units for the sonographic examination between June 2014 and May 2016 due to the liver masses detected during the examination and were included in this prospective study. Nine patients with a lesion size <1 cm and unable to hold their breath adequately were excluded from the study. The B-mode USG and Doppler USG were performed on a total of 87 patients, and while 49 of the cases were women, 38 were seen to be men. The mean age of the patients was 53.51±15.74 (range between 20-87 years). The distribution of the lesions is shown in Table 1. Among the metastatic masses, the primary types were mostly detected as colon, stomach, and pancreatic cancers. Such radiologic methods as USG, computed tomography (CT), and magnetic resonance imaging (MRI) were used in the diagnosis of FLLs (Figure 1). In the diagnosis of benign lesions, however, radiological imaging methods are used. The percutaneous biopsy was performed under USG-guidance for the diagnosis of malignant lesions. The pathological specimens were also evaluated by a pathologist with 10-year experience in liver diseases. Approval was obtained for the present prospective study from the ethics committee. Written consent was also obtained from each patient included in the study. Imaging protocols and Doppler ultrasonography technique The B-mode and Doppler USG were performed by a single radiologist with 11-year experience of conventional USG while the patients were in the supine and lateral decubitus positions, and the procedures were conducted using the Philips USG device (iU22; Philips Healthcare, Andover, MA) and the 2.5 Mhz bandwidth convex probe (Transducer C5-1, B0M2J6, Philips Healthcare, Andover, MA). During the entire examination period, the patients were asked to hold their breath actively by performing deep inspirations as much as possible. On the examination through the B-mode USG, the liver parenchyma was first evaluated to determine whether to be homogeneous or heterogeneous; then, the target lesion in the liver was determined, and the size of the lesion was detected. Additionally, the Doppler USG was performed with the same probe. By using the spectral Doppler USG, the values of the peak-systolic velocity and end-diastolic velocity were measured from the branch of the hepatic artery within the lesion, the branch of the hepatic artery in the liver parenchyma approximately 2 cm from the lesion, and the proper hepatic artery at the level of the portal hilus. The values of RI were calculated automatically by the device: based on the formula: (peak-systolic velocity – end-diastolic velocity)/peak-systolic velocity. We meticulously performed the procedure to obtain the highest possible achievement without noise but with the lowest possible pulse repetition frequency and the lowest wall filter, without the aliasing artifact to obtain the maximum arterial waveform. The RI value obtained from the branch of the hepatic artery in the mass was subtracted from the RI value obtained from the branch of the hepatic artery adjacent to the lesion. The obtained value was divided by the RI value obtained from the hepatic artery branch in the mass, and the rate of difference between the RI values in the mass and the parenchyma was calculated as a percentage. Statistical analyses The statistical analyses of the study findings were performed using the Statistical Package for the Social Sciences software, version 25.0 (SPSS Inc., Chicago, IL, USA). The numerical variables were accounted for as mean±standard deviation (SD) or numbers (percentage ratio), according to availability. The conformity of the variables to the normal distribution was investigated using the visual (histogram and probability graphs) and analytical methods (the Kolmogorov-Smirnov and Shapiro-Wilk tests). However, the descriptive analyses were stated using the averages and SDs for normally distributed variables. Since the RI values obtained from the proper hepatic artery at the level of the portal hilus and the branch of the hepatic artery adjacent to the lesion demonstrated a normal distribution, a comparison was performed between those parameters, and gender, the character of liver parenchyma, and malignant-benign pathology groups using the student's t -test. Since age, size of the lesion, size of the liver, the RI values obtained from the branch of the hepatic artery in the lesion, and the rates of mass/parenchymal RI differences showed no normal distribution, a comparison was conducted between those parameters and gender, the character of the liver parenchyma, and malignant-benign pathology groups using the Mann-Whitney U test. The chi-square test was performed to determine whether there was a statistical significance between gender, the character of the lesion, and malignant-benign pathology groups. However, the one-way ANOVA test was carried out to detect whether a significant relationship was present between the RI values obtained from the proper hepatic artery at the level of the portal hilus and the branch of the hepatic artery adjacent to the lesion and the mass subtypes. The Kruskal-Wallis test was utilized to find out whether there was a significant relationship between such non-normally distributed values as age, size of the lesion, size of the liver, and the RI values obtained from the branch of the hepatic artery in the lesion, and the rate of mass/parenchymal RI differences and mass subtypes. The pair-wise comparisons were also performed through the Mann-Whitney U test and evaluated using the Bonferroni correction. The correlation coefficients and statistical significance were calculated using the Spearman's test for the variables, at least one showing no normal distribution, or the ordinal variables. For achieving the statistical significance, the total type-1 error level was used as 5%, and the values with a p-value of <0.05 were considered statistically significant. The values of diagnostic mass/parenchymal RI difference rates were determined to differentiate the benign and malignant lesions one another by performing the receiver operating characteristic (ROC) curve analysis in 68 patients whose RI values obtained from the branch of the hepatic artery in the mass were lower than the RI values obtained from the branch of the hepatic artery adjacent to the lesion. In the presence of significant threshold limit values, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) levels of these limits were calculated. In the evaluation of the area under the curve (AUC), the cases where the level of type 1 errors was <5% were interpreted that the diagnostic value of the test was statistically significant. RESULTS The descriptive information related to the lesion diameter, liver size, RI values obtained from the branch of the hepatic artery in the lesion, from the branch of the hepatic artery adjacent to the lesion and proper hepatic artery at the level of portal hilus, and the rates of the mass/parenchyma RI value differences are shown in Table 2. The masses and mean RI values are presented in Table 3. Based on the student's t -test, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in malignant lesions, compared with those detected in benign lesions (p <0.001). In the Mann-Whitney U test, however, such values as age and liver size were found to be significantly higher in the male gender than those among females (p=0.004 and p=0.041). The frequency of heterogeneity of the liver parenchyma among the elderly patients was detected to be significantly higher than that found in the younger patients (p=0.044). The age, lesion diameter, liver size, and RI values from the hepatic artery in the lesion were found to be significantly higher in malignant lesions than those detected in benign lesions (p<0.001, p=0.029, p<0.001, and p=0.033, respectively) (Figure 2). Even so, the frequency of homogeneous liver parenchyma was found to be significantly higher in women than that in men in the chi-square test (p=0.025). Compared with those detected in women, the number of malignant lesions was found to be significantly higher in men (p=0.004). In the ANOVA test, additionally, a significant difference was found between the subtypes of the masses and the RI values obtained from the branch of the hepatic artery adjacent to the lesion (p=0.017). However, in the student's t -test performed to detect whether a significant difference was present between the RI values obtained from the branch of the hepatic artery adjacent to the lesion and which subtypes of the masses, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in the metastases, hepatocellular carcinomas (HCCs), and cholangiocellular carcinomas (CCCs) than those of hemangiomas (p=0.01, p=0.004, and p=0.025, respectively). The RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in metastases and HCCs than those of focal nodular hyperplasias (FNHs) (p=0.035 and p=0.031). The Kruskal-Wallis test also revealed that patients’ age and liver size in metastases were significantly higher than those in hemangiomas (p=0.001 and p<0.001). Patients’ age was also found to be significantly higher in HCCs than that in hemangiomas (p=0.003). It was revealed in the Kruskal-Wallis test that mass/parenchymal difference rates of the RI values in metastases and FNHs were found to be significantly higher than those of hemangiomas (p=0.029 and p=0.003). The rates of the mass/parenchymal RI difference values were also found to be significantly higher in FNHs, compared with those in metastases (p=0.039). In the ROC curve analysis, the cut-off value was calculated as 11.3 in the differentiation of benign liver lesions from malignant liver lesions. The AUC-ROC curve was calculated as 0.61 in the range of 0.470–0.742 with a 95% confidence interval (CI). The levels of sensitivity, specificity, PPV, and NPV were calculated as 68.8, 58.3, 59.5, and 67.7%, respectively (Figure 3). DISCUSSION Although different studies have been conducted, related to the use of non-invasive imaging methods in the differentiation of benign and malignant liver lesions in recent years, the entity still keeps posing a problem in clinical practices. Even the combined use of USG, CT, and MRI, may be inconclusive in the determination of the lesions, especially in the detection of small lesions. The USG-guided percutaneous biopsy from the lesion performed by experts in the field can be a safe and effective method. However, there may be various technical inadequacies in small lesions located deep inside the body ( 5 – 7 ). Non-invasive radiological imaging methods, such as CDI, can be benefited as an alternative technique to evaluate the differences of vascularization between the vascularization of the tumors and surrounding parenchyma, and based on the data to differentiate between benign and malignant liver lesions. Arterial flows and thus the measurements via the Doppler USG may be affected by many factors, such as cardiac output, hypertension, atherosclerosis, and vascular compliance. Therefore, we considered that those factors may also have effects on the emergence of different results in the measurements obtained only from the mass in many studies. For this reason, we attempted to standardize the factors we considered affecting the measurements as the elevation rates of percentages by eliminating such factors in terms of the patients by taking measurements from both the mass and the surrounding parenchyma. To the best of our knowledge, there is no study similar to our study in the literature. In our study, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in metastases, HCCs, and CCCs than those of hemangiomas (p = 0.01, p = 0.004, p = 0.025, respectively). The high rate of the mass RI/parenchymal RI values in malignant lesions was evaluated due to the chaotic and relatively lower-resistant flow in the mass, compared to the surrounding parenchyma. In a study, Numata et al. performed a comparison by obtaining the RI values relatively similarly from the lesion and the right or left hepatic artery ( 8 ). As similar to our study findings, Uggowitzer et al. also carried out a study and obtained the RI measurements from the mass, the proper hepatic artery, and the branch of the hepatic artery in the parenchyma ( 9 ). As different from our study, however, Uggowitzer et al. did not calculate the difference between the RI values of the mass and its surrounding as a percentage. Even so, Uggowitzer et al. found a significant difference between the RI values obtained from the proper hepatic artery and branch of the hepatic artery in the mass, and between the RI values obtained from the intra parenchymal branch of the hepatic artery, and the RI values from the hepatic artery in the mass, as different from our study findings (p < 0.001). In the study carried out by the hepatic artery RI values in HCCs were detected to be significantly higher in all liver lesions with different sizes, compared with those in other lesions (p < 0.01) ( 10 ). As consistent with the findings reported by Gaiani et al., the RI values obtained from the hepatic artery in mass were found to be significantly higher in the malignant lesions than those in benign lesions in our study (p = 0.033). Unlike our study findings, in another study by Reinhold et al., no significant difference was determined between the RI values obtained from the hepatic artery in the liver lesions ( 4 ). As different from our study findings, the RI values obtained from the hepatic artery were also found to be lower in HCCs by Shimamoto et al. ( 11 ). As well as the abovementioned findings, there are also some limitations of our study; especially the number of cases with adenomas and CCCs is quite limited. Unfortunately, such a limitation prevented us to perform healthy comparisons between these lesion groups and other lesion subtypes. In our study, all patients were evaluated by a single radiologist; therefore, no comparisons were performed between the results by evaluating the findings by two different radiologists, independent of each other. In this prospective study, the RI values were obtained from the proper hepatic artery, the intra parenchymal branch of the hepatic artery, and the branch of the hepatic artery in the mass in different liver lesions, and whether there was a significant relationship between those RI values was investigated. The difference, especially between the RI values obtained from the branch of the hepatic artery in the mass and the branch of the hepatic artery in the adjacent parenchyma was calculated as a percentage, and the efficiency in the differentiation between the benign and malignant lesions was evaluated by creating a cut-off value. In conclusion, our findings demonstrate that when further studies including larger populations with homogeneous distribution are performed, the increase of the percentage rates related to the differences between the intra-mass and parenchymal RI values to be obtained with CDI can determine the differentiation between the benign and malignant lesions of the liver, which may reduce the use of different radiological modalities, such as CT and MRI, and the requirement of USG-guided biopsy in the future. Abbreviations resistive index (RI), focal liver lesions (FLLs), receiver operating characteristic (ROC), ultrasonography (USG), color and power Doppler imaging (CDI, PDI), computed tomography (CT), magnetic resonance imaging (MRI), standard deviation (SD), positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), hepatocellular carcinomas (HCCs), cholangiocellular carcinomas, focal nodular hyperplasias (FNHs). Declarations Ethical approval and consent to participate: Approval was obtained for the present prospective study from the Necmettin erbakan university faculty of medicine ethics committee. Our study does not conflict with the rules of the Helsinki declaration. Written informed consent was also obtained from each patient included in the study. Consent for publication: Not applicable. Availability of data and materials: The availability of supporting data is likely. Competing interests: There are no conflicts of interest among the authors. Funding: No financial support was received from any institution or individual in the conduct of this study. Authors' contributions: Suat Keskin (Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft, Writing – review & editing). Zeynep Keskin (Data curation, Methodology, Supporting, Resources). Ahmet Yeşildağ (Conceptualization, Data curation, Formal analysis, Investigation, Writing – review & editing) Acknowledgements: As the responsible author, I would like to thank the valuable staff of the Meram Medical Faculty Radiology Department for their support and contributions in the preparation of this article. References Ohnishi K, Nomura F. Ultrasonic Doppler studies of hepatocellular carcinoma and comparison with other hepatic focal lesions. Gastroenterology 1989; 97:1489–1497. Tanaka S, Kitamura T, Fujita M, Nakanishi K, Okuda S. Color Doppler flow imaging of liver tumors. Am J Roentgenol 1990;154:509-514. Tanaka S, Kitamura T, Fujita M, Kasugai H, Inoue A, Ishiguro S. Small hepatocellular carcinoma: Differentiation from adenomatous hyperplastic nodule with color Doppler flow imaging. Radiology 1992;182:161-165. Reinhold C, Hammers L, Taylor CR, Quedens-Case CL, Holland CK, Taylor KJ. Characterization of focal hepatic lesions with duplex sonography: Findings in 198 patients. Am J Roentgenol 1995;164:1131–1135. Bret PM, Labadie M, Bretagnolle M, Paliard P, Fond A, Valette PJ. Hepatocellular carcinoma: Diagnosis by percutaneous fine needle biopsy. Gastrointest Radiol 1988;13:253–255. Buscarini L, Fornari F, Bolondi L, et al. Ultrasound-guided fine-needle biopsy of focal liver lesions: Techniques, diagnostic accuracy and complications. A retrospective study on 2,091biopsies. J Hepatol 1990;11:344–348. Bolondi L, Gramantieri L, Chieco P, et al. Enzymatic cytochemistry, DNA ploidy and agnor quantitation in hepatocellular nodules of uncertain malignant potential in liver cirrhosis. Dig Dis Sci 1996;41:800–808. Numata K, Tanaka K, Kiba T, et al. Use of hepatic tumor index on color Doppler sonography for differentiating large hepatic tumors. Am J Roentgenol 1997;168:991–995. Uggowitzer M, Kugler C, Machan L, et al. Power Doppler imaging and evaluation ofthe resistive index in focal nodular hyperplasia of the liver. Abdom Imaging 1997;22:268-273. Gaiani S, Casali A, Serra C, et al. Assessment of vascular patterns of small liver mass lesions: value and limitation of the different Doppler ultrasound modalities. Am J Gastroenterol 2000;95: 3537-3546. Shimamoto K, Sakuma S, Ishigaki T, Ishiguci T, Itoh S, Fukatsu H. Hepatocellular carcinoma: evaluation with color Doppler US and MR imaging. Radiology 1992;182:149-153. Tables Table1. Characterization graph of the lesions. Lesions’ types Haemangioma FNH HCC Metastasis Adenoma CCC Total 33 10 10 28 2 4 87 Table 2. Descriptive information. RI (resistive index), mm (millimeter) Number Minimum Maximum Mean Std. Deviation Lesion Size (mm) 87 15 159 60.74 35.849 Liver Size (mm) 87 125 235 166.86 23.78 Mass RI 87 0.32 0.87 0.57 0.101 Common Hepatik artery RI 87 0.40 0.88 0.67 0.083 Branch of Hepatic artery RI 87 0.35 0.86 0.59 0.087 The difference ratio of RI in mass/parenchyma (%) 68 1.5 68.4 15.96 13.533 Table 3. Mean RI values of the lesions. RI (resistive index), HCC (hepatocellular cancer), CCC (cholangiocellular cancer), FNH (focal nodular hyperplasia). Group Number Mean + SD (RI) Haemangioma 33 0.54±0.008 HCC 10 0.61±0.041 Metastasis 28 0.58±0.016 CCC 4 0.68±0.072 FNH 10 0.56±0.046 Adenoma 2 0.54±0.205 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 Mar, 2026 Reviewers invited by journal 11 Mar, 2026 Editor invited by journal 19 Feb, 2026 Editor assigned by journal 06 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 05 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8749023","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":604652920,"identity":"b621a970-9225-4f2f-b836-ee864ab4acf7","order_by":0,"name":"Suat Keskin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYDCCA2AygYGBh7GB4QOYRZSWBIgWxhkkamFgYOYhRgvf7ePPJH7+SJOT7znc9ti2zS6Pn72B8cPHHNxaJM/lmEn2JOQYG5xtbDfObUsuluw5wCw5cxtuLQZneNgkeBIqEjfwM7ZJ57YxJ264kcDGzItXC/szyT8JFfXz+4FaLNvqidHCYCbNk5CTwHC2sU2ase0wYS2SZ3iMrWXS0gw3nDnYJtlz7njizJ6DzXj9wneG/eHNNzbJ8vI96c8kfpRVJ/azNx/88BGPFlTAyAYmG4hVDwJ/SFE8CkbBKBgFIwUAAJG6U6d5XJVKAAAAAElFTkSuQmCC","orcid":"","institution":"Medicana Health Group","correspondingAuthor":true,"prefix":"","firstName":"Suat","middleName":"","lastName":"Keskin","suffix":""},{"id":604652921,"identity":"c9d0e328-8e2b-4a6e-b8e0-7e5c989bba87","order_by":1,"name":"Zeynep Keskin","email":"","orcid":"","institution":"Konya City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zeynep","middleName":"","lastName":"Keskin","suffix":""},{"id":604652922,"identity":"f5883db7-eacf-422b-891e-ae3c538fea14","order_by":2,"name":"Ahmet Yeşildağ","email":"","orcid":"","institution":"Karamanoğlu Mehmetbey University","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Yeşildağ","suffix":""}],"badges":[],"createdAt":"2026-01-31 10:38:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8749023/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8749023/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104668741,"identity":"0cd343a3-51f3-4ef3-8b41-d1b27270df89","added_by":"auto","created_at":"2026-03-15 16:54:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":471970,"visible":true,"origin":"","legend":"\u003cp\u003eSize of the hemangioma detected in the right lobe of the liver.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8749023/v1/a979d723a9b776e661a063db.png"},{"id":104668742,"identity":"a92e02bc-95f1-428f-bf9d-cadcea1edf47","added_by":"auto","created_at":"2026-03-15 16:54:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":449897,"visible":true,"origin":"","legend":"\u003cp\u003eMass RI value of heamangioma detected in the right lobe of the liver. RI (resistive index).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8749023/v1/64f9ee413627e72a0ded4aae.png"},{"id":104668740,"identity":"8d8081db-c4a1-4b75-85d9-649e8fdd5d75","added_by":"auto","created_at":"2026-03-15 16:54:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":394585,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristic curve of mass/parenchyma RI difference ratio in differentiating malignant liver lesions from benign liver lesions. ROC (receiver operating characteristics), RI (resistive index).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8749023/v1/31f4ca0057244d3e96300c5c.png"},{"id":104668755,"identity":"5290817a-61bd-49f6-8e38-d7ee06da4781","added_by":"auto","created_at":"2026-03-15 16:54:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1993175,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8749023/v1/f15f5708-595b-4de9-af9e-1a9363afe7b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eQuantitative Assessment of Benign and Malignant Liver Lesions Using Hepatic Artery Resistive Indices (Assessment of Liver Lesions Using Resistive Indices)\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAs an abdominal imaging method, ultrasonography (USG) is of widespread use and facilitates the detection of multiple focal liver lesions (FLLs) in patients\u0026rsquo; groups undergoing routine screening or being admitted for diagnostic abdominal examination. However, performing different imaging methods in the differential diagnosis of benign and malignant liver lesions and even the addition of biochemical and clinical findings to those methods may be insufficient to achieve a definitive diagnosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The color and power Doppler imaging (CDI, PDI) are non-invasive radiological imaging methods working based on the calculation of the mean Doppler frequency shift; in addition, CDI or PDI are performed percutaneously and provides much different vascularization information for the clinical diagnosis. Many healthcare professionals utilize the spectral Doppler USG, CDI and PDI methods in the evaluation of FLLs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In recent studies, it has been revealed that the CDI or PDI methods provide beneficial information in determining tumor vascularization (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to determine whether any distinction can be acquired between the benign and malignant lesions of the liver by calculating the difference between the resistive index (RI) values obtained from the branch of hepatic artery in FLLs, the branch of the hepatic artery in the parenchyma adjacent to the lesion and proper hepatic artery.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eA total of 96 patients (55 female and 41 male) were admitted to the USG unit of the radiology department referred to from the other units for the sonographic examination between June 2014 and May 2016 due to the liver masses detected during the examination and were included in this prospective study. Nine patients with a lesion size \u0026lt;1 cm and unable to hold their breath adequately were excluded from the study. The B-mode USG and Doppler USG were performed on a total of 87 patients, and while 49 of the cases were women, 38 were seen to be men. The mean age of the patients was 53.51\u0026plusmn;15.74 (range between 20-87 years). The distribution of the lesions is shown in Table 1. Among the metastatic masses, the primary types were mostly detected as colon, stomach, and pancreatic cancers. Such radiologic methods as USG, computed tomography (CT), and magnetic resonance imaging (MRI) were used in the diagnosis of FLLs (Figure 1). In the diagnosis of benign lesions, however, radiological imaging methods are used. The percutaneous biopsy was performed under USG-guidance for the diagnosis of malignant lesions. The pathological specimens were also evaluated by a pathologist with 10-year experience in liver diseases. Approval was obtained for the present prospective study from the ethics committee. Written consent was also obtained from each patient included in the study. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImaging protocols and Doppler ultrasonography technique\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe B-mode and Doppler USG were performed by a single radiologist with 11-year experience of conventional USG while the patients were in the supine and lateral decubitus positions, and the procedures were conducted using the Philips USG device (iU22; Philips Healthcare, Andover, MA) and the 2.5 Mhz bandwidth convex probe (Transducer C5-1, B0M2J6, Philips Healthcare, Andover, MA). During the entire examination period, the patients were asked to hold their breath actively by performing deep inspirations as much as possible. On the examination through the B-mode USG, the liver parenchyma was first evaluated to determine whether to be homogeneous or heterogeneous; then, the target lesion in the liver was determined, and the size of the lesion was detected. Additionally, the Doppler USG was performed with the same probe. By using the spectral Doppler USG, the values of the peak-systolic velocity and end-diastolic velocity were measured from the branch of the hepatic artery within the lesion, the branch of the hepatic artery in the liver parenchyma approximately 2 cm from the lesion, and the proper hepatic artery at the level of the portal hilus. \u003c/p\u003e\n\u003cp\u003eThe values of RI were calculated automatically by the device: based on the formula: (peak-systolic velocity \u0026ndash; end-diastolic velocity)/peak-systolic velocity. We meticulously performed the procedure to obtain the highest possible achievement without noise but with the lowest possible pulse repetition frequency and the lowest wall filter, without the aliasing artifact to obtain the maximum arterial waveform. The RI value obtained from the branch of the hepatic artery in the mass was subtracted from the RI value obtained from the branch of the hepatic artery adjacent to the lesion. The obtained value was divided by the RI value obtained from the hepatic artery branch in the mass, and the rate of difference between the RI values in the mass and the parenchyma was calculated as a percentage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical analyses\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analyses of the study findings were performed using the Statistical Package for the Social Sciences software, version 25.0 (SPSS Inc., Chicago, IL, USA). The numerical variables were accounted for as mean\u0026plusmn;standard deviation (SD) or numbers (percentage ratio), according to availability. The conformity of the variables to the normal distribution was investigated using the visual (histogram and probability graphs) and analytical methods (the Kolmogorov-Smirnov and Shapiro-Wilk tests).\u003c/p\u003e\n\u003cp\u003eHowever, the descriptive analyses were stated using the averages and SDs for normally distributed variables. Since the RI values obtained from the proper hepatic artery at the level of the portal hilus and the branch of the hepatic artery adjacent to the lesion demonstrated a normal distribution, a comparison was performed between those parameters, and gender, the character of liver parenchyma, and malignant-benign pathology groups using the student\u0026apos;s \u003cem\u003et\u003c/em\u003e-test.\u003c/p\u003e\n\u003cp\u003eSince age, size of the lesion, size of the liver, the RI values obtained from the branch of the hepatic artery in the lesion, and the rates of mass/parenchymal RI differences showed no normal distribution, a comparison was conducted between those parameters and gender, the character of the liver parenchyma, and malignant-benign pathology groups using the Mann-Whitney U test.\u003c/p\u003e\n\u003cp\u003eThe chi-square test was performed to determine whether there was a statistical significance between gender, the character of the lesion, and malignant-benign pathology groups.\u003c/p\u003e\n\u003cp\u003eHowever, the one-way ANOVA test was carried out to detect whether a significant relationship was present between the RI values obtained from the proper hepatic artery at the level of the portal hilus and the branch of the hepatic artery adjacent to the lesion and the mass subtypes. \u003c/p\u003e\n\u003cp\u003eThe Kruskal-Wallis test was utilized to find out whether there was a significant relationship between such non-normally distributed values as age, size of the lesion, size of the liver, and the RI values obtained from the branch of the hepatic artery in the lesion, and the rate of mass/parenchymal RI differences and mass subtypes. \u003c/p\u003e\n\u003cp\u003eThe pair-wise comparisons were also performed through the Mann-Whitney U test and evaluated using the Bonferroni correction. \u003c/p\u003e\n\u003cp\u003eThe correlation coefficients and statistical significance were calculated using the Spearman\u0026apos;s test for the variables, at least one showing no normal distribution, or the ordinal variables. For achieving the statistical significance, the total type-1 error level was used as 5%, and the values with a p-value of \u0026lt;0.05 were considered statistically significant. \u003c/p\u003e\n\u003cp\u003eThe values of diagnostic mass/parenchymal RI difference rates were determined to differentiate the benign and malignant lesions one another by performing the receiver operating characteristic (ROC) curve analysis in 68 patients whose RI values obtained from the branch of the hepatic artery in the mass were lower than the RI values obtained from the branch of the hepatic artery adjacent to the lesion. In the presence of significant threshold limit values, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) levels of these limits were calculated. In the evaluation of the area under the curve (AUC), the cases where the level of type 1 errors was \u0026lt;5% were interpreted that the diagnostic value of the test was statistically significant. \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe descriptive information related to the lesion diameter, liver size, RI values obtained from the branch of the hepatic artery in the lesion, from the branch of the hepatic artery adjacent to the lesion and proper hepatic artery at the level of portal hilus, and the rates of the mass/parenchyma RI value differences are shown in Table 2. The masses and mean RI values are presented in Table 3. \u003c/p\u003e\n\u003cp\u003eBased on the student\u0026apos;s \u003cem\u003et\u003c/em\u003e-test, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in malignant lesions, compared with those detected in benign lesions (p \u0026lt;0.001). \u003c/p\u003e\n\u003cp\u003eIn the Mann-Whitney U test, however, such values as age and liver size were found to be significantly higher in the male gender than those among females (p=0.004 and p=0.041). The frequency of heterogeneity of the liver parenchyma among the elderly patients was detected to be significantly higher than that found in the younger patients (p=0.044). The age, lesion diameter, liver size, and RI values from the hepatic artery in the lesion were found to be significantly higher in malignant lesions than those detected in benign lesions (p\u0026lt;0.001, p=0.029, p\u0026lt;0.001, and p=0.033, respectively) (Figure 2). Even so, the frequency of homogeneous liver parenchyma was found to be significantly higher in women than that in men in the chi-square test (p=0.025). Compared with those detected in women, the number of malignant lesions was found to be significantly higher in men (p=0.004). \u003c/p\u003e\n\u003cp\u003eIn the ANOVA test, additionally, a significant difference was found between the subtypes of the masses and the RI values obtained from the branch of the hepatic artery adjacent to the lesion (p=0.017). However, in the student\u0026apos;s\u003cem\u003e t\u003c/em\u003e-test performed to detect whether a significant difference was present between the RI values obtained from the branch of the hepatic artery adjacent to the lesion and which subtypes of the masses, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in the metastases, hepatocellular carcinomas (HCCs), and cholangiocellular carcinomas (CCCs) than those of hemangiomas (p=0.01, p=0.004, and p=0.025, respectively). The RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in metastases and HCCs than those of focal nodular hyperplasias (FNHs) (p=0.035 and p=0.031). \u003c/p\u003e\n\u003cp\u003eThe Kruskal-Wallis test also revealed that patients\u0026rsquo; age and liver size in metastases were significantly higher than those in hemangiomas (p=0.001 and p\u0026lt;0.001). Patients\u0026rsquo; age was also found to be significantly higher in HCCs than that in hemangiomas (p=0.003). It was revealed in the Kruskal-Wallis test that mass/parenchymal difference rates of the RI values in metastases and FNHs were found to be significantly higher than those of hemangiomas (p=0.029 and p=0.003). The rates of the mass/parenchymal RI difference values were also found to be significantly higher in FNHs, compared with those in metastases (p=0.039). \u003c/p\u003e\n\u003cp\u003eIn the ROC curve analysis, the cut-off value was calculated as 11.3 in the differentiation of benign liver lesions from malignant liver lesions. The AUC-ROC curve was calculated as 0.61 in the range of 0.470\u0026ndash;0.742 with a 95% confidence interval (CI). The levels of sensitivity, specificity, PPV, and NPV were calculated as 68.8, 58.3, 59.5, and 67.7%, respectively (Figure 3).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAlthough different studies have been conducted, related to the use of non-invasive imaging methods in the differentiation of benign and malignant liver lesions in recent years, the entity still keeps posing a problem in clinical practices. Even the combined use of USG, CT, and MRI, may be inconclusive in the determination of the lesions, especially in the detection of small lesions. The USG-guided percutaneous biopsy from the lesion performed by experts in the field can be a safe and effective method. However, there may be various technical inadequacies in small lesions located deep inside the body (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Non-invasive radiological imaging methods, such as CDI, can be benefited as an alternative technique to evaluate the differences of vascularization between the vascularization of the tumors and surrounding parenchyma, and based on the data to differentiate between benign and malignant liver lesions. Arterial flows and thus the measurements via the Doppler USG may be affected by many factors, such as cardiac output, hypertension, atherosclerosis, and vascular compliance. Therefore, we considered that those factors may also have effects on the emergence of different results in the measurements obtained only from the mass in many studies. For this reason, we attempted to standardize the factors we considered affecting the measurements as the elevation rates of percentages by eliminating such factors in terms of the patients by taking measurements from both the mass and the surrounding parenchyma. To the best of our knowledge, there is no study similar to our study in the literature. In our study, the RI values obtained from the branch of the hepatic artery adjacent to the lesion were found to be significantly higher in metastases, HCCs, and CCCs than those of hemangiomas (p\u0026thinsp;=\u0026thinsp;0.01, p\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.025, respectively). The high rate of the mass RI/parenchymal RI values in malignant lesions was evaluated due to the chaotic and relatively lower-resistant flow in the mass, compared to the surrounding parenchyma. In a study, Numata et al. performed a comparison by obtaining the RI values relatively similarly from the lesion and the right or left hepatic artery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). As similar to our study findings, Uggowitzer et al. also carried out a study and obtained the RI measurements from the mass, the proper hepatic artery, and the branch of the hepatic artery in the parenchyma (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). As different from our study, however, Uggowitzer et al. did not calculate the difference between the RI values of the mass and its surrounding as a percentage. Even so, Uggowitzer et al. found a significant difference between the RI values obtained from the proper hepatic artery and branch of the hepatic artery in the mass, and between the RI values obtained from the intra parenchymal branch of the hepatic artery, and the RI values from the hepatic artery in the mass, as different from our study findings (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the study carried out by the hepatic artery RI values in HCCs were detected to be significantly higher in all liver lesions with different sizes, compared with those in other lesions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). As consistent with the findings reported by Gaiani et al., the RI values obtained from the hepatic artery in mass were found to be significantly higher in the malignant lesions than those in benign lesions in our study (p\u0026thinsp;=\u0026thinsp;0.033). Unlike our study findings, in another study by Reinhold et al., no significant difference was determined between the RI values obtained from the hepatic artery in the liver lesions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As different from our study findings, the RI values obtained from the hepatic artery were also found to be lower in HCCs by Shimamoto et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). As well as the abovementioned findings, there are also some limitations of our study; especially the number of cases with adenomas and CCCs is quite limited. Unfortunately, such a limitation prevented us to perform healthy comparisons between these lesion groups and other lesion subtypes. In our study, all patients were evaluated by a single radiologist; therefore, no comparisons were performed between the results by evaluating the findings by two different radiologists, independent of each other.\u003c/p\u003e \u003cp\u003eIn this prospective study, the RI values were obtained from the proper hepatic artery, the intra parenchymal branch of the hepatic artery, and the branch of the hepatic artery in the mass in different liver lesions, and whether there was a significant relationship between those RI values was investigated. The difference, especially between the RI values obtained from the branch of the hepatic artery in the mass and the branch of the hepatic artery in the adjacent parenchyma was calculated as a percentage, and the efficiency in the differentiation between the benign and malignant lesions was evaluated by creating a cut-off value.\u003c/p\u003e \u003cp\u003eIn conclusion, our findings demonstrate that when further studies including larger populations with homogeneous distribution are performed, the increase of the percentage rates related to the differences between the intra-mass and parenchymal RI values to be obtained with CDI can determine the differentiation between the benign and malignant lesions of the liver, which may reduce the use of different radiological modalities, such as CT and MRI, and the requirement of USG-guided biopsy in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eresistive index (RI), focal liver lesions (FLLs), receiver operating characteristic (ROC), ultrasonography (USG), color and power Doppler imaging (CDI, PDI), computed tomography (CT), magnetic resonance imaging (MRI), standard deviation (SD), positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), hepatocellular carcinomas (HCCs), cholangiocellular carcinomas, focal nodular hyperplasias (FNHs).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u003c/strong\u003e Approval was obtained for the present prospective study from the Necmettin erbakan university faculty of medicine ethics committee. Our study does not conflict with the rules of the Helsinki declaration. Written informed consent was also obtained from each patient included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe availability of supporting data is likely.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThere are no conflicts of interest among the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo financial support was received from any institution or individual in the conduct of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eSuat Keskin (Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing). Zeynep Keskin (Data curation, Methodology, Supporting, Resources). Ahmet Yeşildağ (Conceptualization, Data curation, Formal analysis, Investigation, Writing \u0026ndash; review \u0026amp; editing)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e As the responsible author, I would like to thank the valuable staff of the Meram Medical Faculty Radiology Department for their support and contributions in the preparation of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOhnishi K, Nomura F. Ultrasonic Doppler studies of hepatocellular carcinoma and comparison with other hepatic focal lesions. \u003cem\u003eGastroenterology\u003c/em\u003e 1989; 97:1489\u0026ndash;1497.\u003c/li\u003e\n\u003cli\u003eTanaka S, Kitamura T, Fujita M, Nakanishi K, Okuda S. Color Doppler flow imaging of liver tumors. \u003cem\u003eAm J Roentgenol\u003c/em\u003e 1990;154:509-514.\u003c/li\u003e\n\u003cli\u003eTanaka S, Kitamura T, Fujita M, Kasugai H, Inoue A, Ishiguro S. Small hepatocellular carcinoma: Differentiation from adenomatous hyperplastic nodule with color Doppler flow imaging. \u003cem\u003eRadiology\u003c/em\u003e 1992;182:161-165.\u003c/li\u003e\n\u003cli\u003eReinhold C, Hammers L, Taylor CR, Quedens-Case CL, Holland CK, Taylor KJ. Characterization of focal hepatic lesions with duplex sonography: Findings in 198 patients. \u003cem\u003eAm J Roentgenol\u003c/em\u003e 1995;164:1131\u0026ndash;1135.\u003c/li\u003e\n\u003cli\u003eBret PM, Labadie M, Bretagnolle M, Paliard P, Fond A, Valette PJ. Hepatocellular carcinoma: Diagnosis by percutaneous fine needle biopsy. \u003cem\u003eGastrointest Radiol\u003c/em\u003e 1988;13:253\u0026ndash;255.\u003c/li\u003e\n\u003cli\u003eBuscarini L, Fornari F, Bolondi L, et al. Ultrasound-guided fine-needle biopsy of focal liver lesions: Techniques, diagnostic accuracy and complications. A retrospective study on 2,091biopsies. \u003cem\u003eJ Hepatol\u003c/em\u003e 1990;11:344\u0026ndash;348.\u003c/li\u003e\n\u003cli\u003eBolondi L, Gramantieri L, Chieco P, et al. Enzymatic cytochemistry, DNA ploidy and agnor quantitation in hepatocellular nodules of uncertain malignant potential in liver cirrhosis. \u003cem\u003eDig Dis Sci\u003c/em\u003e 1996;41:800\u0026ndash;808.\u003c/li\u003e\n\u003cli\u003eNumata K, Tanaka K, Kiba T, et al. Use of hepatic tumor index on color Doppler sonography for differentiating large hepatic tumors. \u003cem\u003eAm J Roentgenol\u003c/em\u003e 1997;168:991\u0026ndash;995.\u003c/li\u003e\n\u003cli\u003eUggowitzer M, Kugler C, Machan L, et al. Power Doppler imaging and evaluation ofthe resistive index in focal nodular hyperplasia of the liver. \u003cem\u003eAbdom Imaging\u003c/em\u003e 1997;22:268-273.\u003c/li\u003e\n\u003cli\u003eGaiani\u003csup\u003e \u003c/sup\u003e S, Casali A, Serra C, et al. Assessment of vascular patterns of small liver mass lesions: value and limitation of the different Doppler ultrasound modalities. \u003cem\u003eAm J Gastroenterol\u003c/em\u003e 2000;95: 3537-3546.\u003c/li\u003e\n\u003cli\u003eShimamoto\u003csup\u003e \u003c/sup\u003eK, Sakuma S, Ishigaki T, Ishiguci T, Itoh S, Fukatsu H. Hepatocellular carcinoma: evaluation with color Doppler US and MR imaging. \u003cem\u003eRadiology \u003c/em\u003e1992;182:149-153.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable1.\u0026nbsp;\u003c/strong\u003eCharacterization graph of the lesions.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"489\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eLesions\u0026rsquo; types\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eHaemangioma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eFNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eMetastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eCCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eDescriptive information. RI (resistive index), mm (millimeter)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eMinimum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMaximum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003eLesion Size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e60.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e35.849\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003eLiver Size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e166.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e23.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003eMass RI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003eCommon Hepatik artery RI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026nbsp;Branch of Hepatic artery RI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\n \u003cp\u003eThe difference ratio of RI in mass/parenchyma (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e68.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e15.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e13.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Mean RI values of the lesions. RI (resistive index), HCC (hepatocellular cancer), CCC (cholangiocellular cancer), FNH (focal nodular hyperplasia).\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"315\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eMean + SD (RI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eHaemangioma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.54\u0026plusmn;0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.61\u0026plusmn;0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMetastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.58\u0026plusmn;0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eCCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.68\u0026plusmn;0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eFNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.56\u0026plusmn;0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e0.54\u0026plusmn;0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Liver mass, Ultrasonography, Resistive index, Hepatic artery, Liver parenchyma","lastPublishedDoi":"10.21203/rs.3.rs-8749023/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8749023/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe present study aimed to determine whether any distinction can be acquired between the benign and malignant lesions of the liver by calculating the difference between the resistive index (RI) values obtained from the branch of the hepatic artery in focal liver lesions (FLLs), the branch of the hepatic artery in the parenchyma adjacent to the lesion and proper hepatic artery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 96 patients (55 female and 41 male) were admitted to the ultrasonography unit of the radiology department. The values of diagnostic mass/parenchymal RI difference rates were determined to differentiate the benign and malignant lesions one another by performing the receiver operating characteristic (ROC) curve analysis in 68 patients whose RI values obtained from the branch of the hepatic artery in the mass were lower than the RI values obtained from the branch of the hepatic artery adjacent to the lesion.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn the ROC curve analysis, the cut-off value was calculated as 11.3 in the differentiation of benign liver lesions from malignant liver lesions. The levels of sensitivity, specificity, positive predictive value and negative predictive value were calculated as 68.8, 58.3, 59.5, and 67.7%, respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this prospective study, the RI values were obtained from proper hepatic artery, the intra parenchymal branch of the hepatic artery, and the branch of the hepatic artery in the mass in different liver lesions, and whether there was a significant relationship between those RI values was investigated.\u003c/p\u003e","manuscriptTitle":"Quantitative Assessment of Benign and Malignant Liver Lesions Using Hepatic Artery Resistive Indices (Assessment of Liver Lesions Using Resistive Indices)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-15 16:54:45","doi":"10.21203/rs.3.rs-8749023/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"335292953225122478211477765977297138714","date":"2026-03-13T12:29:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-11T06:14:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-19T10:01:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-06T07:50:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T16:55:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Imaging","date":"2026-02-05T14:48:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b6acb449-9073-432f-8745-6d6c528c8e26","owner":[],"postedDate":"March 15th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-15T16:54:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-15 16:54:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8749023","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8749023","identity":"rs-8749023","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}