Characterization of hypoechoic focal hepatic lesions in patients with fatty liver: diagnostic performance and confidence of contrast-enhanced ultrasound

The objective of this study was to assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) to characterize hypoechoic focal hepatic lesions (HFHL) in fatty liver (FL). A study group of 105 patients with FL and 105 HFHLs (52 malignant and 53 benign) underwent CEUS after SonoVue administration. Two blinded readers independently reviewed baseline ultrasound (US) and CEUS scans and classified each lesion as malignant or benign on a five-point scale of confidence, and recorded whether further imaging work-up was needed. Sensitivity, specificity, areas under the receiver operating characteristic (ROC) curve (A (z)), and interobserver agreement were calculated. We observed that the diagnostic confidence improved after reviewing CEUS scans for both readers (A (z)=0.706 and 0.999 and A (z)=0.665 and 0.990 at baseline US and CEUS, respectively; p<0.0001). Inter-reader agreement increased (weighted k=0.748 at baseline US vs. 0.882 at CEUS). For both readers, after CEUS, the occurrence of correctly characterized lesions increased (from 27/105 27.5%] to 94/105 89.5%], and from 19/105 18.1%] to 93/105 88.6%], respectively; p<0.0001) and the need for further imaging decreased (from 93/105 88.6%] to 26/105 24.8%], and from 96/105 91.4%] to 40/105 38.1%], respectively; p<0.0001). We conclude that CEUS improves the diagnostic performance of radiologists in the characterization of HFHLs in FL and reduces the need for further imaging work-up.