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CEUS LI-RADS: a pictorial review
Insights into Imaging volume 11, Article number: 9 (2020)
Contrast-enhanced ultrasound (CEUS) greatly improved the diagnostic accuracy of US in the detection and characterization of focal liver lesions (FLLs), and it is suggested and often included in many international guidelines as an important diagnostic tool in the imaging work-up of cirrhotic patients at risk for developing hepatocellular carcinoma (HCC). In particular, CEUS Liver Imaging Reporting and Data System (LI-RADS) provides standardized terminology, interpretation, and reporting for the diagnosis of HCC. The aim of this pictorial essay is to illustrate CEUS features of nodules discovered at US in cirrhotic liver according to LI-RADS categorization.
CEUS is a safe, robust, and cost-effective imaging modality
CEUS allows in real time a confident characterization of hepatocellular carcinoma (HCC)
CEUS LI-RADS provides standardized terminology, interpretation, and reporting for the diagnosis of HCC
Worldwide HCC is reported to be the sixth most common tumor and the fourth cause of death related to cancer .
Cirrhotic patients are particularly considered a high-risk group for the onset of HCC, prompting several international scientific societies to publish guidelines recommending surveillance of adults with cirrhosis on the evidence of improved overall survival [2,3,4]. The recommended imaging surveillance tool for early detection of HCC is ultrasound (US), usually performed every 6 months [2, 3]. Once a new nodule suspect for HCC is discovered in the liver of a cirrhotic patient, further imaging work-up with either computed tomography (CT) or magnetic resonance imaging (MRI) is usually recommended [2, 3]. Both techniques require the intravenous administration of contrast media and difficulties may arise in patients with severe renal failure or allergies [5, 6].
Contrast-enhanced US (CEUS) allows to assess non-invasively the contrast enhancement patterns of HCC, without the use of ionizing radiation and with a much higher temporal resolution than CT and MRI [7,8,9,10]. This unique feature of CEUS virtually eliminates the possibility of image acquisition mistiming, especially in the arterial phase . Several studies have reported the improvement in diagnostic accuracy of CEUS in the detection and characterization of FLLs, including HCC [8,9,10,11]. CEUS has been also proved useful in the guidance and response assessment of therapeutic procedures [12,13,14,15,16,17,18].
CEUS examination is performed by injecting intravenously microbubble-based contrast agents (USCAs) consisting of flexible shells (e.g., phospholipids, liposomes) presenting a radius ranging from 1 to 10 μm, containing low solubility gases (e.g., perfluoropropane, perfluorocarbon, or sulphur hexafluoride) [19, 20]. USCAs microbubbles pass through the lung capillary bed and they remain confined within the intravascular space. Although some USCAs may present a post-vascular phase in the liver and spleen, this phase is currently not taken in account for the characterization of HCC . Approximately 20 min after the injection, the USCAs are completely eliminated: the gas diffuses into the blood and then exhaled via the pulmonary route, while the shell components are metabolized by the liver or filtered by the kidney .
USCAs are generally safe and well tolerated with a safety profile better than or similar to CT and MRI contrast media . They are not nephrotoxic and may be used even in patients with severe renal failure, renal obstruction, or chronic obstructive pulmonary disease. Hence, there is no need of laboratory tests for assessing renal function before administering USCAs.
Currently, in many clinical settings, CEUS is recommended as pivotal imaging tool in the diagnostic work-up of liver FLLs, including HCC, also considering its favorable cost-benefit ratio when compared with cross-sectional imaging techniques [24,25,26,27]. In a recent meta-analysis, CEUS showed excellent diagnostic accuracy in differentiating malignant from benign FLLs with pooled sensitivity of 0.92, pooled specificity of 0.87, and diagnostic odds ratio of 104.20 respectively .
The CEUS cases presented in this paper were acquired by means of various ultrasound equipments: RS80A and RS85, (Samsung Medison, Co. Ltd.), iU22 (Philips Ultrasound, Bothell, Wash, USA), and MyLab Twice (Esaote, Genova, Italy). All of these units were provided with multifrequency convex array probes and contrast-specific imaging software.
CEUS LI-RADS system
Firstly released in 2016 by the ACR and then revised in 2017, contrast enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) is a standardized system for technique, interpretation, reporting, and data collection for CEUS exams in patients at risk for developing HCC .
CEUS LI-RADS lexicon integrates with the previously released CT/MRI LI-RADS lexicons, and it is intended to allow the radiologists to (1) use consistent terminology, (2) reduce variability and mistakes in imaging interpretation, (3) promote communication with referring clinicians, and (4) facilitate research and quality assurance .
Noteworthy, although FLL characterization features using CEUS are similar to those of multiphasic CT and/or MRI, there are still important differences between these techniques, regarding both features and characterization algorithm . CEUS LI-RADS is intended for the use with purely intravascular microbubble contrast agents—such as Lumason® (in USA)/SonoVue® (outside USA) and Definity® (in USA, Canada)/Luminity® (outside USA, Canada)—which affects washout and “capsule” characterization [11, 31, 32]. Actually, CEUS washout is true washout. On the other hands, CEUS does not depict “capsule”; hence, “capsule” is not a CEUS major feature. CEUS usually does not depict vascular pseudo-lesions such as arterioportal shunts, a frequent cause of diagnostic confusion on CT and MRI: as consequence, any CEUS enhancing observation is a true lesion .
Of note, the use of a combined blood pool and Kupffer cell agent (Sonazoid®) is not contemplated in FLL characterization using CEUS LI-RADS .
When is CEUS LI-RADS categorization system indicated?
CEUS LI-RADS must be applied only in patients at high risk for developing HCC (cirrhosis, chronic hepatitis B, current or prior HCC, adult liver transplant candidates, and recipients after transplant). CEUS LI-RADS must not be applied to patients without the abovementioned risk factors or < 18 years old. Table 1 lists the man indications of CEUS LI-RADS in patients at high risk for HCC .
CEUS LI-RADS reporting and categories
According to CEUS LI-RADS criteria, the two major features of HCC are (1) arterial phase enhancement (not rim or globular peripheral) and (2) washout. Not surprisingly, CEUS sensitivity in the observation of arterial hypervascularity from nodules in liver cirrhosis has been showed to be significantly higher than that of CT/MRI [34,35,36].
Washout is defined as a reduction in enhancement in whole or in part in comparison with the liver resulting in hypoenhancement. This latter may begin during or after arterial phase. Furthermore, CEUS characterization of washout requires assessment of its onset (late vs. early) and degree (mild vs. marked), not just its presence. Actually, early (< 60 s) and/or marked washout is a major feature for LR-M . On the other hand, late (≥ 60 s) and mild washout is a major feature for HCC .
The degree of washout is defined “mild” when the nodule enhances less than liver, but not some enhancement persists. If this persistent enhancement disappears after 2 min, the degree of washout is still considered mild, even if the nodule eventually becomes “punched-out.” On the other hand, the degree of washout is defined “marked” when the nodule lacks of any contrast enhancement within 2 min after contrast injection: the observation appears black or “punched out.”
The ancillary imaging features can be taken into account for category adjustment when category classification is not definite and, as stated by ACR, they can be used to upgrade or downgrade unclear FLLs categories. Presence of ancillary features favoring malignancy (size growth, mosaic, and nodule in nodule architecture) can only upgrade by one category (except LR-4 to LR-5) unclear lesions. On the other hand, presence of ancillary features favoring benignity (size stability or size reduction) can only downgrade by one category unclear lesions. When conflicting, it is recommended not to use them to adjust category.
The presence of patent veins or the presence of thrombosis must be assessed as well . Currently, there are eight CEUS LI-RADS diagnostic categories with related imaging work-up suggestions (Fig. 1). In particular, categories from 1 to 5 include nodules with increasing probability of malignancy. Of note, a one-to-one correspondence between such categories and histologic progression or grade of cirrhosis-associated nodules does not exist . As consequence, no cirrhotic nodule is included in LR-1 and many HCCs might be categorized LR-4 or lower. The LR categorization impact on the imaging workup options as well, as described in Table 2.
How to apply CEUS LI-R-RADS system?
If after the injection of microbubble contrast agent, any observation results not assessable due to image degradation or omission, CEUS LR-NC (not categorizable) must be used. In this case, information about the cause technical limitations or artifacts should be reported and further work-up advice should be also provided, such as repeat CEUS or perform alternative imaging modality (i.e., CT and/or MRI) within 3 months (Table 2).
CEUS LR-1 and 2 categories include definitely and probably benign observations, respectively: in particular, LR-1 includes three main observation types: (1) cyst, (2) hemangioma, (3) fat deposition/sparing. A liver cyst is defined, as elsewhere in the body, as an anechoic lesion with increased posterior acoustic through transmission showing no contrast enhancement in any phase. Although simple cysts are easily detected and characterized even without the use of any contrast agent, CEUS may be of particular value in the characterization of more complex appearing lesions on B-mode US, showing their complete avascularity (Fig. 2) [8, 15]. Hemangioma is often recognized as a hyperechoic lesion, but it may present variable echogenicity on B-mode US . CEUS easily depicts a typical peripheral globular enhancement in arterial phase followed by progressive centripetal fill-in and iso- or hyperenhancement in portal venous and late phase (Fig. 3) [41, 42]. The filling may be complete or partial depending on lesion size and/or the presence of mixoid or fibrotic degeneration . Hepatic fat deposition/sparing is defined as nonmasslike, nonspherical, hyper/hypoechoic area of parenchyma in a characteristic location for fat deposition/sparing. Characteristic areas include liver parenchyma nearby the gallbladder and anterior to the right portal vein in segment 4. Hepatic fat deposition/sparing shows isoenhancement to the liver in all phases [44,45,46]. If the hyper/hypoechoic area is not in a characteristic location for fat deposition/sparing, categorize as CEUS LR-2 (see below) (Fig. 4). In case of detection of isoenhancing nodule at CEUS, observation should undergo CEUS LR-2 classification if solid nodule < 10 mm (Fig. 5), whereas if isoenhancing nodule is ≥ 10 mm, it should be categorized as CEUS LR-3 (see below). On the other hand, LR-3 nodules with interval size stability for more than 2 years can return to LR-2. These small nodules are probably typical regenerative or low-grade dysplastic nodules . Any isoenhancing observation of any size, nonmasslike and without typical appearance of hepatic fat deposition or fat sparing, should be also categorized as LR-2 (Fig. 6).
Noteworthy, the CEUS enhancement features for HCC, hepatocellular adenoma (HCA,) and focal nodular hyperplasia (FNH) may overlap [47,48,49,50,51,52,53,54]. Hence, on a precautionary basis, in the clinical setting of patients at risk for HCC, nodules with CEUS feature of FNH and HCA should not be categorized as CEUS LI-RADS 1 or CEUS LI-RADS 2.
Any nodule not showing any APHE nor washout must be categorized as CEUS LR-3 regardless of size (Fig. 7). A nodule smaller than 2 cm, without any APHE but showing late and mild washout, should be also assigned to CEUS LR-3 category. On the other hand, any nodule larger than 2 cm, without any APHE but showing late and mild washout, must be assigned to CEUS LR-4 category.
Nodules showing APHE (not rim or peripheral globular) without washout of any type should be categorized, depending on size, as CEUS LR-3 (when the nodule is smaller than 10 mm) or CEUS LR-4 (≥ 10 mm) respectively (Fig. 8). At the same time, nodules showing APHE (not rim or peripheral globular) but presenting with late and mild washout should be categorized, depending on size, as CEUS LR-4 (when the nodule is smaller than 10 mm) or CEUS LR-5 (≥ 10 mm) respectively (Fig. 9).
Rim APHE: “ring-like” APHE in which enhancement is most evident at the periphery of the nodule (Fig. 10);
Early (< 60 s) washout: temporally defined subtype of washout in which onset is within 60 s from contrast injection. Usually marked in degree (Fig. 11);
At CEUS, the vast majority of malignant nodules typically show washout, including liver metastases, intrahepatic cholangiocarcinoma (ICC), and other tumors with fibrotic component which may show delayed central enhancement on CT or MRI [61,62,63,64,65]. Hence, to maintain specificity for HCC, CEUS characterization of washout requires assessment of its “onset” and “degree,” not just its presence. As consequence, observations with late and mild washout may be categorized as CEUS LR-3, LR-4, or LR-5. Nodules with early or marked washout should be categorized LR-M. ICC may be typically included in this category in a cirrhotic liver.
Finally CEUS LR-TIV (definite tumor in vein) includes observation of enhancing tissue within a vein, independently from the detection of a coexisting liver tumor. Tumoral invasion of veins must be differentiated from bland thrombus . To this purpose, the arrival time of microbubble contrast agent to the vein helps to distinguish tumor in vein from bland thrombus :
Early arrival time (~ same time as contrast enhancement of hepatic artery): favors tumor in vein (Fig. 12).
Arrival time of several seconds (~ 10) after contrast enhancement of hepatic artery: favors portal flow in patent portion of non-occlusive/recanalized bland thrombus.
Bland thrombus shows lack of vascularization (Fig. 13). The proximity with any liver mass may help in etiology definition. In particular, if TIV is contiguous or associated with any LI-RADS 4 or 5 lesions, tumor in vein is probably or definitely attributable to HCC, whereas if TIV is near LR-M, it is probably due to non-HCC malignancy. If no masses are detected, etiology is undetermined.
HCC and CEUS LI-RADS: final considerations
CEUS is currently recommended as an adjunct tool in the imaging work-up of HCC, either in the LI-RADS lexicon or in other international guidelines, with encouraging results also in terms of cost-benefit analysis [24, 68, 69]. Of note, there is still lack of consensus among different Scientific Societies regarding the precise role of CEUS in the diagnostic algorithm for the characterization of HCC. On one hand, various scientific societies, including ACR and Japanese, Italian, German, and British, suggest the use of CEUS in the diagnostic algorithm of HCC in their guidelines (www.webaisf.org, www.drg.de, and www.nice.org.uk, respectively). In the latest version of European Association for Study of Liver (EASL) guidelines on the management of HCC, CEUS is also considered a diagnostic tool for HCC as well as CT and MRI . On the other hand, other Korean and American Societies, such as the Korean Liver Cancer Study Group, the American Association for the Study of Liver Diseases, and the Organ Procurement and Transplantation Network, suggest the use of CT and MR only [68, 69]. Further refinement may allow a desirable and better uniformity in international guidelines.
Availability of data and materials
American College of Radiology
Arterial phase hyperenhancement
Focal liver lesions
Focal nodular hyperplasia
Hepatitis B virus
Hepatitis C virus
Liver Imaging Reporting and Data System
Magnetic resonance imaging
Nonalcoholic fatty liver disease
Portal venous phase
US contrast agents
World Health organization, International Agency for Research on Cancer, Global Cancer Observatory Cancer Today – IARC, Lyon, France, 2018 available via http://gco.iarc.fr/today/data/factsheets/cancers/11-Liver-fact-sheet.pdf. Last accessed 8 Jan 2019
European Association for the Study of the Liver (2018) EASL clinical practice guidelines: management of hepatocellular carcinoma. European Association for the Study of the Liver. J Hepatol 69(1):182–236
Heimbach JK, Kulik LM, Finn RS et al (2018) AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 67:358–380
Omata M, Cheng AL, Kokudo N et al (2017) Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int 11:317–370
Thomsen HS (2009) Nephrogenic systemic fibrosis: history and epidemiology. Radiol Clin North Am 47:827–831
Tao SM, Wichmann JL, Schoepf UJ, Fuller SR, Lu GM, Zhang LJ (2016) Contrast-induced nephropathy in CT: incidence, risk factors and strategies for prevention. Eur Radiol 26:3310–3318
Bartolotta TV, Taibbi A, Midiri M, La Grutta L, De Maria M, Lagalla R (2010) Characterisation of focal liver lesions undetermined at grey-scale US: contrast-enhanced US versus 64-row MDCT and MRI with liver-specific contrast agent. Radiol Med 115(5):714–731
Bartolotta TV, Taibbi A, Midiri M, Lagalla R (2009) Focal liver lesions: contrast-enhanced ultrasound. Abdom Imaging 34(2):193–209
Bartolotta TV, Vernuccio F, Taibbi A, Lagalla R (2016) Contrast-enhanced ultrasound in focal liver lesions: where do we stand? Semin Ultrasound CT MR 37(6):573–586
Wilson SR, Burns PN (2010) Microbubble-enhanced US in body imaging: what role? Radiology 257(1):24–39
Wilson SR, Kim TK, Jang HJ, Burns PN (2007) Enhancement patterns of focal liver masses: discordance between contrast-enhanced sonography and contrast-enhanced CT and MRI. AJR Am J Roentgenol 189(1):W7–W12
Mauri G, Porazzi E, Cova L et al (2014) Intraprocedural contrast-enhanced ultrasound (CEUS) in liver percutaneous radiofrequency ablation: clinical impact and health technology assessment. Insights Imaging 5(2):209–216
Seinstra BA, van Delden OM, van Erpecum KJ, van Hillegersberg R, Willem PT, van den Bosch MA (2010) Minimally invasive image-guided therapy for inoperable hepatocellular carcinoma: what is the evidence today? Insights Imaging 1(3):167–181
Hussein RS, Tantawy W, Abbas YA (2019) MRI assessment of hepatocellular carcinoma after locoregional therapy. Insights Imaging 10(1):8. https://doi.org/10.1186/s13244-019-0690-1
Bartolotta TV, Midiri M, Quaia E et al (2005) Benign focal liver lesions: spectrum of findings on SonoVue-enhanced pulse-inversion ultrasonography. Eur Radiol 15(8):1643–1649
Bartolotta TV, Taibbi A, Midiri M, De Maria M (2008) Hepatocellular cancer response to radiofrequency tumor ablation: contrast-enhanced ultrasound. Abdom Imaging 33:501–551
Bartolotta TV, Taibbi A, Matranga D, Midiri M, Lagalla R (2015) 3D versus 2D contrast-enhanced sonography in the evaluation of therapeutic response of hepatocellular carcinoma after locoregional therapies: preliminary findings. Radiol Med 120(8):695–704
Bartolotta TV, Taibbi A, Matranga D et al (2012) Incidence of new foci of hepatocellular carcinoma after radiofrequency ablation: role of multidetector CT. Radiol Med 117(5):739–748
Dietrich CF, Averkiou M, Nielsen MB et al (2018) How to perform contrast-enhanced ultrasound (CEUS). Ultrasound Int Open 4(01):E2–15
Jo PC, Jang HJ, Burns PN, Burak KW, Kim TK, Wilson SR (2017) Integration of contrast-enhanced US into a multimodality approach to imaging of nodules in a cirrhotic liver: how I do it. Radiology 282(2):317–331
Wu M, Li L, Wang J et al (2018) Contrast-enhanced US for characterization of focal liver lesions: a comprehensive meta-analysis. Eur Radiol 28(5):2077–2088
Quaia E (2007) Microbubble ultrasound contrast agents: an update. Eur Radiol 17:1995–2008
Piscaglia F, Bolondi L (2006) The safety of Sonovue in abdominal applications: retrospective analysis of 23188 investigations. Ultrasound Med Biol 32:1369–1375
Westwood M, Joore M, Grutters J et al (2013) Contrast-enhanced ultrasound using SonoVue® (sulphur hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging for the characterisation of focal liver lesions and detection of liver metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 17(16):1–243. https://doi.org/10.3310/hta17160
Lorusso A, Quaia E, Poillucci G, Stacul F, Grisi G, Cova MA (2015) Activity-based cost analysis of contrast-enhanced ultrasonography (CEUS) related to the diagnostic impact in focal liver lesion characterisation. Insights Imaging 6(4):499–508
Bartolotta TV, Taibbi A, Midiri M, Matranga D, Solbiati L, Lagalla R (2011) Indeterminate focal liver lesions incidentally discovered at gray-scale US: role of contrast-enhanced sonography. Invest Radiol 46(2):106–115
Claudon M, Dietrich CF, Choi BI et al (2013) World Federation for Ultrasound in Medicine; European Federation of Societies for Ultrasound. Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver - update 2012: WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol 39(2):187–210
ACR American College of Radiology (2019) ACR appropriateness criteria. Reston VA, USA available from https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria Accessed 18 Mar 2019
Elsayes KM, Hooker JC, Agrons MM et al (2017) 2017 version of LI-RADS for CT and MR imaging: an update. Radiographics 37:1994–2017
Wilson SR, Lyshchik A, Piscaglia F et al (2018) CEUS LI-RADS: algorithm, implementation, and key differences from CT/MRI. Abdom Radiol (NY) 43(1):127–142
Kambadakone AR, Fung A, Gupta RT et al (2018) LI-RADS technical requirements for CT, MRI, and contrast-enhanced ultrasound. Abdominal Radiol 43(1):56–74
Piscaglia F, Wilson SR, Lyshchik A et al (2017) American College of Radiology Contrast Enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) for the diagnosis of hepatocellular carcinoma: a pictorial essay. Ultraschall Med 38(03):320–324
Lyshchik A, Kono Y, Dietrich CF et al (2018) Contrast-enhanced ultrasound of the liver: technical and lexicon recommendations from the ACR CEUS LI-RADS working group. Abdom Radiol (NY) 43(4):861–879
Maruyama H, Takahashi M, Ishibashi H, Yoshikawa M, Yokosuka O (2012) Contrast enhanced ultrasound for characterisation of hepatic lesions appearing non hypervascular on CT in chronic liver diseases. Br J Radiol 85:351–357
Takahashi M, Maruyama H, Shimada T et al (2013) Characterization of hepatic lesions (≤ 30 mm) with liver-specific contrast agents: a comparison between ultrasound and magnetic resonance imaging. Eur J Radiol 82(1):75–84
Sugimoto K, Moriyasu F, Shiraishi J et al (2012) Assessment of arterial hypervascularity of hepatocellular carcinoma: comparison of contrast-enhanced US and gadoxetate disodium-enhanced MR imaging. Eur Radiol 22(6):1205–1213
Bhayana D, Kim TK, Jang HJ, Burns PN, Wilson SR (2010) Hypervascular liver masses on contrast-enhanced ultrasound: the importance of washout. AJR Am J Roentgenol 194:977–983
Jang HJ, Kim TK, Burns PN, Wilson SR (2007) Enhancement patterns of hepatocellular carcinoma at contrast-enhanced US: comparison with histologic differentiation. Radiology 244(3):898–906
Tang A, Valasek MA, Sirlin CB (2015) Update on the liver imaging reporting and data system: what the pathologist needs to know. Adv Anat Pathol 22(5):314–322
Quaia E, Bartolotta TV, Midiri M, Cernic S, Belgrano M, Cova M (2006) Analysis of different contrast enhancement patterns after microbubble-based contrast agent injection in liver hemangiomas with atypical appearance on baseline scan. Abdom Imaging 31(1):59–64
Bartolotta TV, Midiri M, Quaia E et al (2005) Liver haemangiomas undetermined at grey-scale ultrasound: contrast-enhancement patterns with SonoVue and pulse-inversion US. Eur Radiol 15(4):685–693
Bartolotta T, Midiri M, Galia M A et al (2003) Atypical liver hemangiomas: contrast-enhancement patterns with SH U 508A and pulse-inversion US. Radiol Med 106(4):320–328
Bartolotta TV, Taibbi A, Galia M et al (2007) Centrifugal (inside-out) enhancement of liver hemangiomas: a possible atypical appearance on contrast-enhanced US. Eur J Radiol 64(3):447–455
Bartolotta TV, Midiri M, Galia M et al (2007) Characterization of benign hepatic tumors arising in fatty liver with SonoVue and pulse inversion US. Abdom Imaging 32(1):84–91
Bartolotta TV, Taibbi A, Galia M et al (2007) Characterization of hypoechoic focal hepatic lesions in patients with fatty liver: diagnostic performance and confidence of contrast-enhanced ultrasound. Eur Radiol 17(3):650–661
Bartolotta TV, Taibbi A, Picone D, Anastasi A, Midiri M, Lagalla R (2017) Detection of liver metastases in cancer patients with geographic fatty infiltration of the liver: the added value of contrast-enhanced sonography. Ultrasonography 36(2):160–169
Kim TK, Lee KH, Khalili K, Jang HJ (2011) Hepatocellular nodules in liver cirrhosis: contrast-enhanced ultrasound. Abdom Imaging 36(3):244–263
Khanna M, Ramanathan S, Fasih N, Schieda N, Virmani V, McInnes MD (2015) Current updates on the molecular genetics and magnetic resonance imaging of focal nodular hyperplasia and hepatocellular adenoma. Insights Imaging 6(3):347–362
Taibbi A, Brancatelli G, Matranga D, Midiri M, Lagalla R, Bartolotta TV (2019) Focal nodular hyperplasia: a weight-based, intraindividual comparison of gadobenate dimeglumine and gadoxetate disodium-enhanced MRI. Diagn Interv Radiol 25(2):95–101
Giambelluca D, Taibbi A, Midiri M, Bartolotta TV (2019) The “spoke wheel” sign in hepatic focal nodular hyperplasia. Abdom Radiol (NY) 44(3):1183–1184
Sandonato L, Cipolla C, Graceffa G et al (2007) Giant hepatocellular adenoma as cause of severe abdominal pain: a case report. J Med Case Rep 27(1):57
Bartolotta TV, Midiri M, Scialpi M, Sciarrino E, Galia M, Lagalla R (2004) Focal nodular hyperplasia in normal and fatty liver: a qualitative and quantitative evaluation with contrast-enhanced ultrasound. Eur Radiol 14(4):583–591
Bartolotta TV, Taibbi A, Matranga D, Malizia G, Lagalla R, Midiri M (2010) Hepatic focal nodular hyperplasia: contrast-enhanced ultrasound findings with emphasis on lesion size, depth and liver echogenicity. Eur Radiol 20(9):2248–2256
Bartolotta TV, Taibbi A, Brancatelli G et al (2014) Imaging findings of hepatic focal nodular hyperplasia in men and women: are they really different? Radiol Med 119(4):222–230
Wildner D, Bernatik T, Greis C, Seitz K, Neurath MF, Strobel D (2015) CEUS in hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in 320 patients - early or late washout matters: a subanalysis of the DEGUM multicenter trial. Ultraschall Med 36(2):132–139
Chen LD, Ruan SM, Liang JY et al (2018) Differentiation of intrahepatic cholangiocarcinoma from hepatocellular carcinoma in high-risk patients: a predictive model using contrast-enhanced ultrasound. World J Gastroenterol 24(33):3786–3798
Vilana R, Forner A, Bianchi L et al (2010) Intrahepatic peripheral cholangiocarcinoma in cirrhosis patients may display avascular pattern similar to hepatocellular carcinoma on contrast-enhanced ultrasound. Hepatology. 51(6):2020–2029
Han J, Liu Y, Han F et al (2015) The degree of contrast washout on contrast-enhanced ultrasound in distinguishing intrahepatic cholangiocarcinoma from hepatocellular carcinoma. Ultrasound Med Biol 41(12):3088–3095
de Sio I, Iadevaia MD, Vitale LM et al (2014) Optimized contrast-enhanced ultrasonography for characterization of focal liver lesions in cirrhosis: a single-center retrospective study. United European Gastroenterol J 2(4):279–287
Li R, Yuan MX, Ma KS et al (2014) Detailed analysis of temporal features on contrast enhanced ultrasound may help differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma in cirrhosis. PLoS One 9(5):e98612. https://doi.org/10.1371/journal.pone.0098612
Martí-Bonmatí L, Delgado F (2010) MR imaging in liver cirrhosis: classical and new approaches. Insights Imaging 1(4):233–244
Galia M, Taibbi A, Marin D et al (2014) Focal lesions in cirrhotic liver: what else beyond hepatocellular carcinoma? Diagn Interv Radiol 20(3):222–228
Tan GX, Miranda R, Sutherland T (2016) Causes of hepatic capsular retraction: a pictorial essay. Insights Imaging 17(6):831–840
Campos JT, Sirlin CB, Choi JY (2012) Focal hepatic lesions in Gd-EOB-DTPA enhanced MRI: the atlas. Insights Imaging 3(5):451–748/radiol.14132361
Jang HJ, Kim TK, Burns PN, Wilson SR (2015) CEUS: an essential component in a multimodality approach to small nodules in patients at high-risk for hepatocellular carcinoma. Eur J Radiol 84(9):1623–1635
Ogren M, Bergqvist D, Björck M, Acosta S, Eriksson H, Sternby NH (2006) Portal vein thrombosis: prevalence, patient characteristics and lifetime risk: a population study based on 23,796 consecutive autopsies. World J Gastroenterol 12(13):2115–2119
Raza SA, Jang HJ, Kim TK (2014) Differentiating malignant from benign thrombosis in hepatocellular carcinoma: contrast-enhanced ultrasound. Abdom Imaging 39:153–161
Bartolotta TV, Taibbi A, Midiri M, Lagalla R (2019, 2019) Contrast enhanced ultrasound of HCC: where do we stand? Ultrasonography. https://doi.org/10.14366/usg.18060 [Epub ahead of print]
Cassinotto C, Aubé C, Dohan A (2017) Diagnosis of hepatocellular carcinoma: an update on international guidelines. Diagn Interv Imaging 98(5):379–391
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Bartolotta, T.V., Terranova, M., Gagliardo, C. et al. CEUS LI-RADS: a pictorial review. Insights Imaging 11, 9 (2020). https://doi.org/10.1186/s13244-019-0819-2
- Contrast-enhanced ultrasonography
- Hepatocellular carcinoma
- Liver tumor characterization