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

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.

Liver Imaging Reporting and Data System Contrast-Enhanced US Nonradiation Treatment Response Assessment Version 2024.

The American College of Radiology Liver Imaging Reporting and Data System (LI-RADS) standardizes the imaging technique, reporting lexicon, disease categorization, and management for patients with or at risk for hepatocellular carcinoma (HCC). LI-RADS encompasses HCC surveillance with US; HCC diagnosis with CT, MRI, or contrast-enhanced US (CEUS); and treatment response assessment (TRA) with CT or MRI. LI-RADS was recently expanded to include CEUS TRA after nonradiation locoregional therapy or surgical resection. This report provides an overview of LI-RADS CEUS Nonradiation TRA v2024, including a lexicon of imaging findings, techniques, and imaging criteria for posttreatment tumor viability assessment. LI-RADS CEUS Nonradiation TRA v2024 takes into consideration differences in the CEUS appearance of viable tumor and posttreatment changes within and in close proximity to a treated lesion. Due to the high sensitivity of CEUS to vascular flow, posttreatment reactive changes commonly manifest as areas of abnormal perilesional enhancement without washout, especially in the first 3 months after treatment. To improve the accuracy of CEUS for nonradiation TRA, different diagnostic criteria are used to evaluate tumor viability within and outside of the treated lesion margin. Broader criteria for intralesional enhancement increase sensitivity for tumor viability detection. Stricter criteria for perilesional enhancement limit miscategorization of posttreatment reactive changes as viable tumor. Finally, the TRA algorithm reconciles intralesional and perilesional tumor viability assessment and assigns a single LI-RADS treatment response (LR-TR) category: LR-TR nonviable, LR-TR equivocal, or LR-TR viable.

Inter-Reader Agreement for Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System Major Features and Final Categorization: A Subanalysis From a Prospective Multicenter Study.

OBJECTIVES: Contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) is used to definitively diagnose hepatocellular carcinoma (HCC) in patients at risk. However, the user variability associated with CEUS LI-RADS has not been validated in North American and European patients. This study aims to evaluate the inter-reader agreements of CEUS LI-RADS features for, and final categorization of, HCC in patients at risk. METHODS: This retrospective multicenter clinical study used the database of a previous prospective multinational study, evaluating the accuracy of CEUS LI-RADS for HCC diagnosis in patients at risk. All cases were first evaluated by a site physician performing/supervising the CEUS examination. Randomly selected cases were re-evaluated by a blinded central reader. Final diagnosis was confirmed with the reference standard, which was a composite of imaging tests and histology. Cohen's kappa test was used to evaluate inter-reader agreement. RESULTS: This study included 150 liver nodules and 58.0% (87/150) were confirmed as HCC, 4.7% (7/150) non-HCC malignancies, 22.7% (34/150) had no confirmed final diagnosis, and 14.7% (22/150) were nonmalignant. Inter-reader agreements were substantial for CEUS LI-RADS categorization (κ = 0.61; 95% confidence interval [CI]: 0.51-0.71) and major features assessment (ranged κ = 0.64-0.78), LR-5 (κ = 0.65; 95% CI: 0.52-0.77), and LR-M (κ = 0.67; 95% CI: 0.44-0.90), while for LR-1 and LR-2 categorization was almost perfect (κ = 0.85; 95% CI: 0.65-1.00). CONCLUSION: Our study reported a substantial inter-reader agreement for overall CEUS LI-RADS categorization, especially for LR-5 and LR-M, and major imaging features of HCC, further confirming CEUS LI-RADS as a valuable and reliable tool for diagnosis of HCC.

Artifacts and Technical Considerations at Contrast-enhanced US.

Contrast-enhanced US (CEUS), similar to other radiologic modalities, requires specific technical considerations and is subject to image artifacts. These artifacts may affect examination quality, negatively impact diagnostic accuracy, and decrease user comfort when using this emerging technique. Some artifacts are related to commonly known gray-scale US artifacts that can also appear on the contrast-only image (tissue-subtracted image obtained with the linear responses from background tissues nulled). These may include acoustic shadowing and enhancement; reverberation, refraction, and reflection; and poor penetration. Other artifacts are exclusive to CEUS owing to the techniques used for contrast mode image generation and the unique properties of the microbubbles that constitute ultrasound-specific contrast agents (UCAs). UCA-related artifacts may appear on the contrast-only image, the gray-scale image, or various Doppler mode images. Artifacts related to CEUS may include nonlinear artifacts and unintentional microbubble destruction resulting in pseudowashout. The microbubbles themselves may result in specific artifacts such as pseudoenhancement, signal saturation, and attenuation and shadowing and can confound the use of color and spectral Doppler US. Identifying and understanding these artifacts and knowing how to mitigate them may improve the quality of the imaging study, increase user confidence, and improve patient care. The authors review the principles of UCAs and the sound-microbubble interaction, as well as the technical aspects of image generation. Technical considerations, including patient positioning, depth, acoustic window, and contrast agent dose, also are discussed. Specific artifacts are described, with tips on how to identify and, if necessary, apply corrective measures, with the goal of improving examination quality. © RSNA, 2022 Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair.

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

US Quantification of Liver Fat: Past, Present, and Future.

Fatty liver disease has a high and increasing prevalence worldwide, is associated with adverse cardiovascular events and higher long-term medical costs, and may lead to liver-related morbidity and mortality. There is an urgent need for accurate, reproducible, accessible, and noninvasive techniques appropriate for detecting and quantifying liver fat in the general population and for monitoring treatment response in at-risk patients. CT may play a potential role in opportunistic screening, and MRI proton-density fat fraction provides high accuracy for liver fat quantification; however, these imaging modalities may not be suited for widespread screening and surveillance, given the high global prevalence. US, a safe and widely available modality, is well positioned as a screening and surveillance tool. Although well-established qualitative signs of liver fat perform well in moderate and severe steatosis, these signs are less reliable for grading mild steatosis and are likely unreliable for detecting subtle changes over time. New and emerging quantitative biomarkers of liver fat, such as those based on standardized measurements of attenuation, backscatter, and speed of sound, hold promise. Evolving techniques such as multiparametric modeling, radiofrequency envelope analysis, and artificial intelligence-based tools are also on the horizon. The authors discuss the societal impact of fatty liver disease, summarize the current state of liver fat quantification with CT and MRI, and describe past, currently available, and potential future US-based techniques for evaluating liver fat. For each US-based technique, they describe the concept, measurement method, advantages, and limitations. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Universal Liver Imaging Lexicon: Imaging Atlas for Research and Clinical Practice.

The use of standardized terms in assessing and reporting disease processes has well-established benefits, such as clear communication between radiologists and other health care providers, improved diagnostic accuracy and reproducibility, and the enhancement and facilitation of research. Recently, the Liver Imaging Reporting and Data System (LI-RADS) Steering Committee released a universal liver imaging lexicon. The current version of the lexicon includes 81 vetted and precisely defined terms that are relevant to acquisition of images using all major liver imaging modalities and contrast agents, as well as lesion- and organ-level features. Most terms in the lexicon are applicable to all patients undergoing imaging of the liver, and only a minority of the terms are strictly intended to be used for patients with high risk factors for hepatocellular carcinoma. This pictorial atlas familiarizes readers with the liver imaging lexicon and includes discussion of general concepts, providing sample definitions, schematics, and clinical examples for a subset of the terms in the liver imaging lexicon. The authors discuss general, technical, and imaging feature terms used commonly in liver imaging, with the goal of illustrating their use for clinical and research applications. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material is available for this article.

Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Hemoperitoneum in Patients With Cirrhosis.

Hemoperitoneum in cirrhosis is a life-threatening condition that requires emergent evaluation. Contrast-enhanced ultrasound (CEUS) permits multiple dynamic characterizations of abdominal structures through all vascular phases, and contrast extravasation or the presence of microbubbles in the ascites could be a sensitive tool. We reviewed 13 patients with cirrhosis that underwent CEUS due to high suspicion for intra-abdominal bleeding. In 10 cases, CEUS demonstrated extravasation of contrast, including 2 instances where CEUS detected active bleeding despite negative computed tomography. These data support further study of CEUS in direct comparison to other imaging modalities in this clinical context.

Dynamic Changes in Ultrasound Quality for Hepatocellular Carcinoma Screening in Patients With Cirrhosis.

BACKGROUND & AIMS: Identifying patients in whom ultrasound may be inadequate to exclude the presence of hepatocellular carcinoma (HCC) can inform interventions to improve screening effectiveness. We aimed to characterize correlates of suboptimal ultrasound quality and changes in ultrasound quality over time in patients with cirrhosis undergoing HCC screening. METHODS: We performed a retrospective cohort study of patients with cirrhosis who underwent ultrasound examination at 2 large health systems between July 2016 and July 2019. Exam adequacy was graded by radiologists using the LI-RADS Visualization Score (A, B, C); we evaluated changes in visualization over time among patients with >1 ultrasound exams. We performed multivariable logistic regression to identify characteristics associated with limited ultrasound visualization (scores B or C). RESULTS: Of 2053 cirrhosis patients, 1685 (82.1%) had ultrasounds with score A, 262 (12.8%) had score B, and 106 (5.2%) had score C. Limited visualization was associated with alcohol-related or nonalcoholic fatty liver disease cirrhosis and presence of class II-III obesity. Among 1546 patients with >1 ultrasounds, 1129 (73.0%) had the same visualization score on follow-up (1046 score A, 60 score B, 23 score C). However, 255 (19.6%) of 1301 with score A at baseline had limited visualization when repeated (230 score B, 25 score C), and 130 (53.1%) of 245 patients with baseline limited visualization had good visualization when repeated. CONCLUSIONS: Nearly 1 in 5 patients with cirrhosis had moderately-severely limited ultrasound visualization for HCC nodules, particularly those with obesity or alcohol-related or nonalcoholic fatty liver disease cirrhosis. Ultrasound quality can change between exams, including improvement in many patients with limited visualization.

Pulse-Echo Quantitative US Biomarkers for Liver Steatosis: Toward Technical Standardization.

Excessive liver fat (steatosis) is now the most common cause of chronic liver disease worldwide and is an independent risk factor for cirrhosis and associated complications. Accurate and clinically useful diagnosis, risk stratification, prognostication, and therapy monitoring require accurate and reliable biomarker measurement at acceptable cost. This article describes a joint effort by the American Institute of Ultrasound in Medicine (AIUM) and the RSNA Quantitative Imaging Biomarkers Alliance (QIBA) to develop standards for clinical and technical validation of quantitative biomarkers for liver steatosis. The AIUM Liver Fat Quantification Task Force provides clinical guidance, while the RSNA QIBA Pulse-Echo Quantitative Ultrasound Biomarker Committee develops methods to measure biomarkers and reduce biomarker variability. In this article, the authors present the clinical need for quantitative imaging biomarkers of liver steatosis, review the current state of various imaging modalities, and describe the technical state of the art for three key liver steatosis pulse-echo quantitative US biomarkers: attenuation coefficient, backscatter coefficient, and speed of sound. Lastly, a perspective on current challenges and recommendations for clinical translation for each biomarker is offered.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations.

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Liver imaging: it is time to adopt standardized terminology.

Liver imaging plays a vital role in the management of patients at risk for hepatocellular carcinoma (HCC); however, progress in the field is challenged by nonuniform and inconsistent terminology in the published literature. The Steering Committee of the American College of Radiology (ACR)'s Liver Imaging Reporting And Data System (LI-RADS), in conjunction with the LI-RADS Lexicon Writing Group and the LI-RADS International Working Group, present this consensus document to establish a single universal liver imaging lexicon. The lexicon is intended for use in research, education, and clinical care of patients at risk for HCC (i.e., the LI-RADS population) and in the general population (i.e., even when LI-RADS algorithms are not applicable). We anticipate that the universal adoption of this lexicon will provide research, educational, and clinical benefits. KEY POINTS: •To standardize terminology, we encourage authors of research and educational materials on liver imaging to use the standardized LI-RADS Lexicon. •We encourage reviewers to promote the use of the standardized LI-RADS Lexicon for publications on liver imaging. •We encourage radiologists to use the standardized LI-RADS Lexicon for liver imaging in clinical care.

Multicenter Study of ACR Ultrasound LI-RADS Visualization Scores on Serial Examinations: Implications for Surveillance Strategies.

BACKGROUND. The American College of Radiology Ultrasound LI-RADS includes the visualization score as a subjective measure of examination quality and the expected level of sensitivity. Whether a single suboptimal visualization score warrants a change in surveillance strategy is unknown. OBJECTIVE. The purpose of this study is to determine the relative stability of visualization scores on serial surveillance ultrasound examinations in patients at risk for HCC. METHODS. This retrospective study included patients at risk for HCC who underwent at least two HCC surveillance ultrasound examinations at one of three institutions between January 2017 and November 2020. The frequencies of the score remaining unchanged after variable numbers of preceding examinations with the given score were determined. A mixed-effects logistic model was fitted to identify factors associated with a repeat score of C (denoting severe limitations) versus a change to score A (indicating no or minimal limitations) or score B (denoting moderate limitations). RESULTS. A total of 3169 patients underwent at least two ultrasound examinations, yielding a total of 9602 examinations. A total of 8030 examinations (83.6%) were assigned score A; 1378 (14.4%), score B; and 194 (2.0%), score C. The frequency of score A was 88%, 91%, and 93% after one, two, and three consecutive prior examinations with score A, respectively. The frequency of score B was 45%, 48%, and 55% after one, two, and three consecutive prior examinations with score B. The frequency of score C was 42%, 67%, and 80% after one, two, and three consecutive prior examinations with score C. Among 109 examinations with score C in 91 patients with an available follow-up examination, no factor (including age, sex, severe steatosis, advanced cirrhosis, ascites, body mass index, and a change in the ultrasound machine, sonographer, or radiologist) was significantly associated with repeat score C (all p > .05). Although not statistically significant, presence of severe steatosis and presence of advanced cirrhosis had the highest odds ratios (2.88 and 2.38, respectively) for repeat score C in multivariable analysis. CONCLUSION. Only 42% of patients with visualization score C on a single surveillance examinations have score C on follow-up examinations; however, after two or more score C examinations, the chance of future score C substantially increases. CLINICAL IMPACT. The findings may inform decisions regarding alternative surveillance strategies in patients with visualization score C on ultrasound. This decision should consider the number of previous examinations with score C.

Associations of Ultrasound LI-RADS Visualization Score With Examination, Sonographer, and Radiologist Factors: Retrospective Assessment in Over 10,000 Examinations.

BACKGROUND. When performing ultrasound (US) for hepatocellular carcinoma (HCC) screening, numerous factors may impair hepatic visualization, potentially lowering sensitivity. US LI-RADS includes a visualization score as a technical adequacy measure. OBJECTIVE. The purpose of this article is to identify associations between examination, sonographer, and radiologist factors and the visualization score in liver US HCC screening. METHODS. This retrospective study included 6598 patients (3979 men, 2619 women; mean age, 58 years) at risk for HCC who underwent a total of 10,589 liver US examinations performed by 91 sonographers and interpreted by 50 radiologists. Visualization scores (A, no or minimal limitations; B, moderate limitations; C, severe limitations) were extracted from clinical reports. Patient location (emergency department [ED], in-patient, outpatient), sonographer and radiologist liver US volumes during the study period (< 50, 50-500, > 500 examinations), and radiologist practice pattern (US, abdominal, community, interventional) were recorded. Associations with visualization scores were explored. RESULTS. Frequencies of visualization scores were 71.5%, 24.2%, and 4.2% for A, B, and C, respectively. Scores varied significantly (p < .001) between examinations performed in ED patients (49.8%, 40.1%, and 10.2%), inpatients (58.8%, 33.9%, and 7.3%), and outpatients (76.7%, 20.3%, and 2.9%). Scores also varied significantly (p < .001) by sonographer volume (< 50 examinations: 58.4%, 33.7%, and 7.9%; > 500 examinations: 72.9%, 22.5%, and 4.6%); reader volume (< 50 examinations: 62.9%, 29.9%, and 7.1%; > 500 examinations: 67.3%, 28.0%, and 4.7%); and reader practice pattern (US: 74.5%, 21.3%, and 4.3%; abdominal: 67.0%, 28.1%, and 4.8%; community: 75.2%, 21.9%, and 2.9%; interventional: 68.5%, 24.1%, and 7.4%). In multivariable analysis, independent predictors of score C were patient location (ED/inpatient: odds ratio [OR], 2.62; p < .001) and sonographer volume (< 50: OR, 1.55; p = .01). Among sonographers performing 50 or more examinations, the percentage of outpatient examinations with score C ranged from 0.8% to 5.4%; 9/33 were above the upper 95% CI of 3.2%. CONCLUSION. The US LI-RADS visualization score may identify factors affecting quality of HCC screening examinations and identify outlier sonographers in terms of poor examination quality. The approach also highlights potential systematic biases among radiologists in their quality assessment process. CLINICAL IMPACT. These findings may be applied to guide targeted quality improvement efforts and establish best practices and performance standards for screening programs.

Nontraditional Uses of US Contrast Agents in Abdominal Imaging and Intervention.

With the increasing availability of contrast-enhanced US (CEUS) worldwide and in the United States, the potential applications of this modality in abdominal imaging and intervention are continuing to expand. CEUS leverages the many inherent benefits of US with a safe and unique microbubble contrast agent. When injected intravenously, US contrast agents (UCAs) function as a pure blood pool agent, augmenting diagnostic US examinations such as vascular imaging. In the procedure suite, UCA can be used to improve needle visualization and depict active extravasation. UCA may also be injected through needles and tubes into various body spaces, allowing the assessment of the urinary system, indwelling catheters, and other tracts and cavities. Some venous and lymphatic lesions may be diagnosed with the direct injection of a UCA into these lesions. The authors highlight some of the many applications that are relevant to the abdominal imaging professional and interventional radiologist but should not be considered a complete list, and users of UCAs should continue to consider uses beyond those traditionally highlighted in recent literature. Online supplemental material is available for this article. ©RSNA, 2022.

Use of Web-Based Calculator for the Implementation of ACR TI-RADS Risk-Stratification System.

In this article, we demonstrate the use of a software-based radiologist reporting tool for the implementation of American College of Radiology Thyroid Imaging, Reporting and Data System thyroid nodule risk-stratification. The technical details are described with emphasis on addressing the information security and patient privacy issues while allowing it to integrate with the electronic health record and radiology reporting dictation software. Its practical implementation is assessed in a quality improvement project in which guideline adherence and recommendation congruence were measured pre and post implementation. The descriptions of our solution and the release of the open-sourced codes may be helpful in future implementation of similar web-based calculators.

Clinical Importance of Incidental Homogeneous Renal Masses That Measure 10-40 mm and 21-39 HU at Portal Venous Phase CT: A 12-Institution Retrospective Cohort Study.

BACKGROUND. Incidental homogeneous renal masses are frequently encountered at portal venous phase CT. The American College of Radiology Incidental Findings Committee's white paper on renal masses recommends additional imaging for incidental homogeneous renal masses greater than 20 HU, but single-center data and the Bosniak classification version 2019 suggest the optimal attenuation threshold for detecting solid masses should be higher. OBJECTIVE. The purpose of this article is to determine the clinical importance of small (10-40 mm) incidentally detected homogeneous renal masses measuring 21-39 HU at portal venous phase CT. METHODS. We performed a 12-institution retrospective cohort study of adult patients who underwent portal venous phase CT for a nonrenal indication. The date of the first CT at each institution ranged from January 1, 2008, to January 1, 2014. Consecutive reports from 12,167 portal venous phase CT examinations were evaluated. Images were reviewed for 4529 CT examinations whose report described a focal renal mass. Eligible masses were 10-40 mm, well-defined, subjectively homogeneous, and 21-39 HU. Of these, masses that were shown to be solid without macroscopic fat; classified as Bosniak IIF, III, or IV; or confirmed to be malignant were considered clinically important. The reference standard was renal mass protocol CT or MRI, ultrasound of definitively benign cysts or solid masses, single-phase contrast-enhanced CT or unenhanced MRI showing no growth or morphologic change for 5 years or more, or clinical follow-up 5 years or greater. A reference standard was available for 346 masses in 300 patients. The 95% CIs were calculated using the binomial exact method. RESULTS. Eligible masses were identified in 4.2% of patients (514/12,167; 95% CI, 3.9-4.6%). Of 346 masses with a reference standard, none were clinically important (0%; 95% CI, 0-0.9%). Mean mass size was 17 mm; 72% (248/346) measured 21-30 HU, and 28% (98/346) measured 31-39 HU. CONCLUSION. Incidental small homogeneous renal masses measuring 21-39 HU at portal venous phase CT are common and highly likely benign. CLINICAL IMPACT. The change in attenuation threshold signifying the need for additional imaging from greater than 20 HU to greater than 30 HU proposed by the Bosniak classification version 2019 is supported.

Imaging Features at the Periphery: Hemodynamics, Pathophysiology, and Effect on LI-RADS Categorization.

Liver lesions have different enhancement patterns at dynamic contrast-enhanced imaging. The Liver Imaging Reporting and Data System (LI-RADS) applies the enhancement kinetic of liver observations in its algorithms for imaging-based diagnosis of hepatocellular carcinoma (HCC) in at-risk populations. Therefore, careful analysis of the spatial and temporal features of these enhancement patterns is necessary to increase the accuracy of liver mass characterization. The authors focus on enhancement patterns that are found at or around the margins of liver observations-many of which are recognized and defined by LI-RADS, such as targetoid appearance, rim arterial phase hyperenhancement, peripheral washout, peripheral discontinuous nodular enhancement, enhancing capsule appearance, nonenhancing capsule appearance, corona enhancement, and periobservational arterioportal shunts-as well as peripheral and periobservational enhancement in the setting of posttreatment changes. Many of these are considered major or ancillary features of HCC, ancillary features of malignancy in general, features of non-HCC malignancy, features associated with benign entities, or features related to treatment response. Distinction between these different patterns of enhancement can help with achieving a more specific diagnosis of HCC and better assessment of response to local-regional therapy. ©RSNA, 2021.

Impact of Implementing Contrast-Enhanced Ultrasound for Antegrade Nephrostogram After Percutaneous Nephrolithotomy.

OBJECTIVES: To report results from a quality improvement (QI) project evaluating diagnostic performance, hospital resource use, and patient response data for postoperative contrast-enhanced ultrasound (CEUS) antegrade nephrostogram after percutaneous nephrolithotomy. METHODS: For this Health Insurance Portability and Accountability Act-compliant, Institutional Review Board-approved study, QI data were deidentified and analyzed. On the first postoperative day after percutaneous nephrolithotomy, patients underwent both CEUS and fluoroscopic antegrade nephrostogram. For CEUS, 1.0 mL of Lumason (sulfur hexafluoride lipid type A microspheres; Bracco Diagnostics, Inc, Monroe Township, NJ) was injected via an indwelling nephrostomy tube, with ureteral patency confirmed by identifying intravesical ultrasound (US) contrast. Diagnostic performance for ureteral patency and contrast extravasation was calculated (with fluoroscopy as the reference standard). The examination time, room time, physician time, hospital costs, and patient response data were compared. The mean, standard deviation, 95% confidence interval, differences in mean, and 95% confidence interval of differences were calculated. RESULTS: Eighty-one examinations were performed in 73 patients during the QI period. The sensitivity and specificity of CEUS for ureteral patency were 96% and 57%, respectively. There was no significant difference in time metrics between modalities, and the cost analysis showed lower direct and indirect costs for CEUS. Patient responses revealed lower levels of comfort for CEUS relative to fluoroscopy, without significant differences in reported pain or effort levels. CONCLUSIONS: Contrast-enhanced US showed very high sensitivity for ureteral patency; the relatively low specificity may have resulted from false-negative results in fluoroscopy. The hospital costs and resource use of CEUS compared favorably to fluoroscopy. Contrast-enhanced US also offers inherent advantages, including portability and lack of ionizing radiation.

Abbreviated-protocol screening MRI vs. complete-protocol diagnostic MRI for detection of hepatocellular carcinoma in patients with cirrhosis: An equivalence study using LI-RADS v2018.

BACKGROUND: The high operational cost of MRI limits its utility for hepatocellular carcinoma (HCC) screening. Abbreviated-protocol dynamic contrast-enhanced MRI (aMRI) may help lower cost while maintaining the high accuracy of complete-protocol diagnostic MRI (cMRI). PURPOSE: To compare aMRI to cMRI for HCC detection in cirrhosis patients. STUDY TYPE: Cross-sectional study. STUDY POPULATION: Cirrhosis patients undergoing MRI for suspected HCC. FIELD STRENGTH/SEQUENCE: 1.5T and 3T; aMRI (coronal T2 -weighted, axial dynamic contrast-enhanced T1 -weighted fat-suppressed sequences); cMRI (aMRI sequences and unenhanced axial T2 -, T1 -, and diffusion-weighted sequences). ASSESSMENT: From each cMRI, an abbreviated exam was created by extracting only the aMRI sequences. Five radiologists independently reviewed aMRI and cMRI and assigned per-patient screening results by the presence/absence of any actionable observation per Liver Imaging and Reporting Data System v2018 (LI-RADS 4, 5, M, or TIV categories). Per-patient HCC status was determined by the composite reference standard of histopathology, follow-up imaging, consensus expert panel imaging review, and clinical follow-up. STATISTICAL TESTS: Interreader agreement between aMRI and cMRI was compared with that of cMRI and tested for interchangeability against a tolerance margin of 0.05. Per-patient screening sensitivity, specificity, and accuracy were compared between aMRI and cMRI and tested for equivalence against a tolerance margin of 0.05. RESULTS: In 93 cirrhosis patients, five radiologists recorded on average 121 liver observations. Interreader screening agreement probability (and 95% confidence interval confidence interval [CI]) was 0.914 [0.900, 0.926] between aMRI and cMRI, and 0.927 [0.908, 0.942] for cMRI; their difference was within the 0.05 margin for interchangeability. In 86 patients in whom a final HCC status could be determined, the detection sensitivity and specificity of aMRI was 0.921 [0.864, 0.956] and 0.886 [0.844, 0.918], within the 5% equivalence margin to cMRI, 0.936 [0.881, 0.965] and 0.883 [0.840, 0.915], respectively. DATA CONCLUSION: Abbreviated-protocol screening MRI is interchangeable with, and equivalent to, complete-protocol diagnostic MRI for per-patient HCC detection in cirrhosis. LEVEL OF EVIDENCE: 4 Technical Efficacy: Stage 6 J. Magn. Reson. Imaging 2020;51:415-425.