Contrast-enhanced ultrasound liver imaging reporting and data system: clinical validation in a prospective multinational study in North America and Europe

Abstract

Background and aims: The objective of this study is to determine the diagnostic accuracy of the American College of Radiology Contrast-Enhanced Ultrasound (CEUS) Liver Imaging Reporting and Data System LR-5 characterization for HCC diagnosis in North American or European patients.

Approach and results: A prospective multinational cohort study was performed from January 2018 through November 2022 at 11 academic and nonacademic centers in North America and Europe. Patients at risk for HCC with at least 1 liver observation not previously treated, identified on ultrasound (US), or multiphase CT or MRI performed as a part of standard clinical care were eligible for the study. All participants were examined with CEUS of the liver within 4 weeks of CT/MRI or tissue diagnosis to characterize up to 2 liver nodules per participant using ACR CEUS Liver Imaging Reporting and Data System. Definite HCC diagnosis on the initial CT/MRI, imaging follow-up, or histology for CT/MRI-indeterminate nodules were used as reference standards. A total of 545 nodules had confirmed reference standards in 480 patients, 73.8% were HCC, 5.5% were other malignancies, and 20.7% were nonmalignant. The specificity of CEUS LR-5 for HCC was 95.1% (95% CI 90.1%-97.7%), sensitivity 62.9% (95% CI 57.9%-67.7%), positive predictive value 97.3% (95% CI 94.5%-98.7%), and negative predictive value 47.7% (95% CI 41.7%-53.8%). In addition, benign CEUS characterization (LR-1 or LR-2) had 100% specificity and 100% positive predictive value for nonmalignant liver nodules.

Conclusions: CEUS Liver Imaging Reporting and Data System provides an accurate categorization of liver nodules in participants at risk for HCC.

FIGURE 1.

Study flow diagram. Abbreviation: MDD, Multidisciplinary discussion.

FIGURE 2.

Typical CEUS LR-5 pattern of HCC and LR-M pattern of ICC. B-mode image of 3 cm HCC in the liver (arrows) (A), with APHE (B), no washout at 60 sec (C) with late and mild washout at 120 sec (D). B-mode image of 1.5 cm ICC in the liver (arrows) (E), with APHE (F), early washout appearing before 60 sec from contrast injection (G) with marked washout degree (H). Despite similar arterial phase appearance with typical hyperenhancement (B,F), difference in timing (late (C) vs. early (G)) and degree of washout (mild (D) vs. marked (H)) allows accurate differentiation of HCC from non-hepatocellular malignancy, such as ICC.

FIGURE 3.

STARD diagram tracking total participants and total nodules with their CEUS categorization and reference standard diagnosis. Exclusion at recruitment and following reference standard diagnosis are emphasized.