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Kościuszko et al. Hepatoma Res 2021;7:51 https://dx.doi.org/10.20517/2394-5079.2021.17 Page 5 of 16

Simultaneously, modern scanners produce high-quality isovolumetric images that can be reconstructed in
[25]
multiple imaging planes .
Up to date, MRI seems to be the best imaging modality in liver lesions assessment. Several publications have
shown that MRI is superior for lesion characterisation of liver pathology when compared to CT. It is only
moderately better for lesion detection but contributes clinically crucial additional information in a sizeable
number of patients [30-32] .

MRI has the advantages of providing excellent soft tissue contrast without exposing the patient to ionising
radiation. Advances in both MRI hardware and software technology have significantly contributed to the
detection, characterisation and staging of hepatic neoplasms .
[33]

[34]
MRI in paediatric patients can be performed with either 3 or 1.5 T systems . Imaging at 3 T has a better
signal-to-noise ratio and spatial resolution than 1.5 T imaging when combined with acceleration techniques
such as parallel imaging and compressed sensing , which makes it preferable in younger children [36,37] .
[35]

Although new, but with proven advantages, hepatobiliary agents have been used to evaluate the biliary
system’s anatomy, function and pathology .
[38]

There are three FDA-approved MR contrast agents with differing degrees of hepatocyte uptake and biliary
excretion. Gadoxetic acid is discussed in more detail in this paper. It has been marketed in the US since
2008 (approved as Primovist® in Europe since 2004). Almost 50% of gadoxetic acid is taken up by
[39]
hepatocytes and excreted into biliary canaliculi . Hepatobiliary phase liver imaging shows peak contrast
[40]
enhancement at 20 min with a persistent enhancement for more than 2 h . The early enhancement is the
[41]
main reason this agent is preferred in the paediatric population . Gadoxetate is safe in children older than
two months . The advantages of gadoxetate are improved characterisation of liver lesions, enhanced
[42]
detection of metastases, better evaluation of the relationship of tumours to the biliary tree (to evaluate the
biliary tree for benign disease and for tumours communicating with the biliary tree ) and increased
[43]
[39]
diagnostic confidence of focal nodular hyperplasia (FNH) differentiation from liver metastases . If needed,
they can guide the biopsy of more suspicious lesions . This last benefit is significant in children who have
[44]
been treated for a primary tumour, as there is an increased incidence of FNH in those patients .
[45]
PREPARE AND PERFORM (SYSTEMATIC REVIEW)
We found 16 relevant articles that contribute to the application of 3D visualisation in paediatric liver
surgery. The papers are summarised in Tables 2 and 3. Table 4 summarises the outcome measures used in
the reviewed research studies.

[46]
Plumley et al. were the first to describe the role of helical (spiral) CT scan, with 3D reconstruction, in the
preoperative assessment of solid paediatric tumours. From the nine described cases, one patient was a child
with hepatoblastoma. The surgical treatment was feasible after performing the spiral-CT scan and 3D
reconstruction, even though initially the tumour seemed unresectable. The authors believed that the
excellent resolution of vascular structures and the ability to evaluate the tumour’s 3D relationship to these
structures in multiple projections allow preoperative surgical strategies that result in safe and complete
surgical resection of tumours.