Evaluation of Contrast-enhanced US LI-RADS version 2017: Application on 2020 Liver Nodules in Patients with Hepatitis B Infection

Abstract

Background: Use of contrast material-enhanced (CE) US Liver Imaging Reporting and Data System (LI-RADS) version 2017 has not been validated in large populations where hepatitis B virus (HBV) is endemic. Purpose: To evaluate the diagnostic performance of CE US LI-RADS version 2017 in a population with a high prevalence of HBV infection. Materials and Methods: In this retrospective study, liver nodules in patients with HBV who were evaluated from January 2004 to December 2016 were categorized as CE US LR-1 to LR-5 through LR-M. A subgroup of LR-M nodules was reclassified as LR-5, and additional analysis was performed. The reference standard consisted of histologic evaluation or composite imaging and clinical follow-up findings. Diagnostic performance was assessed with sensitivity, specificity, positive predictive value (PPV), and negative predictive value. Results: A total of 2020 nodules in 1826 patients (median age, 54 years 6 12 [standard deviation]; 1642 men) were included. Of the 1159 LR-5 lesions, 1141 were hepatocellular carcinoma (HCC); three, intrahepatic cholangiocarcinomas; six, other malignancies; six, atypical hyperplasia; and three, benign lesions. The PPV of LR-5 for HCC was 98% (95% confidence interval [CI]: 98%, 99%). In LR-M nodules, 153 showed arterial phase hyperenhancement, early washout, and absence of punched-out appearance within 5 minutes, and 142 of 153 (93%; 95% CI: 89%, 97%) were HCC. If these nodules were reclassified as LR-5, LR-M specificity and PPV as a predictor of non-HCC malignancy increased from 88% (95% CI: 87%, 89%) and 36% (95% CI: 31%, 41%) to 96% (95% CI: 95%, 97%) and 58% (95% CI: 51%, 65%), respectively (P , .001). Despite reclassification, LR-5 specificity and PPV remained high (94% [95% CI: 92%, 96%] and 98% [95% CI: 97%, 99%], respectively). Conclusion: The contrast-enhanced US Liver Imaging Reporting and Data System version 2017 category LR-5 is effectively predictive of the presence of hepatocellular carcinoma. In patients with hepatitis B virus infection, performance may be further improved by reclassification of category LR-M nodules with arterial phase hyperenhancement, early washout, and no punched-out appearance to LR-5. Published under a CC BY 4.0 license.

Can contrast enhanced ultrasound differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma?

“…The feature of washout within 60 s per LR-M criteria may be the primary reason why a substantial number of HCCs were classified as LR-M. In our study, 96.1% (124/129) of LR-M HCCs presented early washout, which is close to the results of 96% (214/224) in the study of Zheng et al[ 21 ]. Liu et al[ 13 ] found that the average washout time of ICCs was 27.5 s, compared with 70.1 s for HCCs ( P < 0.05).…”

“…Some studies also demonstrated that the efficacy of marked washout in differentiating ICC from HCC can only be slightly improved even by postponing the onset time of marked washout to 3 min[ 15 , 18 ]. Zheng et al[ 21 ] found 142 out of 153 LR-M nodules showing early washout within 60 s and without punch-out before 5 min were HCCs. The authors re-categorized lesions showing the aforementioned washout patterns into LR-5, and the specificity and PPV of LR-M as a predictor of non-HCC malignancy were remarkably improved from 88% to 96% and 36% to 58%, respectively ( P < 0.001).…”

“…In this system, the LR-M category represents malignancies but is not specific for HCC[ 20 ]. However, previous studies revealed a high sensitivity of LR-M criteria for diagnosing non-HCC malignancy but a quite low positive predictive value (PPV) because of a high proportion of HCC in this category[ 15 , 17 , 21 ]. Until now, the diagnostic accuracy of LR-M criteria in differentiating ICC and LR-M HCC (defined as HCC, categorized as LR-M according to CEUS LI-RADS) has not been fully studied.…”

Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System in Diagnosing Hepatocellular Carcinoma: Diagnostic Performance and Interobserver Agreement

“…In this regard, only marked or early washout may not be the best criterion to rule out HCC as LR-M classification and further refinement of the LR-M category may be necessary. To improve the diagnostic performance of LR-M, Zheng et al [17] pointed out that if a nodule showing arterial phase hyperenhancement, early washout, and an ab-▶ sence of punched-out appearance within 5 minutes is reclassified as LR-5, then the LR-M specificity and PPV as a predictor of non-HCC malignancy would increase significantly. The clinical value of this new LR-M classification should be verified in a large multi-center prospective study.…”

Contrast-enhanced ultrasound liver reporting and data system for hepatocellular carcinoma diagnosis

“…Regarding the LR-M category (8% of lesions), 38% were ICC, 10% were mixed HCC-ICC, 48% were HCC, and 2% were metastases. A large study of 2020 patients with hepatitis B virus (HBV) infection from China validated CEUS LI-RADS® for patient populations in whom HBV is endemic -with LR-5 showing high specificity of 96% and positive predictive value of 98% for the diagnosis of HCC [44] . More recently, similar diagnostic accuracy was observed in another large retrospective study of patients from China who were predominantly (92%) HBV positivewith LR-5 showing a sensitivity and specificity of 73% and 97%, respectively for nodules 20 mm or less [45] .…”