Clinically significant portal hypertension (CSPH) is a landmark in the natural history of cirrhosis, influencing clinical decisions in patients with hepatocellular carcinoma (HCC). Previous small series suggested that splanchnic volume measurements may predict portal hypertension. We aimed to evaluate whether volumetry obtained by standard multidetector computerised tomography (MDCT) can predict CSPH in patients with HCC. We included 175 patients with HCC, referred for hepatic venous pressure gradient (HVPG) evaluation, in whom contemporary MDCT was available. Liver volume, spleen volume (SV) and liver segmental volume ratio (LSVR: volume of the segments I-III/volume of the segments IV-VIII) were calculated semi-automatically from MDCT. Other non-invasive tests (NITs) were also employed. Volume parameters could be measured in almost 100% of cases with an excellent inter-observer agreement (intraclass correlation coefficient >0.950). SV and LSVR were independently associated with CSPH (HVPG ≥10 mmHg) and did not interact with aetiology. The volume Index (VI), calculated as the product of SV and LSVR, predicted CSPH (AUC 0.83; 95% CI 0.77-0.89). Similar results were observed in an external cohort (n = 23) (AUC 0.87; 95% CI 0.69-1.00). Setting a sensitivity and specificity of 98%, VI could have avoided 35.9% of HVPG measurements. The accuracy of VI was similar to that of other NITs. VI also accurately predicted HVPG greater than 12, 14, 16 and 18 mmHg (AUC 0.81 [95% CI 0.74-0.88], 0.84 [95% CI 0.77-0.91], 0.85 [95% CI 0.77-0.92] and 0.87 [95% CI 0.79-0.94], respectively). Quantification of liver and spleen volumes by MDCT is a simple, accurate and reliable method of CSPH estimation in patients with compensated cirrhosis and HCC. An increase in portal pressure strongly impacts outcomes after surgery in patients with early hepatocellular carcinoma (HCC). Direct measurement through hepatic vein catheterization remains the reference standard for portal pressure assessment, but its invasiveness limits its application. Therefore, we evaluated the ability of CT scan-based liver and spleen volume measurements to predict portal hypertension in patients with HCC. Our results indicate that the newly described index, based on quantification of liver and spleen volume, accurately predicts portal hypertension. These results suggest that a single imaging test may be used to diagnose and stage HCC, while providing an accurate estimation of portal hypertension, thus helping to stratify surgical risks.

This review provides an overview of the cross-sectional imaging features of gastrointestinal (GI) metastases presenting with a linitis plastica (LP) pattern and illustrates these findings through a series of cases from various primary tumors. It also addresses key diagnostic challenges, with particular attention to differential diagnosis. The term linitis plastica (LP) refers to the macroscopic appearance of a hollow organ with diffuse mural tumor infiltration, leading to loss of parietal distensibility. Although rare, primary LP can occur throughout the gastrointestinal (GI) tract. First described in the stomach—the most common site—it is typically associated with undifferentiated adenocarcinoma composed of poorly cohesive cells, often with signet ring morphology. Beyond primary GI tumors, LP-like metastases may also arise from extragastrointestinal primaries, most notably breast carcinoma (particularly the lobular subtype), as well as urinary bladder and prostate carcinomas. LP-like GI metastases typically manifest as circumferential, enhancing wall thickenings with exaggerated zonal anatomy and luminal narrowing. Due to diffuse parietal tumor infiltration—often with mucosal preservation—the submucosa and serosa appear disproportionately thickened and show greater enhancement relative to the muscularis propria (MP). This specific imaging appearance is known as the malignant target sign, which must be distinguished from the benign target sign, where the most prominent low-density layer corresponds to edematous submucosa. Additional key features include homogeneous enhancement with loss of layer differentiation on delayed-phase imaging and a concentric ring pattern on MR. Secondary findings may also be present, such as intestinal obstruction and concomitant peritoneal carcinomatosis (PC). Gastrointestinal metastases with an LP pattern present a significant diagnostic challenge, as they can mimic both primary tumors and benign inflammatory or infectious conditions. Accurate diagnosis is critical because management strategies differ substantially. Since the mucosa is often spared, endoscopy and superficial biopsies may yield false-negative results. Therefore, while immunohistochemistry (IHC) remains essential for confirmation, radiologists play a pivotal role in raising suspicion for LP-like GI metastases and recommending deep, extensive biopsies to obtain adequate representative tissue. Furthermore, in cases of an unknown primary tumor, recognition of the LP pattern can provide important clues to the potential site of origin.

BACKGROUND This review aims to summarize the imaging features on cross-sectional imaging mo-dalities of metastases to the gastrointestinal tract (GI) with a linitis plastica (LP) pat-tern and to present a series of cases from different primary tumours. Challenging questions concerning their diagnosis will be discussed in detail, including their differ-ential diagnosis. The term LP is to describe the macroscopic appearance of any hollow organ with dif-fuse mural tumour infiltration, responsible for the loss of parietal distensibility. Pri-mary LP, however rare, may be found throughout the GI tract. First described in the stomach, which represents the most frequent location, it is associated with undifferen-tiated adenocarcinoma with poorly cohesive cells, often presenting signet ring fea-tures. In addition to primary GI LP, LP-like metastases may occur in association with prima-ry tumours arising beyond the GI tract, namely breast (especially the lobular type), urinary bladder and prostate carcinomas. MAIN TEXT LP-like GI metastases appear as circumferential and enhancing thickenings of the GI, with an exaggerated zonal anatomy and a narrowed lumen. As a result of the diffuse parietal tumour infiltration that frequently preserves the mucosa, the infiltrated sub-mucosa and serosa appear disproportionately expanded with increased enhancement compared to the muscularis propria (MP). This appearance constitutes the malignant target sign, which is to be differentiated from its non-tumoral counterpart, the benign target sign, where the low density intervening and most prominent layer is the edem-atous submucosa. A homogeneous enhancement with loss of layer differentiation at the delayed phase and a concentric ring pattern on MR have also been described as key imaging features, in addition to associated findings, such as secondary intestinal occlusion and concom-itant peritoneal carcinomatosis (PC). CONCLUSIONS GI metastases with LP pattern cause a diagnostic challenge as they may mim-ic primary tumours as well as benign conditions such as inflammatory/infectious dis-eases. Achieving the correct diagnosis is crucial, as patient management differs. Since the mucosa may be spared, endoscopies and biopsies are frequently negative. Thus, alt-hough immunohistochemistry (IHC) studies are essential, radiologists play a para-mount role in suggesting LP-like GI metastases and proposing deep and extensive bi-opsies to obtain substantial representative tissue to confirm the diagnosis. Moreover, in the event of an unknown primary tumour, recognition of the LP pattern may be extremely helpful in suggesting possible primary tumours.