Visibility of focal liver lesions: Comparison between kupffer phase of CEUS with sonazoid and hepatobiliary phase of gadoxetic acid-enhanced MRI

A combined model based on radiomics features of Sonazoid contrast-enhanced ultrasound in the Kupffer phase for the diagnosis of well-differentiated hepatocellular carcinoma and atypical focal liver lesions: a prospective, multicenter study

OBJECTIVE

The objective of this study was to develop a combined model based on radiomics features of Sonazoid contrast-enhanced ultrasound (CEUS) during the Kupffer phase and to evaluate its value in differentiating well-differentiated hepatocellular carcinoma (w-HCC) from atypical benign focal liver lesions (FLLs).

METHODS

A total of 116 patients with preoperatively Sonazoid-CEUS confirmed w-HCC or benign FLL were selected from a prospective multiple study on the clinical application of Sonazoid in FLLs conducted from August 2020 to March 2021. According to the randomization principle, the patients were divided into a training cohort and a test cohort in a 7:3 ratio. Seventy-nine patients were used for establishing and training the radiomics model and combined model. In comparison, 37 patients were used for validating and comparing the performance of the models. The diagnostic efficacy of the models for w-HCC and atypical benign FLLs was evaluated using ROCs curves and decision curves. A combined model nomogram was created to assess its value in reducing unnecessary biopsies.

RESULTS

Among the patients, there were 55 cases of w-HCC and 61 cases of atypical benign FLLs, including 28 cases of early liver abscess, 16 cases of atypical hepatic hemangioma, 8 cases of hepatocellular dysplastic nodules (DN), and 9 cases of focal nodular hyperplasia (FNH). The radiomics model and combined model we established had AUCs of 0.905 and 0.951, respectively, in the training cohort, and the AUCs of the two models in the test cohort were 0.826 and 0.912, respectively. The combined model outperformed the radiomics feature model significantly. Decision curve analysis demonstrated that the combined model achieved a higher net benefit within a specific threshold probability range (0.25 to 1.00). A nomogram of the combined model was developed.

CONCLUSION

The combined model based on the radiomics features of Sonazoid-CEUS in the Kupffer phase showed satisfactory performance in diagnosing w-HCC and atypical benign FLLs. It can assist clinicians in timely detecting malignant FLLs and reducing unnecessary biopsies for benign diseases.

Characterization of hepatobiliary phase hypointense nodules without arterial phase hyperenhancement on gadoxetic acid-enhanced MRI via contrast-enhanced ultrasound using perfluorobutane

PURPOSE

Hepatobiliary phase (HBP) hypointense nodules without arterial phase hyperenhancement (APHE) on gadoxetic acid-enhanced MRI (GA-MRI) may be nonmalignant cirrhosis-associated nodules or hepatocellular carcinomas (HCCs). We aimed to characterize HBP hypointense nodules without APHE on GA-MRI by performing contrast-enhanced ultrasound using perfluorobutane (PFB-CEUS).

METHODS

In this prospective, single-center study, participants at high-risk of HCC having HBP hypointense nodules without APHE at GA-MRI were enrolled. All participants underwent PFB-CEUS; if APHE and late, mild washout or washout in the Kupffer phase were present, the diagnosis of HCC was established according to the v2022 Korean guidelines. The reference standard consisted of histopathology or imaging. The sensitivity, specificity, and positive/negative predictive values of PFB-CEUS for detecting HCC were calculated. Associations between clinical/imaging features and the diagnosis of HCC were evaluated with logistic regression analyses.

RESULTS

In total, 67 participants (age, 67.0 years ± 8.4; 56 men) with 67 HBP hypointense nodules without APHE (median size, 1.5 cm [range, 1.0-3.0 cm]) were included. The prevalence of HCC was 11.9% (8/67). The sensitivity, specificity, and positive and negative predictive values of PFB-CEUS for detecting HCC were 12.5%(1/8), 96.6%(57/59), 33.3%(1/3) and 89.1%(57/64), respectively. Mild-moderate T2 hyperintensity on GA-MRI (odds ratio, 5.756; P = 0.042) and washout in the Kupffer phase on PFB-CEUS (odds ratio, 5.828; P = 0.048) were independently associated with HCC.

CONCLUSION

Among HBP hypointense nodules without APHE, PFB-CEUS was specific for detecting HCC, which had a low prevalence. Mild-moderate T2 hyperintensity on GA-MRI and washout in the Kupffer phase on PFB-CEUS may be useful to detect HCC in those nodules.

Diagnosing Hepatocellular Carcinoma Using Sonazoid Contrast-Enhanced Ultrasonography: 2023 Guidelines From the Korean Society of Radiology and the Korean Society of Abdominal Radiology

Sonazoid, a second-generation ultrasound contrast agent, was introduced for the diagnosis of hepatic nodules. To clarify the issues with Sonazoid contrast-enhanced ultrasonography for the diagnosis of hepatocellular carcinoma (HCC), the Korean Society of Radiology and Korean Society of Abdominal Radiology collaborated on the guidelines. The guidelines are de novo, evidence-based, and selected using an electronic voting system for consensus. These include imaging protocols, diagnostic criteria for HCC, diagnostic value for lesions that are inconclusive on other imaging results, differentiation from non-HCC malignancies, surveillance of HCC, and treatment response after locoregional and systemic treatment for HCC.

An alternative second performance of contrast-enhanced ultrasound for large focal liver lesion is necessary for sufficient characterization

Focal liver lesions (FFLs) evaluated using contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT) may have the same or similar findings or substantial discrepant findings. Such phenomenon can be found in two performances of CEUS that the second performance of CEUS conducted shortly following the initial performance of CEUS. Discrepancy of two performances of CEUS for FFLs occurring in the same patient at a short internal has not been well addressed, which raises challenge for CEUS for the evaluation of FFLs. In this case study, such phenomenon is illustrated and implication is obtained.

Dynamic Contrast-Enhanced Ultrasonography with Sonazoid for Diagnosis of Microvascular Invasion in Hepatocellular Carcinoma

The aim of the present study was to investigate the imaging features observed in pre-operative Sonazoid contrast-enhanced ultrasound (SZ-CEUS) and the correlations with the presence of microvascular invasion (MVI) in hepatocellular carcinoma (HCC) patients. In this single-center retrospective study, 31 patients with surgically and histopathologically confirmed HCC lesions were included. Patients were classified according to the presence of MVI into the MVI-positive group (n = 15) and MVI-negative group (n = 16). The CEUS examinations were performed within 2 or 3 d before surgery. Features, including tumor necrosis and ultrasound contrast agent (UCA) distribution characteristics in the arterial phase (AP), tumor types (single nodular [SN] or non-single nodular [non-SN]) in the post-vascular phase (PVP), wash-in time, wash-in slope, time to peak (TTP) and peak intensity (PI), were assessed. Univariate analysis revealed statistically significant differences between the two groups with respect to tumor necrosis (p = 0.002), inhomogeneous distribution of contrast agent in the AP (p = 0.001) and non-SN type in the PVP (p < 0.001). There was no significant difference in the quantitative parameters. Multivariate analysis revealed that non-SN type in the PVP was a significant independent risk factor for MVI of HCC (odds ratio = 30.51, 95% confidence interval [CI]: 2.335-398.731, p = 0.009). The area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 0.873, 93.3%, 81.3%, 82.4% and 92.9%, respectively. Thus, SZ-CEUS can provide useful information for the diagnosis of MVI in HCC.

Prospective assessment of diagnostic efficacy and safety of SonazoidTM and SonoVue® ultrasound contrast agents in patients with focal liver lesions

Objectives

To assess the respective diagnostic value of Sonazoid™ and SonoVue® for characterizing FLLs as benign or malignant and the corresponding safety.

Methods

This prospective Phase 3 study was conducted at 17 centres in China and Korea (May 2014 to April 2015); 424 patients (20 to 80 years) with at least 1 untreated focal liver lesion (FLL) (< 10 cm in diameter) underwent a contrast-enhanced ultrasound (CEUS) examination (218 received Sonazoid of 0.12 μL microbubbles/kg; 206 received SonoVue of 2.4 mL). Three independent blinded readers evaluated pre- and post-contrast images characterising the FLLs as benign or malignant.

Results

Sonazoid-enhanced and SonoVue-enhanced ultrasound provided a statistically significant improvement in specificity for all 3 readers comparing to unenhanced ultrasound (for Sonazoid: p = 0.0093, < 0.0001, 0.0011; for SonoVue: p = 0.002, 0.03, 0.12, respectively). Difference in accuracy improvement between the 2 groups was within the pre-specified non-inferiority margin of 20% for all 3 readers (6.1%, 95% CI: − 5.0 to 17.2; − 7.5%, 95% CI: − 18.4 to 3.5; − 0.3%, 95% CI: − 11.3 to 10.7).

The diagnostic confidence level for all 3 readers increased with post-contrast images relative to pre-contrast images. Both contrast agents were well tolerated.

Conclusion

Results showed a similar efficacy for Sonazoid™ and SonoVue® in diagnosing FLLs as benign or malignant, and underlined the benefit of CEUS imaging over unenhanced ultrasound imaging in reaching a confident diagnosis without having to refer patients for additional imaging exams.

Diagnostic accuracy of imaging modalities in differentiating xanthogranulomatous cholecystitis from gallbladder cancer

Background

The aim of this study was to assess the diagnostic performance of radiological imaging in differentiating xanthogranulomatous cholecystitis (XGC) from gallbladder cancer (GBC).

Methods

A retrospective analysis of the radiological imaging performed in patients who had pathologically confirmed XGC or GBC between December 2004 to April 2016 was performed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each imaging modality, and combined imaging modalities were calculated.

Results

A total of 218 patients (XGC =109, GBC =109) were identified; 19 patients received all of abdominal ultrasound (US), contrast-enhanced ultrasound (CEUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT); 21 received four of these imaging examination types; 45 received three examinations; 58 received two examinations; and 75 received only one examination. The sensitivity and specificity of CEUS was 90% and 93%, respectively, higher than abdominal US (80%, 86%), CT (71%, 92%), MRI (75%, 90%), and PET/CT (55%, 90%) (all values respective). The sensitivity, specificity, NPV, and PPV of the US combined with CEUS were 91%, 90%, 94%, and 85%, respectively. Although the specificity of CEUS + CT and CEUS + MRI were 100% and 92%, respectively, the sensitivity of CEUS + CT and CEUS + MRI were both only 67%.

Conclusions

The Abdominal US is not sufficiently accurate to confidently guide clinical practice, and CEUS showed better diagnostic performance than the other imaging modalities in differentiating XGC from GBC. The combination of abdominal CEUS and CT is helpful for differential diagnosis, as it indicates GBC with better specificity and PPV.