Nodules Identified on Surveillance Ultrasound for HCC

Abstract

Objectives Following positive surveillance ultrasound (US), magnetic resonance imaging (MRI) is recommended for further characterization. We propose contrast‐enhanced ultrasound (CEUS) shows equivalent efficacy. Methods This prospective institutional review board approved study recruited 195 consecutive at‐risk patients with a positive surveillance US. All had CEUS and MRI. Biopsy (n = 44) and follow‐up are gold standard. MRI and CEUS results are classified according to liver imaging reporting and data system (LI‐RADS) and patient outcome. Results As an US‐based modality, CEUS is superior in confirming findings from surveillance US, correlation in 189/195 (97%) on CEUS compared to 153/195 (79%) on MRI. Within these negative MRI examinations, there are 2 hepatocellular carcinoma (HCC) and 1 cholangiocarcinoma (iCCA) diagnosed on CEUS and proven by biopsy. From 195 patients, there are 71 malignant diagnoses from all sources, including 58 LR‐5 (45 on MRI and 54 on CEUS) and 13 others, including HCC outside of LR‐5 category, and LR‐M with biopsy proven iCCA (3 on MRI and 6 on CEUS). CEUS and MRI show concordant results in the majority of patients (146/195, 75%), including 57/146 malignant and 89/146 benign diagnoses. There are 41/57 concordant LR‐5 and 6/57 concordant LR‐M. When CEUS and MRI are discordant, CEUS upgraded 20 (10 biopsy‐proven) from MRI LR‐3/4 to CEUS LR‐5 or LR‐M by showing washout (WO) that MRI failed to show. Additionally, CEUS characterized time and intensity of WO and diagnosed 13/20 LR‐5 by showing late and weak WO and 7 LR‐M by showing fast and marked WO. CEUS is 81% sensitive and 92% specific in diagnosing malignancy. MRI is 64% sensitive and 93% specific. Conclusions CEUS performance is at least equivalent if not superior to MRI for initial evaluation of lesions from surveillance US.

Comparing Magnetic Resonance Imaging and Contrast‐Enhanced Ultrasound (CEUS) for the Characterization of Nodules Found on Hepatocellular Carcinoma Surveillance

“…CEUS was also more likely than CE‐MRI to reproduce and characterize the nodule seen on the community US (97% vs 78.5%) 7 . In six patients (3%) without a correlate mass found on CEUS, the CE‐MRI also showed no correlate or mass.…”

“…Of all the nodules characterized, the CEUS and CE‐MRI were concordant 75% of the time 7 . This includes 57 patients with malignancy or suspicion of malignancy (LR‐5 in 41, LR‐M in 6, and LR‐4 in 10 patients) and 89 patients with benign lesions (LR‐3 in 39 and LR‐1 in 27 patients) or no mass/correlate (23 patients).…”

“…Ultimately, there were 71 patients with a malignant diagnosis, including 58 with HCC and 13 with intrahepatic cholangiocarcinoma (iCCA). CEUS, when compared with CE‐MRI, had a superior sensitivity (81% vs 64%) for the diagnosis of malignancy, without compromising specificity (92% vs 93%) 7 …”

“…The study by Hu et al in the Journal in Ultrasound Medicine 7 provides further real‐world evidence for the role of CEUS in the characterization of nodules found on surveillance US and how best to incorporate CEUS into a diagnostic algorithm that also includes CE‐MRI. This is the first study to evaluate CEUS and CE‐MRI prospectively in patients who had new nodules found during a community‐based ultrasound surveillance.…”

“…This includes 57 patients with malignancy or suspicion of malignancy (LR‐5 in 41, LR‐M in 6, and LR‐4 in 10 patients) and 89 patients with benign lesions (LR‐3 in 39 and LR‐1 in 27 patients) or no mass/correlate (23 patients). Of the 25% with discordant diagnosis, CEUS established the diagnosis of malignancy in 20 patients (LR‐5 in 13 and LR‐M in 7 patients), compared with MRI that established the diagnosis of HCC in only 4 patients 7 …”