Contrast-Enhanced Ultrasound Findings in Patients with Rare Solitary Necrotic Nodule of the Liver - a Multicenter Report.

PURPOSE: This multicenter retrospective study highlights the contrast-enhanced ultrasound (CEUS) findings in a series of histologically proven solitary necrotic nodules (SNN) of the liver, a poorly understood pathologic entity of uncertain origin that mimics malignancy. MATERIALS AND METHODS: 22 patients (M/F 13/9; mean age 59.4 years, SD ±â€Š10.7, range 35-81) with histological diagnosis of SNN and CEUS were selected from clinical, imaging, and pathological archives of 7 US interventional centers, each of which provided 1 to 6 cases (mean 2.8). Pathological diagnosis was made on 20 US-guided biopsies and 2 surgical specimens. 2 patients had 2 SNNs with identical CEUS findings so that imaging analysis was carried out on 24 nodules. RESULTS: SNN was an incidental finding in healthy people in 10 cases (45.5 %), and it was discovered during follow-up for either known extrahepatic malignancies (9 cases = 41 %) or chronic liver disease (3 cases = 13.5 %). SNNs had a mean size of 19.3 mm (SD ±â€Š6.5, range 9-40). On B-mode US, SNNs appeared hypoechoic in 14 cases (66.7 %), "target-like" in 7 cases (29.2 %), and homogeneously hyperechoic in 1 case (4.1 %). On CEUS, all lesions appeared devoid of contrast enhancement ("punched out" aspect) in the arterial, portal venous, and late phases after US contrast agent injection. A uniformly thin, hyperenhancing ring in the early arterial phase and isoenhanced with the surrounding parenchyma in the portal venous and late phases was found in 10 nodules (41.6 %). Clinical and imaging follow-up (mean duration 42.2 months, SD ±â€Š34.9, range 2-108) was available in 15 patients with 16 SNNs: no changes in size and echostructure were seen. CONCLUSION: CEUS can contribute to the diagnosis of SNN when a "punched out" appearance in all vascular phases with or without thin rim enhancement in the very early arterial phase is present in healthy subjects in whom a focal liver lesion is incidentally found. In patients with a history of chronic liver disease or malignancy, US-guided biopsy represents the unavoidable first-line diagnostic modality.

Use of Contrast-Enhanced Ultrasound in Ablation Therapy of HCC: Planning, Guiding, and Assessing Treatment Response.

Contrast-enhanced ultrasonography (CEUS) plays an important role in the management of patients treated with ablation therapies, in the diagnostic, therapeutic and monitoring phases. Compared to contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging, CEUS presents several advantages in imaging HCC, including real time imaging capability, high sensitivity for tumor vascularity, absence of renal toxicity, no ionizing radiation, repeatability of injections, good compliance by the patient and low cost. The purpose of this review is to evaluate the role of CEUS in the management of the patients with HCC treated with ablation therapies and describe how in our protocol CEUS is integrated with the other imaging modalities such as contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging.

Role of Contrast-Enhanced Ultrasound in the Detection of Complications After Ultrasound-Guided Liver Interventional Procedures.

The role of contrast-enhanced ultrasound (CEUS) in interventional ultrasound-guided procedures in the liver has been increasingly recognized. However, little is known about the capability of CEUS for diagnosing complications after liver biopsy and ablation with special regard to postprocedural hemorrhage. The aim of this Pictorial Essay is to present the CEUS features of a wide spectrum of vascular complications (with or without bleeding) and injuries of the surrounding abdominal and chest wall occurring after liver interventional procedures.

External validation of the ITA.LI.CA prognostic system for patients with hepatocellular carcinoma: A multicenter cohort study.

Several staging systems for hepatocellular carcinoma (HCC) have been developed. The Barcelona Clinic Liver Cancer staging system is considered the best in predicting survival, although limitations have emerged. Recently, the Italian Liver Cancer (ITA.LI.CA) prognostic system, integrating ITA.LI.CA tumor staging (stages 0, A, B1-3, C) with the Child-Turcotte-Pugh score, Eastern Cooperative Oncology Group performance status, and alpha-fetoprotein with a strong ability to predict survival, was proposed. The aim of our study was to provide an external validation of the ITA.LI.CA system in an independent real-life occidental cohort of HCCs. From September 2008 to April 2016, 1,508 patients with cirrhosis and incident HCC were consecutively enrolled in 27 Italian institutions. Clinical, tumor, and treatment-related variables were collected, and patients were stratified according to scores of the Barcelona Clinic Liver Cancer system, ITA.LI.CA prognostic system, Hong Kong Liver Cancer system, Cancer of the Liver Italian Program, Japanese Integrated System, and model to estimate survival in ambulatory patients with hepatocellular carcinoma. Harrell's C-index, Akaike information criterion, and likelihood-ratio test were used to compare the predictive ability of the different systems. A subgroup analysis for treatment category (curative versus palliative) was performed. Median follow-up was 44 months (interquartile range, 23-63 months), and median overall survival was 34 months (interquartile range, 13-82 months). Median age was 71 years, and patients were mainly male individuals and hepatitis C virus carriers. According to ITA.LI.CA tumor staging, 246 patients were in stage 0, 472 were in stage A, 657 were in stages B1/3, and 133 were in stage C. The ITA.LI.CA prognostic system showed the best discriminatory ability (C-index = 0.77) and monotonicity of gradients compared to other systems, and its superiority was also confirmed after stratification for treatment strategy. CONCLUSION: This is the first study that independently validated the ITA.LI.CA prognostic system in a large cohort of Western patients with incident HCCs. The ITA.LI.CA system performed better than other multidimensional prognostic systems, even after stratification by curative or palliative treatment. This new system appears to be particularly useful for predicting individual HCC prognosis in clinical practice. (Hepatology 2018;67:2215-2225).

Adherence to Barcelona Clinic Liver Cancer guidelines in field practice: Results of Progetto Epatocarcinoma Campania.

BACKGROUND AND AIM: The Barcelona Clinic Liver Cancer (BCLC) algorithm is the standard system for clinical management of hepatocellular carcinoma (HCC). Data on adherence to this therapeutic paradigm are scarce. This field practice study aimed to provide a description of HCC cirrhotic patients in Southern Italy, to evaluate the adherence to BCLC guidelines and its impact on patients' survival. METHODS: We analyzed the region-wide Italian database of Progetto Epatocarcinoma Campania, which includes data of HCC cirrhotic patients, prospectively collected from January 2013 to December 2015 in 16 regional centers. RESULTS: Overall, 1008 HCC patients were enrolled: 70.6% patients received therapies recommended by BCLC algorithm, while 29.4% underwent different treatments. Among patients who were treated in adherence to guidelines, a higher rate of diagnosis on surveillance programs, better liver function, lower rate of alpha-fetoprotein > 200 ng/mL, more early-stage and monofocal HCC, lower frequency of nodules > 5 cm, portal vein thrombosis and metastases were observed. The overall survival was evaluated according to HCC stage and no differences between groups and patients managed differently were found. The multivariate analysis showed that non-adherence to treatment guidelines was independently associated to the BCLC stage B, Child-Pugh classes B and C, and the presence of neoplastic thrombosis and metastases. CONCLUSION: Adherence to BCLC algorithm in field practice was high in early and end-stage HCC patients, but it was poor in intermediate and advanced patients.

Biopsy of Liver Target Lesions under Contrast-Enhanced Ultrasound Guidance - A Multi-Center Study.

PURPOSE: To retrospectively characterize the prevalence and impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for the biopsy of liver target lesions (LTLs) at six interventional ultrasound centers. MATERIALS AND METHODS: The six participating centers retrospectively selected all patients in whom biopsy needles were positioned in LTLs during CEUS. The prevalence of CEUS-guided biopsies at each center between 2005 and 2016, contrast agent consumption, procedure indications, diagnostic yield and complications were assessed. Informed consent was obtained for all patients. RESULTS: CEUS-guided biopsy of LTLs was carried out in 103 patients (68 M/35 F, median age: 69 yrs) with 103 liver target lesions (median size: 20 mm) using cutting needles (18 - 20 g) in 94 cases (91.2 %). CEUS-guided biopsy represented 2.6 % (range: 0.8 - 7.7 %) of 3818 biopsies on LTLs carried out at the participating centers. Indications to CEUS-guided biopsy were: a target lesion not visible on non-enhanced US (27.2 %), improvement of conspicuity of the target (33 %), choice of non-necrotic area inside the target (39.8 %). 26 patients (25.2 %) had a previously non-diagnostic cyto-histological exam. The diagnostic accuracy of the technique was 99 %. No major complications followed infusion of contrast agent or biopsy performance. CONCLUSION: The indications for CEUS-guided biopsy for LTLs are limited, but CEUS can be useful in challenging clinical scenarios, e. g. poorly visualized or invisible lesions or sampling of non-necrotic areas in the target lesions. There is also a potential advantage in using CEUS to guide repeat biopsies after unsuccessful sampling performed using the standard ultrasound technique.

Management and prognosis of hepatocellular carcinoma in the elderly: Results of an in-field multicenter cohort study.

AIMS: This multicentre cohort study evaluated the role of ageing on clinical characteristics, treatment allocation and outcome of new hepatocellular carcinomas (HCCs), in clinical practice. MATERIAL & METHODS: From September 2008, 541 patients >70 years old (elderly group), and 527 ≤70 years old (non-elderly group) with newly diagnosed HCC were consecutively enrolled in 30 Italian centres. Differences in clinical characteristics and treatment allocation between groups were described by a multivariable logistic regression model measuring the inverse probability weight to meet the elderly group. Survival differences were measured by unadjusted and adjusted (by inverse probability weight) survival analysis. RESULTS: Elderly patients were mainly females, hepatitis C virus infected and with better conserved liver function (P<.001). At presentation, HCC median size was similar in both groups while, in youngers, HCC was more frequently multinodular (P=.001), and associated with neoplastic thrombosis (P=.009). Adjusted survival analysis showed that age did not predict short-mid-term survival (within 24 months), while it was a significant independent predictor of long-term survival. Moreover, age had a significant long-term survival impact mainly on early HCC stages (Barcelona Clinic for Liver Cancer [BCLC] 0-A), its impact on BCLC B stage was lower, while it was negligible for advanced-terminal stages. CONCLUSIONS: Age per se does not impact on short-mid-term prognosis (≤24 months) of HCC patients, and should not represent a limitation to its management.

Trend of improving prognosis of hepatocellular carcinoma in clinical practice: an Italian in-field experience.

BACKGROUND: Recent data suggest that outcome of hepatocarcinoma is improving. AIMS: In order to explore whether survival is also increasing in clinical practice, we compared two multicenter independent in-field cohorts of cirrhotics with newly diagnosed HCCs. METHODS: Cohort 1 (C1) consisted of 327 patients enrolled between January and December 1998, and cohort 2 (C2) included 826 patients enrolled between September 2008 and November 2012. Patients were stratified according to Child-Pugh score, MELD score, and HCC staged according to TNM, BCLC systems. RESULTS: At baseline, C2 patients were significantly older, with more frequent comorbidities and better liver function. In C2, HCC was more frequently detected under regular ultrasound surveillance (P < 0.001), BCLC early stages were more frequent, and rates of smaller and uni/paucinodular tumors were significantly higher. Treatment of any type was more frequently offered to C2 patients (P < 0.001). Proportion of patients treated by TACE increased, and radiofrequency ablation was the most used ablative treatment. Survival rate was significantly higher in C2 being C1 and C2 survival at 1-3 years 72-25 and 75-44 %, respectively. Child-Pugh score A, BCLC stage A, single nodule, size ≤ 3 cm, belonging to cohort C2 and treatment per se independently predicted survival. CONCLUSIONS: This in-field study showed a trend on improved HCC outcomes over time, which seems to be mainly due to a better presentation thanks to the wider application of surveillance and increased propensity to treat patients. These encouraging data should support further efforts to implement such approach to HCC in everyday clinical practice.

A novel needle guide system to perform percutaneous laser ablation of liver tumors using the multifiber technique.

BACKGROUND: Previous studies have shown that laser ablation with the multifiber technique is effective in the treatment of liver tumors. However, the correct positioning of multiple needles may be challenging. PURPOSE: To investigate the use of a novel needle guide system that was developed to perform percutaneous laser ablation of liver tumors with the multifiber technique under ultrasonographic guidance. MATERIAL AND METHODS: Between February 2009 and June 2011, 116 patients (104 hepatocellular carcinomas and 12 metastases) with 127 liver nodules (median diameter, 3.0 cm; range, 1.5-6.0) were treated. Nineteen nodules were in high-risk locations. A needle guide with separate channels to insert two needles in a parallel position and at a prefixed distance was used. RESULTS: Needles were positioned inside the target nodule easily and quickly, and correct spacing (1.5-1.8 cm) between light sources was immediately achieved. Complete tumor ablation was achieved in a single session in 112 (88.2%) lesions. In nodules ≤3.0 cm and >3.0 cm in size, ablation was complete in 93.6% and 79.6% of cases, respectively. Of note, complete ablation was achieved in 91.7% of nodules up to 5.0 cm. CONCLUSION: With the new guidance system, needles could be inserted in parallel fashion, which facilitated positioning the needles in geometrical configurations to maximize the ablative effect. Worthy of note, the complete ablation rate in nodules >3.0 cm using the new guide system was higher than what has been reported in the literature so far.

Emprint Microwave Thermoablation System: Bridging Thermal Ablation Efficacy between Human Patients and Porcine Models through Mathematical Correlation.

To investigate the in vivo ablation characteristics of a microwave ablation antenna in the livers of humans with tumors, a retrospective analysis of the ablation zones was conducted after applying Emprint microwave ablation systems for treatment. Percutaneous microwave ablations performed between January 2022 and September 2022 were included in this study. Subsequently, immediate post-ablation echography images were subjected to retrospective evaluation to state the long ablated diameter, short ablated diameter, and volume. The calculated ablation lengths and volume indices were then compared between in vivo and ex vivo results obtained from laboratory experiments conducted on porcine liver. The ex vivo data showed a good correlation between energy delivered and both increasing ablated dimensions (both p < 0.001) and volume (p < 0.001). The in vivo data showed a good correlation for dimensions (p = 0.037 and p = 0.019) and a worse correlation for volume (p = 0.142). When comparing ex vivo and in vivo data for higher energies, the ablated volumes grew much more rapidly in ex vivo cases compared to in vivo ones. Finally, a set of correlations to scale ex vivo results with in vivo ones is presented. This phenomenon was likely due to the absence of perfusion, which acts as a cooling system.

Development of a risk score to predict portal vein tumor thrombosis in patients with hepatocellular carcinoma.

BACKGROUND: Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma and is one of the most negative prognostic factors. The management of patients with PVTT is challenging. The aim of the study was to develop a score predictive of tumor thrombosis. METHODS: Data from a large cohort of 2243 hepatocellular carcinoma patients (all stages) recorded in the Progetto Epatocarcinoma Campania (January 2013-April 2021) database were analyzed. To construct the score, univariate generalized estimated equation models, the bootstrap approach for internal validation, and a regression coefficient-based scoring system were used. RESULTS: PVTT (any location) was found in 14.4% of cases and was related to shorter survival. Males, younger patients, and symptomatic cases were more prevalent among the PVTT group. At multivariate analysis, size ≥5 cm, massive or infiltrative hepatocellular carcinoma growth, and alpha-fetoprotein ≥400 ng/mL were significantly associated with PVTT. A risk prediction score of PVTT based on eight variables was developed. Using a continuous score, the risk was associated with an odds ratio (OR) of 1.30 (1.27-1.34; P  < 0.001). Considering a dichotomous score >8 versus a score ≤8 the OR for PVTT was 11.33 (8.55-15.00; P  < 0.001). CONCLUSION: The risk score for PVTT might be useful for clinicians to optimize hepatocellular carcinoma management by picking out patients with more aggressive cancers and higher mortality rates. Prospective validation of the score is needed before its application in daily clinical practice.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare focal liver lesions - non-infectious, non-neoplastic.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of non-infectious and non-neoplastic focal liver lesions (FLL) are discussed. Improved detection and characterization of common FLL are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper is on non-infectious and non-neoplastic FLL and their appearance on B-mode, Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Effectiveness, safety, and local progression after percutaneous laser ablation for hepatocellular carcinoma nodules up to 4 cm are not affected by tumor location.

OBJECTIVE: A high-risk location--defined as the tumor margin being less than 5 mm from large vessels or vital structures--represents a well-known limitation and contraindication for radiofrequency ablation of hepatocellular carcinoma (HCC) nodules. The aim of this study was to verify whether HCC nodule location negatively affected the outcome of percutaneous laser ablation in terms of its primary effectiveness, safety, and ability to prevent local tumor progression. MATERIALS AND METHODS: The medical records and radiologic examinations of 164 cirrhotic patients (90 men, 74 women; mean age ± SD, 68.6 ± 8.3 years) with 182 HCC nodules 4 cm or smaller (mean diameter ± SD, 2.7 ± 0.78 cm) that had been treated by laser ablation between 1996 and 2008 were retrospectively analyzed. One hundred six patients had 116 nodules in high-risk sites (high-risk group), whereas 58 patients had 66 tumors located elsewhere (standard-risk group). RESULTS: The overall median follow-up was 81 months (range, 6-144 months). The initial complete ablation rate per nodule did not significantly differ between the high-risk group and the standard-risk group (92.2% vs 95.5%, respectively; p = 0.2711). Rates of major complications (high-risk group vs standard-risk group, 1.9% [including one death] vs 0%) and minor complications (5.6% vs 1.0%) were not statistically different between the two groups. Only side effects were recorded significantly more often in high-risk patients than in standard-risk patients (31.5% vs 19.8%; p = 0.049). There was no significant difference in either cumulative incidence of local tumor progression (p = 0.499) or local tumor progression-free survival (p = 0.499, log rank test) between the high-risk group and the standard-risk group. CONCLUSION: When laser ablation is used to treat small HCC nodules, tumor location does not have a significant negative impact on the technique's primary effectiveness or safety or on its ability to achieve local control of disease.

Influence of ablative margin on local tumor progression and survival in patients with HCC ≤4 cm after laser ablation.

BACKGROUND: Ablation of the normal hepatic parenchyma surrounding the tumor (ablative margin [AM]) is necessary to prevent local tumor progression. PURPOSE: To assess the prognostic value of the ablative margin in patients with HCC ≤4 cm treated with US-guided laser ablation. MATERIAL AND METHODS: A cohort of 116 patients (53 women and 63 men, age range 42-82 years) with 132 HCC nodules ≤4 cm completely ablated by US-guided laser ablation was retrospectively analyzed. Rates of local tumor progression were compared using different ablative margin cut-offs (≥2.5, 5.0, 7.5, and 10.0 mm). Survival probability curves were obtained with the Kaplan-Meier method. RESULTS: The mean period of follow-up was 42 months (range 3-114 months). Local tumor progression was identified in 24 out of 132 lesions (18%), with an average time to progression of 24 months (range 6-36 months). A significant difference in local tumor progression was observed only if the ablative margin was ≥7.5 mm (7% vs. 23%, P = 0.020). Survival curves of patients with or without an ablative margin ≥7.5 mm were not different (P = 0.665; mean survival time 43.8 ± 3.1 and 46.8 ± 6.1 for an AM < or ≥7.5 mm, respectively). CONCLUSION: An ablative margin ≥7.5 mm turned out to be useful in preventing local tumor progression but did not affect long-term survival in patients with HCC ≤4 cm treated with laser ablation.

The Use of Ceus Software with No Contrast Media Administration in the Diagnosis of Pneumoperitoneum.

BACKGROUND: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. AIM: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. SUBJECTS AND METHODS: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists (with 5, 5, and 25 years of experience). The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. RESULTS: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity (93% vs. 70%, respectively) and specificity (98% vs. 88%, respectively). CONCLUSION: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses.

Intracavitary contrast-enhanced ultrasound in ultrasound-guided percutaneous management of abdominal fluid collections/abscesses by a single clinician: an example of point-of-care ultrasound.

PURPOSE: To assess the role of intracavitary contrast-enhanced ultrasound (IC-CEUS) as a focused ultrasound (US) examination aimed at supporting a single physician in the management of interventional procedures for abdominal fluid collections/abscesses. METHODS: In 43 patients (27 M/16 F, median age 68 years, range 35-91), a single physician performed catheter drainage (42) or needle aspiration (3) for the following: 14 infected abdominal fluid collections, 11 non-infected abdominal fluid collections, 9 pyogenic liver abscesses, 8 gallbladder empyema, and 3 infected pancreatic fluid collections. IC-CEUS (0.1-0.2 mL of SonoVue in 20 mL of saline) was carried out during catheter/needle placement and during the follow-up for catheters left in place. RESULTS: Immediate IC-CEUS allowed to verify the (1) correct positioning of the needle/catheter inside the target in all cases and (2) communication with adjacent structures so as to choose a proper treatment in 21% of the cases. Follow-up IC-CEUS aided in the management of 40 catheters left in place. Appropriate treatment was implemented in 19.3% of the cases because of the presence of biliary fistulas and gallbladder perforation. IC-CEUS helped the physician with the appropriate timing of catheter removal by providing information on catheter malfunction (due to obstruction/dislodgement) and the size of residual undrained cavities. No side effects were registered following IC-CEUS. CONCLUSION: Even if not strictly performed at bedside, IC-CEUS may represent an example of point-of-care ultrasound since it allows an interventional clinician to assess needle/catheter placement success, make treatment decisions, and choose the optimal timing for catheter removal with low costs and without side effects.

Endometriomas in the region of a scar from Cesarean section: sonographic appearance and clinical presentation vary with the size of the lesion.

PURPOSE: To describe the sonographic (US) appearances of endometriomas developed in the vicinity of a scar from Cesarean section and compare sonographic and clinical characteristics of large (> or =3 cm) scar endometriomas (LSEs) with small scar endometriomas (SSEs). METHOD: Twenty-eight consecutive women (mean age, 31 years; range, 20-42) with 31 scar endometriomas (mean diameter, 2.7 cm; range, 0.7-6 cm) were examined by US, including color Doppler imaging prior to surgery. Clinical and US findings in women with LSE were compared with those of women with SSE. RESULTS: Twelve patients had 12 LSEs with a mean longest diameter of 4.1 cm (range, 3-6 cm); in 1 case, a large nodule was associated with a small lesion. Sixteen women had 18 SSEs with a mean lesion size of 1.8 cm (range, 0.7-2.6 cm).The mean time interval between the last Cesarean section and hospital admission was longer in patients with LSE (66 versus 40 months; p < 0.01) as was the mean duration of symptoms before admission (43 versus 17 months; p < 0.01); in addition, 41.6% of patients with LSE had undergone previous inconclusive diagnostic examinations (CT, MRI, fine needle aspiration, or laparoscopy) compared with 0% in patients with SSE (p < 0.05). LSEs more frequently showed cystic portions and fistulous tracts (p < 0.05), loss of round/oval shape (p < 0.05), and increased vascularity (p < 0.05) than SSEs did. CONCLUSION: LSEs were associated with a delay in diagnosis and some US findings that could result in further diagnostic difficulties.

Status of, and strategies for improving, adherence to HCC screening and surveillance.

Hepatocellular carcinoma (HCC) represents the second leading cause of cancer deaths worldwide and the main cause of death in patients with cirrhosis. Secondary prevention of HCC can be accomplished through the serial application of screening tests (ultrasound with or without alpha-fetoprotein) to detect the presence of subclinical lesions amenable to potentially curative treatment, such as surgery and ablation. The efficacy of HCC screening is accepted by hepatologists in terms of decline in cancer-specific mortality, but its translation into clinical practice is less than ideal. The effectiveness of HCC screening is hampered by several factors: failure to identify at-risk patients, failure to access care and failure to detect HCC. For each of these steps, possible improvements are discussed in order to face the changing etiology of cirrhosis and expand the screening of at-risk populations by including selected nonalcoholic fatty liver disease patients.

A critical appraisal of the use of ultrasound in hepatic steatosis.

Introduction: Nonalcoholic fatty liver disease (NAFLD) spans steatosis through nonalcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). NAFLD carries an increased risk of cardio-metabolic and liver-related events accounting for a substantial economic burden. Given that the natural history of NAFLD is critically dependent on the stage of fibrosis, non-invasively identifying the subgroup of patients at a higher risk of progressive disease is key. Areas covered: This review highlights the recent developments in the use of ultrasound-based techniques in NAFLD and their performance in predicting metabolic derangements, cardiovascular risk, and progression of liver disease, notably including diagnosis of fibrosing NASH, identification, and treatment of HCC. Expert opinion: Our ability to identify NAFLD patients and to estimate steatofibrosis with various ultrasound-based techniques has undergone tremendous progress over the last few years. However, it is more difficult to capture the inflammatory component of NASH with such ultrasound-assisted techniques. Moreover, semi-quantitative, quantitative, elastographic, and contrast-enhanced ultrasound techniques are increasingly being appreciated and made available but not all such techniques will gain success in the clinical and research area. Therefore, further research will precisely define the role of the most innovative ultrasonographic techniques, while reducing costs and increasing feasibility.