Characterization of Primary and Recurrent Nodules in Liver Cirrhosis Using Contrast-Enhanced Ultrasound: Which Vascular Criteria Should Be Adopted?

Abstract

Purpose: To assess the impact of different vascular patterns at contrast-enhanced ultrasound (CEUS) on the characterization of small liver nodules (10 – 30 mm) in cirrhosis and to determine whether primary nodules and recurrent nodules (after a previously treated hepatocellular carcinoma) display variations in enhancement pattern.

Materials and Methods: A total of 135 cirrhotic patients were evaluated. A diagnosis of hepatocellular carcinoma (HCC) was established according to AASLD Guidelines, based on imaging (computed tomography and/or magnetic resonance) or liver biopsy. All patients underwent CEUS. Different CEUS patterns were evaluated in terms of diagnostic accuracy: HYPER-HYPO: Arterial hyperenhancement followed by washout (hypoechoic appearance compared with surrounding parenchyma) in late phase; HYPER-ISO: Arterial hyperenhancement followed by isoenhancement (isoechoic appearance) in late phase; ISO-ISO: Isoenhancement in all vascular phases.

Results: A total of 155 consecutive primary (n = 90) or recurrent (n = 65) nodules were detected. HCC was diagnosed in 127 nodules (71 primary, 56 recurrent). A characteristic HYPER-HYPO CEUS pattern was revealed in 52/127 (40.9 %) HCCs (31 primary, 21 recurrent) giving a positive predictive value (PPV) of 98 % (97 % primary, 100 % recurrent) and an accuracy of 51 % (54 % primary, 46 % recurrent). A HYPER-ISO pattern was noted in 46 HCCs (31 primary, 15 recurrent). Assuming this pattern to also be indicative of HCC, the PPV and accuracy were 94 % (93 % primary, 97 % recurrent) and 77 % (84 % primary, 68 % recurrent), respectively. An ISO-ISO pattern was present in 29 HCCs (9 primary, 20 recurrent) and 22 non-HCCs (14 primary, 8 recurrent).

Conclusion: These data confirm that the HYPER-HYPO pattern at CEUS is definitely diagnostic for HCC in cirrhosis and that the HYPER-ISO pattern has a similar PPV, indicating that this pattern is highly suspicious for HCC. The ISO-ISO pattern was found in > 50 % of recurrent nodules and indicates a high risk of HCC.

Zusammenfassung

Ziel: Die Bewertung der Auswirkung verschiedener Durchblutungsmuster im kontrastverstärkten Ultraschall (CEUS) bei der Charakterisierung kleiner Leberknoten (10 – 30 mm) bei Zirrhose sowie die Ermittlung, ob primäre Knoten und rekurrierende Knoten (nach einem zuvor behandelten hepatozellulären Karzinom) Unterschiede im Muster der Kontrastaufnahme aufweisen.

Material und Methoden: Insgesamt wurden 135 Patienten mit Zirrhose untersucht. Die Diagnose des hepatozellulären Karzinoms (HCC) wurde gemäß der AASLD Richtlinien aufgrund der darstellenden Verfahren (Computertomografie und/oder Magnetresonanz) oder einer Leberbiopsie gestellt. Bei allen Patienten wurde ein CEUS durchgeführt. Verschiedene CEUS-Muster wurden hinsichtlich der diagnostischen Genauigkeit bewertet: HYPER-HYPO: Arterielle hyperechogene Kontrastaufnahme gefolgt vom Wash-out (Hypoechogenität im Vergleich zum umgebenden Parenchym) in der Spätphase; HYPER-ISO: Arterielle hyperechogene Kontrastaufnahme gefolgt von einer isoechogenen Kontrastaufnahme (Isoechogenität) in der Spätphase; ISO-ISO: Isoechogene Kontrastaufnahme in allen Durchblutungsphasen.

Ergebnisse: Aufeinander folgend wurden insgesamt 155 primäre (n = 90) oder rekurrierende (n = 65) Knoten entdeckt. Ein HCC wurde bei 127 Knoten (71 primär, 56 rekurrierend) diagnostiziert. Ein charakteristisches HYPER-HYPO CEUS-Muster wurde bei 52/127 (40.9 %) HCCs entdeckt (31 primär, 21 rekurrierend), was einen positiven prädiktiven Wert (PPV) von 98 % (97 % primär, 100 % rekurrierend) und eine Genauigkeit von 51 % (54 % primär, 46 % rekurrierend) ergibt. Ein HYPER-ISO Muster wurde bei 46 HCCs festgestellt (31 primär, 15 rekurrierend). In der Annahme, dass dieses Muster auch auf ein HCC schließen lässt, betrugen der PPV 94 % (93 % primär, 97 % rekurrierend) und die Genauigkeit 77 % (84 % primär, 68 % rekurrierend). Ein ISO-ISO Muster lag bei 29 HCCs vor (9 primär, 20 rekurrierend) und bei 22 Fällen mit Ausschluss eines HCCs (14 primär, 8 rekurrierend).

Schlussfolgerung: Diese Daten bestätigen, dass das HYPER-HYPO Muster im CEUS diagnostisch eindeutig für ein HCC bei Zirrhose spricht und dass das HYPER-ISO Muster einen ähnlichen PPV besitzt, was dafür spricht, dass dieses Muster höchst verdächtig für ein HCC ist. Das ISO-ISO Muster wurde in > 50 % der rekurrierenden Knoten gefunden und indiziert ein hohes HCC-Risiko.

Key words

hepatocellular carcinoma - cirrhosis - contrast-enhanced ultrasound - washout

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