Differentiating malignant and benign focal liver lesions in children using CEUS LI-RADS combined with serum alpha-fetoprotein

Comparison of ultrasonographic features between two types of hepatic echinococcosis and hepatoblastoma in children

Introduction

The prevalence of hepatic alveolar echinococcosis (AE) and cystic echinococcosis (CE) is notably high among children in western China, with the mortality rate for untreated children potentially reaching up to 90%. Meanwhile, hepatoblastoma is the most common malignant liver tumor in children, yet its treatment differs significantly from that of hepatic echinococcosis. This study aimed to compare and analyze the ultrasonographic and contrast-enhanced ultrasound (CEUS) characteristics of hepatic CE, AE, and hepatoblastoma in children, providing more imaging evidence for accurate clinical diagnosis.

Methods

A retrospective analysis was conducted on preoperative data from children with pathologically confirmed hepatic echinococcosis in our hospital between 2012 and 2024. Furthermore, children consecutively diagnosed with hepatoblastoma between 2020 and 2024, confirmed by histopathological examination, were selected as the control group. Clinical data, conventional ultrasound images, and CEUS characteristics of hepatic echinococcosis and hepatoblastoma were analyzed and compared.

Results

The mean ages of 22 children with hepatic CE and nine children with hepatic AE were 11.6 ± 2.8 years and 11.8 ± 3.6 years, respectively. The mean age of 36 children with hepatoblastoma was 2.9 ± 3.0 years. Significant differences were observed in age and history of residence or travel to endemic areas among children with hepatic echinococcosis and hepatoblastoma (P < 0.001). Hepatic CE and hepatoblastoma showed a higher proportion of cystic degeneration [≥50% (54.5%, 12/22), and between 0% and <50% (47.2%, 17/36, respectively)], while hepatic AE predominantly showed no cystic degeneration (88.9%, 8/9). Clear boundaries were most commonly seen in hepatic CE lesions (95.5%, 21/22), while unclear boundaries were more frequent in hepatic AE lesions (88.9%, 8/9) (P < 0.05). Calcification was more prevalent in hepatic AE compared to hepatic CE and hepatoblastoma (P < 0.05). Hepatoblastoma exhibited richer color Doppler signals (94.4%, 34/36) compared to hepatic CE and AE (P < 0.05). CEUS was performed on two hepatic echinococcosis and nine hepatoblastoma lesions. On CEUS, one hepatic AE lesion showed peripheral hyperenhancement in the arterial phase, while one hepatic CE lesion showed no significant enhancement. In hepatoblastoma, nine lesions demonstrated hyperenhancement in the arterial phase and hypoenhancement in the late phase.

Conclusion

This study demonstrates the value of ultrasound in differentiating hepatic echinococcosis from hepatoblastoma in children. Hepatic CE typically manifests as a well-defined cystic or cystic-solid mass, while hepatic AE often presents as an ill-defined cystic-solid or solid mass with diffuse calcifications. Conversely, hepatoblastoma appears as a partially well-defined cystic-solid or solid mass with abundant color Doppler signals within and around the lesion.

New strategy of LI-RADS v2018 to improve the sensitivity for small hepatocellular carcinoma ≤ 3.0 cm on extracellular-contrast enhanced MRI

INTRODUCTION

We aimed to modify LI-RADS version 2018 to improve sensitivity and determine the value of the combination of high alpha-fetoprotein (AFP) levels for small HCC (sHCC, ≤ 30 mm) diagnosis.

METHODS

A total of 984 patients at high risk for HCC, with 1204 observations (including 997 small observations ≤ 30 mm), who underwent extracellular contrast-enhanced MRI were enrolled from five independent centers. Blinded readers evaluated the LI-RADS features and categorized each observation according to the LI-RADS v2018, modified LI-RADS and EASL. Odds ratios of LI-RADS major features (MFs) and several high AFP levels for sHCC diagnosis were analyzed using multivariable logistic regression. The modified LR-5 criteria was developed by including no APHE at any size with two MFs, and non-rim APHE with one MF (≥ 10 mm) or with two MFs (< 10 mm). The diagnostic performance of each version of the LR-5 was compared using generalized estimating equations.

RESULTS

APHE, washout, enhancing capsule and five high AFP levels were independently associated with sHCC. In three datasets, the modified LI-RADS had higher sensitivities for sHCC (76.8 ∼ 85.5 % vs. 73.7 ∼ 75.9 %, P < 0.05) to the LR-5 v2018. The modified LI-RADS with AFP ≥ 200 ng/mL as an additional feature or as an alternative to threshold growth provided higher sensitivities for sHCC than LI-RADS v2018 (82.1 ∼ 90.1 % vs. 73.7 ∼ 75.9 %, all P < 0.05), modified LI-RADS (82.1 ∼ 90.1 % vs. 76.8 ∼ 85.5 %, all P < 0.05) and EASL version 2018 (82.1 ∼ 90.1 % vs. 73.3 ∼ 74.7 %, all P < 0.05), with comparable specificities (all P > 0.05).

CONCLUSION

The new strategy of LI-RADS v2018 provides significantly higher sensitivity and comparable specificity than those of LI-RADS v2018 for sHCC diagnosis on ECA-MRI.

Application of Quantitative Parameters of Contrast-Enhanced Ultrasound in Common Benign and Malignant Lesions in Pediatric Livers: A Preliminary Study

We aimed to investigate the diagnostic utility of quantitative parameters of contrast-enhanced ultrasound (CEUS) for benign and malignant liver lesions in pediatric patients. This was a single-center retrospective analysis of children with liver lesions who underwent CEUS at our hospital between July 2019 and February 2023. The CEUS perfusion patterns for all lesions were qualitatively analyzed using histopathology, contrast-enhanced magnetic resonance imaging, contrast-enhanced computed tomography, or long-term clinical follow-up as reference standards. The CEUS images were quantitatively analyzed using SonoLiver® software (TomTec Imaging Systems, Munich, Germany) to obtain data regarding quantitative parameters and dynamic vascular pattern (DVP) parametric images, including rise time (RT), time to peak (TTP), mean transit time (mTT), and maximum intensity (IMAX). Statistical analysis was carried out using Student's t-test and receiver operating characteristic (ROC) curve analysis to evaluate the diagnostic value of quantitative parameters. A total of 53 pediatric cases were included in this study, and 88.57% (31/35) of malignant lesions exhibited hyper-enhancement with rapid washout patterns; the same proportion of DVP parametric images exhibited washout patterns. Conversely, 94.44% (17/18) of benign lesions showed hyper-enhancement with slow washout patterns, and the same proportion of DVP parametric images showed no-washout patterns. RT, TTP, and mTT were significantly shorter in the malignant group than in the benign group (p < 0.05), while IMAX showed no significant difference (p > 0.05). ROC analysis indicated that mTT < 113.34 had the highest diagnostic value, with an area under the curve of 0.82. CEUS quantitative analysis had an accuracy of 98.11%, while qualitative analysis had an accuracy of 92.45%, with no statistically significant difference (p > 0.05). Quantitative analysis of CEUS provides valuable assistance in differentiating benign and malignant liver lesions in children. Among all quantitative parameters, mTT holds promise as a potentially valuable tool for identifying liver tumors.

Utility of the pediatric liver contrast-enhanced ultrasound criteria in differentiating malignant and benign multifocal lesions

BACKGROUND

The pediatric liver contrast-enhanced ultrasound (CEUS) criteria were developed to improve the diagnostic performance of CEUS in differentiating pediatric benign and malignant liver lesions. However, the diagnostic performance of CEUS in the evaluation of multiple focal liver lesions in the pediatric population has not yet been fully evaluated.

OBJECTIVE

To evaluate the diagnostic performance of the pediatric liver CEUS criteria in differentiating benign and malignant multifocal liver lesions in children.

MATERIALS AND METHODS

From April 2017 to September 2022, the CEUS characteristics of multifocal liver lesions in patients < 18 years were analyzed. Lesions classified as CEUS-1, CEUS-2 or CEUS-3 were considered benign and lesions classified as CEUS-4 or CEUS-5 were considered malignant. The diagnostic performance of the pediatric liver CEUS criteria (i.e. sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) was assessed.

RESULTS

After exclusion, 21 patients (median age, 36.0 months; range, 1.0-204 months; 7 boys) were included. There were significant differences in the serum alpha fetoprotein level (P= 0.039) and the presence of washout (P < 0.001) between children with malignant and benign lesions. The sensitivity, specificity, PPV, NPV and accuracy of the pediatric liver CEUS criteria were 100.0% (10/10), 90.9% (10/11), 90.9% (10/11), 100.0% (10/10) and 95.2% (20/21), respectively.

CONCLUSION

The pediatric liver CEUS criteria had excellent diagnostic performance in differentiating benign and malignant multifocal liver lesions in children.