Histologic Patterns That Hinder Detection of Cirrhosis on Routine Abdominal Imaging: Steatosis, Centrizonal Sinusoidal Fibrosis, and Biliary-type Cirrhosis

Abstract

Early detection of cirrhosis is essential for guiding management and prognostic surveillance for hepatocellular carcinoma. Although elastography-based techniques are increasingly used, abdominal computed tomography (CT) remains the most routinely performed imaging modality in chronic liver disease surveillance. To evaluate concordance between routine abdominal CT and histology for detection of cirrhosis and investigate potential drivers of discordance. Surgical liver pathology specimens (2018–2019) with corresponding abdominal CT within 90 days were included. Radiology and pathology reports were analyzed for the presence or absence of cirrhosis; discordant cases underwent double-blinded rereview by subspecialists. Pathology rereview assessed fibrosis stage, pattern, and quality (progressive versus regressive; Beijing classification), as well as with secondary histologic findings. Initial concordance for cirrhosis/no cirrhosis was 88.7% (754 of 850). Rereview improved concordance to 95.8% (786 of 820), with 3 “Rad-overcalls” and 17 “Rad-undercalls” corrected by radiology. Persistent “Rad-overcalls” (n = 17) were explained by reclassified pathology (n = 12; 70.5%) or centrizonal sinusoidal fibrosis (n = 4; 23.5%). Among 29 persistent “Rad-undercalls,” underlying etiologies included steatotic liver disease (n = 7; 24.2%), biliary atresia (n = 4; 13.7%), active hepatitis (n = 3; 10.3%), primary sclerosing cholangitis (n = 2; 7%), and primary biliary cholangitis (n = 1; 3.5%). All discordant pediatric cases (n = 4) had biliary cirrhosis unrecognized on CT. Discordance was significantly higher in biliary cirrhosis from biliary atresia (100%) versus primary sclerosing cholangitis or primary biliary cholangitis (12.5% each; P < .001). Routine abdominal CT demonstrates high concordance with histology for detection of cirrhosis. Discordance arises mainly from centrizonal sinusoidal fibrosis, biliary atresia, and steatotic liver disease, underscoring limitations of CT in these settings.