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Value of Contrast-Enhanced Sonography for the Characterization of Focal Hepatic Lesions in Patients with Diffuse Liver Disease: Receiver Operating Characteristic Analysis

¹ Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea.
² Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea.

View larger version (16K): [in a new window]   Fig. 1A. —Graph shows receiver operating characteristic curves for each radiologist with and without contrast-enhanced sonography. Graphs show performance of radiologists 1 (A) and 2 (B). Radiologists achieved higher area under the receiver operating characteristic curve (Az) values when contrast-enhanced sonography was added for interpretation than when only baseline sonography was reviewed. Difference in Az values between with and without contrast-enhanced sonography was statistically significant (p < 0.05). Solid line (Az, 0.753 [A], 0.830 [B]) = without contrast-enhanced sonography, dotted line (Az, 0.971 [A], 0.974 [B]) = with contrast-enhanced sonography.

View larger version (16K): [in a new window]   Fig. 1B. —Graph shows receiver operating characteristic curves for each radiologist with and without contrast-enhanced sonography. Graphs show performance of radiologists 1 (A) and 2 (B). Radiologists achieved higher area under the receiver operating characteristic curve (Az) values when contrast-enhanced sonography was added for interpretation than when only baseline sonography was reviewed. Difference in Az values between with and without contrast-enhanced sonography was statistically significant (p < 0.05). Solid line (Az, 0.753 [A], 0.830 [B]) = without contrast-enhanced sonography, dotted line (Az, 0.971 [A], 0.974 [B]) = with contrast-enhanced sonography.

View larger version (55K): [in a new window]   Fig. 2A. —Hemangioma in 53-year-old woman with hepatic steatosis. Transverse native B-mode sonogram (upper left) shows heterogeneous and hypoechoic mass with subtle hypoechoic rim (arrows) in steatotic liver. On color Doppler sonogram (upper middle), spotty vascularities are noted at periphery of lesion. This was considered to be indeterminate lesion by both radiologists and was classified as malignant lesion. It could not be assigned specific diagnosis on baseline sonography. Serial contrast-enhanced agent detection images obtained 18 sec (upper right), 34 sec (lower left), 88 sec (lower middle), and 3 min (lower right) after contrast injection show peripheral globular enhancement with progressive centripetal fill-in (arrows). This lesion was correctly diagnosed as hemangioma on basis of features of contrast-enhanced sonography by both radiologists.

View larger version (66K): [in a new window]   Fig. 2B. —Hemangioma in 53-year-old woman with hepatic steatosis. Confirmatory arterial (left) and portal (right) phase CT scans show mass (arrows) with nodular peripheral vascularity and central fill-in enhancement.

View larger version (70K): [in a new window]   Fig. 3. —Hepatocellular carcinoma in 57-year-old man with liver cirrhosis and steatosis. Oblique sagittal native B-mode sonogram (upper left) shows lobulated, hypoechoic mass (arrow) with posterior acoustic enhancement (arrowheads) in cirrhotic liver. Note finely increased echogenicity of background liver, suggesting combined hepatic steatosis. On power Doppler sonogram (upper middle), no intratumoral vascularity is noted. This was considered to be indeterminate lesion by one radiologist and a definitely malignant lesion by another radiologist and was classified as a malignant lesion by both radiologists. However, one radiologist answered that this lesion was not specifically characterized and requested further imaging. Other radiologist correctly characterized this lesion as hepatocellular carcinoma. Serial contrast-enhanced agent detection images obtained 29 sec (upper right), 35 sec (lower left), 83 sec (lower middle), and 3 min (lower right) after contrast injection show early heterogenous enhancement (arrows) of lesion on arterial phases (upper right and lower left) and washout (arrowheads) during portal (lower middle) and delayed (lower right) phases. On basis of features of contrast-enhanced sonography, this lesion was correctly characterized as hepatocellular carcinoma and no further imaging workup was requested by either radiologist.

View larger version (62K): [in a new window]   Fig. 4. —Single hepatic metastasis from stomach cancer in 54-year-old man with hepatic steatosis. Transverse native B-mode sonogram (upper left) shows small hypoechoic nodule (arrow) in segment III of steatotic liver. Contrast-enhanced transverse agent detection image (upper middle) obtained 26 sec after injection shows rimlike enhancement (arrow) of tumor. On subsequent serial contrast-enhanced images obtained 35 sec (upper right), 90 sec (lower left), and 5 min (lower middle) after injection, tumor is hypoechoic. Portal phase CT scan (lower right) shows small hypoattenuating lesion with rimlike enhancement (arrow).

View larger version (70K): [in a new window]   Fig. 5. —Hepatic abscess mimicking malignant tumor in 57-year-old man with chronic hepatitis B. Native B-mode gray-scale sonogram (upper left) depicts heterogeneous low-echoic mass (arrow), which was interpreted as malignant tumor by both radiologists. On color Doppler sonogram (upper middle), faint vascularity (arrow) is noted at periphery of lesion. Serial contrast-enhanced agent detection images obtained 26 sec (upper right), 34 sec (lower left), 95 sec (lower middle), and 3 min (lower right) after injection show early heterogeneous enhancement of lesion (arrows) on arterial phases (upper right, lower left) and washout in portal (lower middle) and delayed (lower right) phases. On basis of these contrast-enhanced sonographic features, this lesion was incorrectly characterized as hepatocellular carcinoma and further imaging workup was not requested by either radiologist. Percutaneous sonographically guided aspiration and subsequent culture confirmed hepatic abscess infected by Klebsiella organisms.

View larger version (77K): [in a new window]   Fig. 6. —Hepatocellular carcinoma mimicking hemangioma in 66-year-old man with liver cirrhosis. Baseline gray-scale sonogram (upper left) shows hyperechoic mass (arrow) at dome of left lateral segment. Note coarse echogenicity and surface undulation of liver, suggesting liver cirrhosis. This lesion was believed to be indeterminate by both radiologists. They recommended further imaging for lesion characterization. Serial contrast-enhanced agent detection images obtained 27 sec (upper right), 36 sec (lower left), and 3 min (lower right) after injection depict peripheral nodular enhancement, which is more apparent as time passes. During interpretation of contrast-enhanced sonograms, this lesion was assigned as probably benign and characterized as hemangioma by both radiologists; however, one of radiologists recommended further workup for lesion characterization.

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