Revisão Acesso aberto Revisado por pares

Joint Consensus Statement of the Indian National Association for Study of the Liver and Indian Radiological and Imaging Association for the Diagnosis and Imaging of Hepatocellular Carcinoma Incorporating Liver Imaging Reporting and Data System

2019; Elsevier BV; Volume: 9; Issue: 5 Linguagem: Inglês

10.1016/j.jceh.2019.07.005

ISSN

2213-3453

Autores

Sonal Krishan, Radha K. Dhiman, Navin Kalra, Raju Sharma, Sanjay Saran Baijal, Anil Arora, Ajay Gulati, Anu Eapan, Ashish Verma, Shyam Keshava, Amar Mukund, Sanjeev Deva, Ravi Chaudhary, Karthick Ganesan, Sunil Taneja, Ujjwal Gorsi, Shivanand Gamanagatti, Kumble S. Madhusudan, P. Puri, S. Shalimar, Shallini Govil, Manav Wadhavan, Sanjiv Saigal, Ashish Kumar, Shallini Thapar, Ajay Duseja, Neeraj Saraf, Anubhav Khandelwal, Sumit Mukhopadyay, Ajay Gulati, Nitin Shetty, Nipun Verma,

Tópico(s)

Hepatitis B Virus Studies

Resumo

Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind. Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind. Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD),1Bruix J. Sherman M. American Association for The Study Of Liver DiseasesManagement of hepatocellular carcinoma: an update.Hepatology. 2011; 53: 1020-1022Crossref PubMed Scopus (5407) Google Scholar the European Association for the Study of the Liver (EASL),2Galle Peter R. Forner Alejandro Llovet Josep M. et al.EASL clinical practice guidelines: management of: hepatocellular carcinoma.J Hepatol. 2018; 69: 182-236Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar the Asian Pacific Association for the Study of the Liver,3Omata Masao Ann-Lii Cheng Kokudo Norihiro Asia–pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update.Hepatol Int. 2017; 11: 317-370Crossref PubMed Scopus (0) Google Scholar the Japan Society of Hepatology,4Kokudo N.1 Hasegawa K. Akahane M. et al.Evidence-based clinical practice guidelines for hepatocellular carcinoma: the Japan society of Hepatology 2013 updates (3rd JSH-HCC guidelines).Hepatol Res. 2015; 45: 123-127Google Scholar the Korean Liver Cancer Study Group,52014 KLCSG-NCC Korea practice guideline for the management of hepatocellular carcinoma Korean liver cancer study group (KLCSG) and national cancer center, Korea (NCC).Gut Liver. 2015; 9: 267-317PubMed Google Scholar Hong Kong,6Tung-Ping Poon Ronnie Tan-To Cheung Tom Chong-Hei Kwok Philip et al.Hong Kong consensus recommendations on the management of hepatocellular carcinoma.Liver Cancer. 2015; 4: 51-69Google Scholar and the National Comprehensive Cancer Network7Benson Al B. D'Angelica Michael I. Abbott Daniel E. et al.NCCN guidelines insights: hepatobiliary cancers, version 1.2017.Natl Compr Canc Netw. 2017; 15: 563-573Crossref PubMed Google Scholar in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 20188Elsayes Khaled M. Hooker Jonathan C. Agrons Michelle M. et al.2017 version of LI-RADS for CT and MR imaging: an update.Radiographics. 2017; 37: 1994-2007Crossref PubMed Scopus (86) Google Scholar, 9Chernyak Victoria Fowler Kathryn J. Kamaya Aya et al.Liver imaging reporting and data system (LI-RADS) version 2018: imaging of hepatocellular carcinoma in at-risk patients.Radiology. 2018; 289: 816-830Crossref PubMed Scopus (61) Google Scholar) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind. The multidisciplinary group comprising of hepatologists and diagnostic and interventional radiologists reviewed the latest available scientific evidence and developed a set of mutually agreed best practice statements, based on various clinical and radiological parameters for the purpose of standardization. Grading of Recommendations Assessment, Development, and Evaluation system was used for grading evidence and strength of recommendation10Brian P. Kavanaghthe GRADE system for rating clinical guidelines.PLoS Med. 2009 Sep; 6: E1000094Google Scholar as shown in Table 1.Table 1Grading of Evidence and Recommendations (Adapted From the GRADE System).Grading of evidenceHigh quality (A)Further research is very unlikely to change our confidence in the estimate of effect.Moderate quality (B)Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.Low or very low quality (C)Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect is uncertain.Grading of recommendationStrong recommendation (1)Warranted Factors influencing the strength of the recommendation included the quality of the evidence, presumed important patient outcomes, and costWeaker recommendation (2)Variability in preferences and values or more uncertainty: more likely a weak recommendation is warranted. Recommendation is made with less certainty; higher cost or resource consumptionGRADE: Grading of Recommendations Assessment, Development, and Evaluation Open table in a new tab GRADE: Grading of Recommendations Assessment, Development, and Evaluation The age-adjusted incidence rate of HCC in India for men ranges from 0.7 to 7.5 and for women from 0.2 to 2.2 per 100,000 persons per year.11Subrat K. Acharya epidemiology of hepatocellular carcinoma in India.J Clin Exp Hepatol. 2014; 4: 27-33Google Scholar Worldwide, the single largest risk factor for the development of HCC is cirrhosis of liver because of any etiology, present in 70%–90%. Paul et al. had estimated that during a cumulative 563 person years follow-up of cirrhotics, 9 cases of HCC were detected with an annual incidence rate of 1.6% (95% confidence interval [CI] 0.07–3.0).12Paul S.B. Sreenivas V. Gulati M.S. Incidence of hepatocellular carcinoma among Indian patients with cirrhosis of liver: an experience from a tertiary care center in northern India.Indian J Gastroenterol. 2007; 26: 274-278PubMed Google Scholar HCCs detected when symptomatic were associated with a poor prognosis.13Zhang B.H. Yang B.H. Tang Z.Y. Randomized controlled trial of screening for hepatocellular carcinoma.J Cancer Res Clin Oncol. 2004; 130: 417-422Crossref PubMed Scopus (845) Google Scholar In a randomized controlled trial (RCT) from China on 18,816 patients with hepatitis B, twice yearly ultrasound (USG) and measurement of serum alpha feto protein (AFP) concentration was compared with no surveillance. Survival of screened participants was 66% at 1 year, 53% at 3 years, and 46% at 5 years versus 31%, 7%, and 0%, respectively, in similar patients without screening.14Thompson Coon J. Rogers G. Hewson P. et al.Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis health.Technol Assess. 2007; 11: 1-206Crossref PubMed Google Scholar A systematic review of cost-effectiveness, analyzing 5 models and 2 studies, found 6 monthly USG with or without AFP to be cost-effective.15Kumar Ashish Acharyay Subrat K. Singhz Shivaram P. et al.The Indian national association for study of the liver (INASL) consensus on prevention, diagnosis and management of hepatocellular carcinoma in India: the Puri recommendations.J Clin Exp Hepatol. 2014; 4: S3-S26Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The INASL recommends that all patients at risk of developing HCC and who are eligible for HCC therapy are candidates for regular HCC surveillance in India.16Kyoung Jeon Woo Surveillance of hepatocellular carcinoma: is only ultrasound enough?.Clin Mol Hepatol. 2017; 23: 222-223Google Scholar Ultrasound (US) has been found to be variably sensitive in detecting asymptomatic tumors in the context of surveillance (60–94%), and the sensitivity for detecting early stage tumors is lower (63%) as shown in a recent meta-analysis but is currently the best surveillance tool for early-stage HCC among patients with cirrhosis.15Kumar Ashish Acharyay Subrat K. Singhz Shivaram P. et al.The Indian national association for study of the liver (INASL) consensus on prevention, diagnosis and management of hepatocellular carcinoma in India: the Puri recommendations.J Clin Exp Hepatol. 2014; 4: S3-S26Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 17Morgan T.A. Maturen K.E. Dahiya N. et al.US LI-RADS: ultrasound liver imaging reporting and data system for screening and surveillance of hepatocellular carcinoma.Abdom Radiol (NY). 2018; 43: 41-55Crossref PubMed Scopus (16) Google Scholar Performing US every 6 months instead of annually significantly improves the sensitivity of detecting early HCC to 70% (≥2 cm). However, it is operator dependent. Based on tumor doubling time, recent Korean study, and multicentric Italian study,16Kyoung Jeon Woo Surveillance of hepatocellular carcinoma: is only ultrasound enough?.Clin Mol Hepatol. 2017; 23: 222-223Google Scholar, 17Morgan T.A. Maturen K.E. Dahiya N. et al.US LI-RADS: ultrasound liver imaging reporting and data system for screening and surveillance of hepatocellular carcinoma.Abdom Radiol (NY). 2018; 43: 41-55Crossref PubMed Scopus (16) Google Scholar USG screening every 6 months is a reasonable strategy. A 3-monthly interval increases the likelihood of detecting small nodules of up to 10 mm but not the higher number of HCC lesions or lesions >30 mm. US Liver Imaging Reporting and Data System (LI-RADS) have proposed standardization in performing and reporting liver lesions, and this will improve the performance of US and unify management recommendations.18Trevisani F. De N.S. Rapaccini G. Semiannual and annual surveillance of cirrhotic patients for hepatocellular carcinoma: effects on cancer stage and patient survival (Italian experience).Am J Gastroenterol. 2002; 97: 734-744Crossref PubMed Google Scholar A stringent recall policy algorithm is crucial when an abnormal finding (i.e. a newly focal hepatic nodule/mass, known focal hepatic nodule with changing echo patterns or growth) is detected during routine US screening with the aim to diagnose HCC at an early stage when curative treatment approaches can be applied. All patients found to have a nodule on USG should undergo dynamic cross-sectional imaging. Serum AFP is the most widely tested biomarker in HCC. Unfortunately, even with the most efficient cut-off (10–20 μg/L), diagnostic sensitivity is around 60%. It does not perform well as a surveillance test because fluctuating levels may occur in any chronic HBV, HCV, not necessarily due to HCC formation. If elevated is helpful to define patients at risk.19Yamamoto K. Imamura H. Matsuyama Y. et al.AFP, AFP-L3, DCP, and GP73 as markers for monitoring treatment response and recurrence and as surrogate markers of clinicopathological variables of HCC.J Gastroenterol. 2010; 45: 1272-1282Crossref PubMed Scopus (105) Google Scholar A recent meta-analysis demonstrated that at any cut-off, addition of AFP to USG does not provide any advantage in detecting early HCCs with only nonsignificant increase in pooled sensitivity from 63% to 69%.20Singal A. Volk M.L. Waljee A. et al.Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.Aliment Pharmacol Ther. 2009; 30: 37-47Crossref PubMed Scopus (386) Google Scholar Nevertheless, it is a cheap and widely available blood test, and in certain clinical situations does have a role.Key Statements—HCC Screening1.Surveillance for HCC can detect tumors early in the course and potentially amenable to treatment. Hence, all patients at risk of developing HCC and who are eligible for HCC treatment are the candidates for regular HCC surveillance—A12.Following patients should be subjected to the surveillance for HCC:•Patients with cirrhosis:oChild-Pugh class A and B cirrhotic patient; of any etiology—A1oChild-Pugh class C cirrhotic patient; of any etiology or those who are listed for liver transplantation—A1•Patients without cirrhosis:oPatients with chronic hepatitis B: males >40 years and females >50 years—A1oPatients with chronic HBV infection of any age with family history of HCC—B1•Patients with chronic hepatitis C and advanced fibrosis—A13.US abdomen for liver lesions performed every 6 months by an experienced radiologist is the recommended test of surveillance for HCC—B24.Serum alfa-fetoprotein has no additive role in surveillance for HCC—B2.*Though it is felt that this is a cheap and readily available test and may have a role in certain clinical settings. 1.Surveillance for HCC can detect tumors early in the course and potentially amenable to treatment. Hence, all patients at risk of developing HCC and who are eligible for HCC treatment are the candidates for regular HCC surveillance—A12.Following patients should be subjected to the surveillance for HCC:•Patients with cirrhosis:oChild-Pugh class A and B cirrhotic patient; of any etiology—A1oChild-Pugh class C cirrhotic patient; of any etiology or those who are listed for liver transplantation—A1•Patients without cirrhosis:oPatients with chronic hepatitis B: males >40 years and females >50 years—A1oPatients with chronic HBV infection of any age with family history of HCC—B1•Patients with chronic hepatitis C and advanced fibrosis—A13.US abdomen for liver lesions performed every 6 months by an experienced radiologist is the recommended test of surveillance for HCC—B24.Serum alfa-fetoprotein has no additive role in surveillance for HCC—B2. *Though it is felt that this is a cheap and readily available test and may have a role in certain clinical settings. Multiphasic computed tomography (CT) and magnetic resonance (MR) imaging with extracellular contrast agents are universally endorsed as the first-line modalities for diagnosis and staging of HCC. These examinations should include late hepatic arterial, portal venous, and at about 3–5 min, delayed phase acquisitions. Precontrast imaging is needed for MR imaging but, in order to reduce radiation dose, may be omitted during CT acquisition as there is hardly any loss of significant diagnostic information except in the patients previously treated with locoregional embolic or ablative therapies. The per-lesion sensitivity of MR imaging for nodular HCC of all sizes is 77%–100%, while that of CT is 68%–91%.21Lee Yoon Jin Lee Jeong Min Lee Ji Sung et al.Hepatocellular carcinoma: diagnostic performance of multidetector CT and MR imaging—a systematic review and meta-analysis.Radiology. 2015; 275: 97-109Crossref PubMed Scopus (175) Google Scholar Thus, while MR imaging may be preferred over CT, there is insufficient data to recommend MR imaging over CT in community or less-specialized centers. MR imaging with hepatobiliary (HPB) agents is the most sensitive method for detection of small HCCs and of premalignant lesions likely to progress to overt HCC.22Kartik S. Jhaveri MRI with hepatobiliary contrast.Cancer Image. 2015; 15: O18Google Scholar These agents permit acquisition of HPB phase images that provide additional information on hepatocellular function. In comparative studies, gadoxetate disodium–enhanced MR imaging had significantly higher per-lesion sensitivity and/or overall accuracy for the diagnosis of HCC than multiphasic CT.23Granito A. Galassi M. Piscaglia F. et al.Impact of gadoxetic acid (Gd-EOB-DTPA)-Enhanced magnetic resonance on the non-invasive diagnosis of small hepatocellular carcinoma: a prospective study.Aliment Pharmacol Ther. 2013; 37: 355-363Crossref PubMed Scopus (58) Google Scholar, 24Sano K. Ichikawa T. Motosugi U. et al.Imaging study of early hepatocellular carcinoma: usefulness of gadoxetic acid-enhanced MR imaging.Radiology. 2011; 261: 834-844Crossref PubMed Scopus (212) Google Scholar, 25Khalili K. Kim T.K. Jang H.J. et al.Optimization of imaging diagnosis of 1-2 Cm hepatocellular carcinoma: an analysis of diagnostic performance and resource utilization.J Hepatol. 2011; 54: 723-728Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Physiologic changes in intranodular blood flow that accompany carcinogenesis aided by acquisition of images before (precontrast) and dynamically after extracellular contrast agent administration permit diagnosis on dynamically acquired images. For MR imaging, three-dimensional T1-weighted sequences usually are utilized for dynamic imaging. Typically, contrast agents are administered at rates of 4–6 mL/s for CT and 2 mL/s for MR imaging followed by saline infusion (20–40 cc) to clear residual contrast material from the intravenous tubing and injected vein. For CT, 1.5–2 mL per kilogram of body weight and for MR imaging, the dose varies from 0.025 to 0.1 mmol gadolinium per kilogram.26Sangiovanni A. Manini M.A. Iavarone M. et al.The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis.Gut. 2010; 59: 638-644Crossref PubMed Scopus (257) Google Scholar Acquisition of three enhanced phases are recommended: late hepatic arterial, portal venous, and delayed phase. The late arterial phase (AP) is characterized by the enhancement of the hepatic artery and its branches as well as early enhancement of the portal vein; the hepatic veins are not yet enhanced by antegrade flow. This phase coincides with peak arterial perfusion and enhancement of liver tumors, and it is critical for detection and characterization of hypervascular HCC.27Choi J.Y. Lee J.M. Sirlin C.B. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (176) Google Scholar Contrast agent bolus tracking or use of a test bolus is recommended27Choi J.Y. Lee J.M. Sirlin C.B. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (176) Google Scholar, 28Choi Jin-Young Lee Jeong-Min Claude B. Sirlin CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part I. Development, growth, and spread: key pathologic and imaging aspects.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (0) Google Scholar The portal venous phase coincides with peak parenchymal enhancement is characterized by enhancement of hepatic veins as well as portal veins and is acquired at around 60–80 s after the start of contrast agent injection.27Choi J.Y. Lee J.M. Sirlin C.B. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (176) Google Scholar The delayed phase is acquired at 3–5 min.27Choi J.Y. Lee J.M. Sirlin C.B. CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (176) Google Scholar These latter phases are critical for characterizing key imaging features of HCC such as washout appearance and capsule appearance, and they help to differentiate small HCCs from small intrahepatic cholangiocarcinomas (ICCs), which typically show prolonged central enhancement (delayed phase). The portal venous and delayed phases also may be useful for measuring nodule diameter, depicting hypovascular nodules including early HCCs, and identifying vascular thrombosis. The precontrast image serves as a baseline to gauge subsequent enhancement. For observations that are hyperintense on precontrast MR images, subtraction images (postcontrast minus precontrast) may be helpful for detection of enhancement.28Choi Jin-Young Lee Jeong-Min Claude B. Sirlin CT and MR imaging diagnosis and staging of hepatocellular carcinoma: Part I. Development, growth, and spread: key pathologic and imaging aspects.Radiology. 2014; 273: 30-50Crossref PubMed Scopus (0) Google ScholarKey Statements: Optimal Imaging Protocol5.Basic technical requirements as included in Table 2 for USG, Table 3 for contrast enhanced ultrasound (CEUS), Table 4 for CT, Table 5 for magnetic resonance imaging (MRI)—these are basic recommended standard agreed protocols. These requirements are must for optimal screening, detection, characterization, and follow-up of liver nodules/HCC as well as in evaluating response to treatment.6.Dynamic CT and MRI using extracellular contrast agent should be acquired at least in late arterial, hepatic venous, and delayed phases. The acquisition of noncontrast phase is optional, except when evaluating response to locoregional therapy. A17.Diffusion weighted imaging (DWI) while not essential is an useful adjunct in characterization of liver lesions and evaluating response to treatment. B18.HPB-specific MRI if available can help in characterizing indeterminate liver lesions. B1Table 2Recommended Technical Protocol for Ultrasound (USG) Liver.Longitudinal imagesRecommended viewsLeft lobe:•left of midline•at midline; include proximal abdominal aorta, celiac artery, and SMA•with IVC; include caudate lobe, MPV, and pancreatic head•with left portal veinRight lobe:•with gallbladder•with right kidney•including right hemidiaphragm and adjacent pleural space•far lateralMain portal vein; include grayscale and color DopplerCommon bile duct at porta hepatis; include diameter measurementOptional viewsColor Doppler of the right and left portal veins, and hepatic veinsSpectral Doppler of main portal vein to assess waveform, velocity, and flow directionTransverse imagesRecommended viewsDome with hepatic veins; include entire right and left lobe with medial and lateral liver edges (on separate images as needed)Left lobe:•with left portal vein•falciform ligament to evaluate for the presence of patent paraumbilical veinMain portal vein bifurcationRight lobe:•with right portal vein•with main portal vein•with gallbladder•with right kidney•near liver tipOptional viewsColor Doppler view of additional vascular structuresCine loopsRecommended views–Optional viewsLongitudinal and transverse cine sweeps of left and right lobes, including as much hepatic parenchyma as possibleReprinted with permission from American College of Radiology. Ultrasound LI-RADS v2017. Accessed September 8, 2018. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS. Open table in a new tab Table 3Recommended Protocol for CEUS.3ARequired systems and models•Ultrasound scanner with contrast-specific imaging capability, including dual-screen and timer display•Refer to contrast-specific instructions provided by scanner manufacturerContrast agents•Current version of CEUS LIRADS applies to pure blood-pool agents but not to combined blood-pool/Kupffer cell agents such as Sonazoid®Imaging—Recommended•Precontrast—identify the following:•Target nodule(s)•Optimal patient position: supine, oblique, or left lateral decubitus•Optimal scan plane: usually longitudinal (reduces out-of-plane resp. motion)•Optimal patient breathing: quiet or suspended (neutral, inspiration, expiration)•Arterial phase (AP):•Image continuously from contrast injection until peak AP enhancement to capture peak AP enhancement, characterize APHE, and determine presence of early washout•Portal venous phase (PVP) to late phase (LP)•Image intermittently (every 30s) to minimize microbubble destruction until microbubbles have cleared completely from the circulation (4–6min) to detect late washout and assess its degreeImaging—suggested•Sweep liver in PVP or LP to identify additional nodules. These may manifest as focal hypoenhancing observations in liverRecording—recommended and optional•Record continuous cine loop from bubble arrival through peak APHE as a minimum requirement. Optionally the cine loop can be continued beyond the APHE peak until 60 s after injection.•Record static images at 60 s and with every intermittent (every ∼30s) acquisition thereafterImaging parameters•Use low (˂0.3) mechanical index to avoid microbubble destruction•Use default machine settingsDual-screen imaging•Using B-mode image for guidance, place calipers on observation on both screens simultaneously to facilitate enhancement characterizationTiming•Begin timer after end of contrast injection, at beginning of saline flush (i.e., time 0 coincides with beginning of flush)•Record time in seconds at which washout is first detectedInjection technique•Use ≥20 G catheter•Central venous lines and infusion ports are acceptable if safety and aseptic requirements are met•Hand inject contrast over 2–3 s, maintaining constant syringe pressure•Flush with 5–10 mL normal saline at about 2 mL/s•Repeat injection as needed, per contrast manufacturer guidelines•Do not exceed maximum total contrast dose listed in package insertDiameter measurement•Use B-mode (precontrast)•Use same imaging mode and plane as prior exam to assess growth3BAPHE: arterial phase hyperenhancement; LIRADS: Liver Imaging Reporting and Data System.Reprinted with permission from American College of Radiology. CEUS LI-RADS v2017. Accessed September 8, 2018. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS. Open table in a new tab Table 4Technical Criteria for CT.CTRecommended equipment•Multidetector CT with ≥8 detector rowsRequired images•Arterial phase (late arterial phase strongly preferred)•Portal venous phase•Delayed phaseSuggested images•Precontrast, if patient has had locoregional treatment•Multiplanar reformationsCT: computed tomography.Reprinted with permission from American College of Radiology. CT/MRI LI-RADS v2018 core. Accessed September 8, 2018. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS. Open table in a new tab Table 5Technical Criteria for MRI.MRI with extracellular contrast agents or gadobenate dimeglumineRecommended equipment•1.5T or 3T•Torso phased-array coilRequired images•Unenhanced T1-weighted OP and IP imaging•T2-weighted imaging (fat suppression per institutional preference)•Multiphase T1-weighted imaging•Precontrast imaging•Arterial phase (late arterial phase strongly preferred)•Portal venous phase•Delayed phaseSuggested or optional images•Diffusion-weighted imaging•Subtraction imaging•Multiplanar acquisition•1 to 3-hr hepatobiliary phase with gadobenate dimeglumineMRI with gadoxetate disodiumRecommended equipment•1.5T or 3T•Torso phased-array coilRequired images•Unenhanced T1-weighted OP and IP imaging•T2-weighted imaging (fat suppression per institutional preference)•Multiphase T1-weighted imaging•Precontrast imaging•Arterial phase (late arterial phase strongly preferred)•Portal venous phase•Transitional phase (2–5 min after injection)•Hepatobiliary phaseSuggested or optional images•Diffusion-weighted imaging•Subtraction imaging•Multiplanar acquisitionMRI: magnetic resonance imaging.Reprinted with permission from American College of Radiology. CT/MRI LI-RADS v2018 core. Accessed September 8, 2018. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS. Open table in a new tab

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