Real-life assessment of standardized contrast-enhanced ultrasound (CEUS) and CEUS algorithms (CEUS LI-RADS®/ESCULAP) in hepatic nodules in cirrhotic patients—a prospective multicenter study

• Published in: European radiology Vol. 31; no. 10; pp. 7614 - 7625
• Main Authors: Strobel, D., Jung, E.-M., Ziesch, M., Praktiknjo, M., Link, A., Dietrich, C. F., Klinger, C., Schultheiß, M., Jesper, D., Schellhaas, B.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.10.2021; Springer Nature B.V
• Subjects: Accuracy; Algorithms; Carcinoma, Hepatocellular - complications; Carcinoma, Hepatocellular - diagnostic imaging; Cirrhosis; Computed tomography; Contrast Media; Diagnosis; Diagnostic Radiology; Diagnostic systems; Guidelines; Hepatocellular carcinoma; Histology; Humans; Imaging; Internal Medicine; Interventional Radiology; Lesions; Life assessment; Liver; Liver cancer; Liver cirrhosis; Liver Cirrhosis - complications; Liver Cirrhosis - diagnostic imaging; Liver Neoplasms - complications; Liver Neoplasms - diagnostic imaging; Magnetic Resonance Imaging; Medical diagnosis; Medical imaging; Medicine; Medicine & Public Health; Neuroradiology; Nodules; Patients; Prospective Studies; Radiology; Retrospective Studies; Ultrasonic imaging; Ultrasonography; Ultrasound; Carcinoma, hepatocellular; Diagnostic imaging; Liver; Contrast media; Ultrasonography
• ISSN: 0938-7994; 1432-1084; 1432-1084
• DOI: 10.1007/s00330-021-07872-3

Objectives Hepatocellular carcinoma (HCC) can be diagnosed non-invasively with contrast-enhanced ultrasound (CEUS) in cirrhosis if the characteristic pattern of arterial phase hyperenhancement followed by hypoenhancement is present. Recent studies suggest that diagnosis based on this “hyper-hypo” pattern needs further refinement. This study compares the diagnostic accuracies of standardized CEUS for HCC according to the current guideline definition and following the newly developed CEUS algorithms (CEUS LI-RADS®, ESCULAP) in a prospective multicenter real-life setting. Methods Cirrhotic patients with liver lesions on B-mode ultrasound were recruited prospectively from 04/2018 to 04/2019, and clinical and imaging data were collected. The CEUS standard included an additional examination point after 4–6 min in case of no washout after 3 min. The diagnostic accuracies of CEUS following the guidelines (“hyper-hypo” pattern), based on the examiner’s subjective interpretation (“CEUS subjective”), and based on the CEUS algorithms ESCULAP and CEUS LI-RADS® were compared. Results In total, 470 cirrhotic patients were recruited in 43 centers. The final diagnosis was HCC in 378 cases (80.4%) according to the reference standard (histology 77.4%, MRI 16.4%, CT 6.2%). The “hyper-hypo” pattern yielded 74.3% sensitivity and 63% specificity. “CEUS subjective” showed a higher diagnostic accuracy (sensitivity, 91.5%; specificity, 67.4%; positive predictive value, 92%; negative predictive value, 66%). Sensitivity was higher for ESCULAP (95%) and “CEUS subjective” (91.5%) versus CEUS LI-RADS® (65.2%; p < 0.001). Specificity was highest for CEUS LI-RADS® (78.6%; p < 0.001). Conclusions CEUS has an excellent diagnostic accuracy for the non-invasive diagnosis of HCC in cirrhosis. CEUS algorithms may be a helpful refinement of the “hyper-hypo” pattern defined by current HCC guidelines. Key Points • Contrast-enhanced ultrasound (CEUS) has a high diagnostic accuracy for the non-invasive diagnosis of hepatocellular carcinoma (HCC) in cirrhosis. • The CEUS algorithm ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) showed the highest sensitivity, whereas the CEUS LI-RADS® (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System) algorithm yielded the highest specificity. • A standardized CEUS examination procedure with an additional examination point in the late phase, after 4–6 min in lesions with no washout after 3 min, is vital.