Diagnostic performance of contrast-enhanced US in small liver nodules not conclusively characterized after MRI in cirrhotic patients

Belén Saborido; Anna Darnell; Alejandro Forner; Ángeles García-Criado; Alba Díaz; Carmen Ayuso; Ramon Vilana; Jordi Bruix; María Reig; Jordi Rimola

doi:10.1007/s00330-025-11495-3

Diagnostic performance of contrast-enhanced US in small liver nodules not conclusively characterized after MRI in cirrhotic patients

Eur Radiol. 2025 Mar 7. doi: 10.1007/s00330-025-11495-3. Online ahead of print.

Authors

Belén Saborido¹, Anna Darnell¹, Alejandro Forner^{2

3

4}, Ángeles García-Criado^{1

3

4

5}, Alba Díaz^{3

5

6}, Carmen Ayuso^{1

3

5}, Ramon Vilana¹, Jordi Bruix³, María Reig^{2

3

4

5}, Jordi Rimola^{7

8

9}

Affiliations

¹ BCLC Group, Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
² BCLC Group, Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
³ IDIBAPS, Barcelona, Spain.
⁴ Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
⁵ University of Barcelona, Barcelona, Spain.
⁶ BCLC Group, Pathology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
⁷ BCLC Group, Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain. jrimola@clinic.cat.
⁸ IDIBAPS, Barcelona, Spain. jrimola@clinic.cat.
⁹ Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain. jrimola@clinic.cat.

PMID: 40055232
DOI: 10.1007/s00330-025-11495-3

Abstract

Objective: In patients at risk of hepatocellular carcinoma (HCC), new focal liver lesions identified at ultrasound screening require further characterization by CT or MRI. If these techniques cannot conclusively characterize a lesion, a biopsy or an alternative imaging modality such as contrast-enhanced ultrasound (CEUS) is considered. We aimed to determine the diagnostic yield of CEUS in a sequential noninvasive diagnostic strategy for solitary nodules ≤ 20 mm detected in cirrhotic patients during US surveillance characterized as inconclusive on MRI.

Methods: Post hoc analysis of a single-center prospective cohort of high-risk patients (Child A or B) with no prior history of HCC and new liver nodules (≤ 20 mm) detected on screening US who underwent CEUS after inconclusive MRI (LI-RADS-2, LI-RADS-3, LI-RADS-4, or LI-RADS-M) between January 2006 and February 2017. We compared the characterization of nodules by LI-RADS v.2018 alone vs characterization after considering subsequent CEUS-LR v.2017 against the final diagnosis by biopsy or follow-up.

Results: Of the 75 nodules included, CEUS upgraded 45 (63.4%); of these, 13 nodules classified as LR3 or LR4 at MRI were classified as CEUS-LR5. Altogether, 15 (21.1%) nodules inconclusive on MRI were classified as CEUS-LR5. CEUS yielded 37.5% (95% CI: 22.73‒54.20%) sensitivity and 100% specificity (95% CI: 88.78-100%) for HCC.

Conclusion: Adding CEUS to the workup of liver nodules with inconclusive MRI findings demonstrated high specificity for HCC, particularly benefiting nodules categorized as LR3 at MRI.

Key points: Question MRI's limited sensitivity in diagnosing small HCCs in cirrhotic patients results in inconclusive classification of a high proportion of screening-detected lesions. Findings Adding CEUS to the work-up for inconclusive liver nodules at MRI yielded 100% specificity (95% CI: 88.78-100%) and 37.5% (95% CI: 22.73-54.20%) sensitivity for the HCC diagnosis. Clinical relevance CEUS is a valuable problem-solving tool in the work-up of small liver nodules with inconclusive MRI findings in cirrhotic patients.

Keywords: Cirrhosis; Contrast-enhanced ultrasound; Hepatocellular carcinoma; Liver; Magnetic resonance.