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Parenchymal pseudolesions include focal fatty change, focal sparing, inflammatory pseudotumor, confluent fibrosis, pseudotumor hypertrophy and hepatic peliosis. Focal fatty changes are the most frequent of them. Approximately 30-40% of fatty liver infiltration cases occur focally, either as solitary areas, or as multiple areas with a more widespread distribution and lead to differential diagnosis with liver neoplasm. We present several cases of hepatic parenchymal pseudolesions, exemplified by 2D and contrast enhanced ultrasound imaging We report the case of a 72-year-old Caucasian man, who presented with a three- day history of right upper quadrant abdominal pain. He also complained of anorexia and significant weight loss in one month. The ultrasound exam showed an imprecisely- defined heterogeneous mass situated in his right hepatic lobe measuring 68 mm × 46 mm. Diffuse homogeneous hyperenhancement in the arterial phase and washout during the delayed phase was observed at contrast- enhanced ultrasound (CEUS), therefore malignancy was suspected. Because the MRI scan showed suspicious appearance of malignant lesion, liver biopsy was performed. Microscopic examination revealed nonspecific benign characteristics The metastatic work- up was also negative. After 3 months, the patient was in good condition. The case of a patient with neoplastic history and pseudotumoral fatty free infiltration and three other cases of atypical localisation of focal fatty infiltration or focal fatty sparing are also detailed. Non- neoplastic abnormalities are clearly depicted with modern imaging techniques such as CEUS. CEUS has high accuracy in the diagnosis of liver focal fatty infiltration or sparing. [ABSTRACT FROM AUTHOR]

Hepatic pseudolesions are non- neoplastic abnormalities of the liver which may be sub- divided into parenchymal pseudolesions and vascular pseudolesions. Vascular pseudolesions include non- neoplastic hepatic pseudolesions such as intrahepatic shunts and vascular abnormalities associated with Budd- Chiari syndrome or portal vein thrombosis. We present several cases of hepatic vascular pseudolesions, exemplified by 2D and contrast- enhanced ultrasound imaging (CEUS), to be considered in the differential diagnosis of real liver tumors. First case belongs to a 63-year-old patient who was diagnosed with a liver abscess (LA) two years ago. Significant resolution of the LA was observed in the follow- up evaluation. In the vicinity of the residual abscess, Doppler US examination revealed a blood flow pattern with arterial and venous communication suggestive of arterio- portal shunt (APS). CEUS showed a homogeneous enhancement of this area and it also indicated the presence of the APS. Furthermore, an imprecisely delimited area with late and incomplete wash out was depicted in the late phase which led to differential diagnostic challenges with malignant tumors. Another case of a 74- years- old man with vascular abnormalities associated with Budd- Chiari syndrome secondary to multicentric hepatocellular carcinoma is illustrated in this topic. three cases with enhancement anomalies caused by portal vein thrombosis are also detailed in this paper. The main clinical difficulty is to detect the non- neoplastic lesions and to discriminate between them and benign and malignant hepatic neoplasms. CEUS may be an useful tool for the characterization of hepatic vascular pseudolesions. [ABSTRACT FROM AUTHOR]

Hemangiomas are among the most common benign solid lesions that can occur in the liver. Generally, they occur as a single lesion less than 3 cm diameter, but there are also described cases with multiple or bigger lesions (up to 20 cm). The diagnosis is confirmed by using imaging methods, thus their incidence has increased due to the recent improvement and widespread use of imaging. The aim of this study was to evaluate the usefulness of CEUS in clinical practice. We performed a retrospective study for the year 2021 in the Gastroenterology Department of Emergency County Hospital of Craiova, Romania, including patients with diagnosed hepatic hemangioma. It is based on a group of 35 patients, 12 men and 18 women, ages ranged from 34 to 85 years. There were detected 65 focal liver lesions (21 patients with single lesion, 14 patients with 2 or more lesions) suspected as hemangiomas after performing standard abdominal US, which were further investigated by CEUS and/or contrast-enhanced CT or MRI and diagnosed as hepatic hemangiomas due to the typical enhancement pattern identified, consistent with EFSUMB guidelines. Out of the 35 patients included in our study, 25 had no pre-existing liver damage, 8 had moderate diffuse steatosis and 2 had ethanolic liver cirrhosis. Within standard B-mode US of the 65 lesions, there were found 12 cases (18,5%) with a hypoechoic appearance, 52 cases (80%) with a hyperechoic appearance and 1 case (1,5%) with an isoechoic appearance. None of them showed intralesional vessels at color or power Doppler exam. Out of the 65 FLL, 47 cases (72,3%) were diagnosed as hepatic hemangiomas by CEUS, after presenting typical enhancing pattern: centripetal fill-in in the arterial phase (all 47 cases), partial (20 cases) or complete (27 cases) centripetal filling and sustained enhancement in portal and late phases; 1 case (1,6%) showed no enhancement in any on the vascular phases of CEUS, therefore it was also performed a contrast enhanced CT which confirmed the diagnosis of sclerosed hemangioma (atypical variant); 14 cases (21,5%) were investigated and diagnosed only by contrast-enhanced CT/MRI due to their associated pathology which required detailed investigations (without performing CEUS); 3 cases (4,6%) had typical aspect at standard B-mode US, being diagnosed without the necessity of any other investigations. Contrast enhanced imaging has an unmatched value for HH diagnosis due to their typical enhancement pattern of the contrast agent, therefore CEUS could be considered the first-line investigation in all the patients with suspected hemangioma after performing a standard B-mode US. [ABSTRACT FROM AUTHOR]

CEUS has increased the capability of ultrasonography for the detection of focal liver lesions (FLL). The differential diagnosis between hepatocellular carcinoma (HCC) and other malignant tumors may be limited by similarities in the appearance of CEUS. The aim of this study was to evaluate the role of combination of LR-4 and LR-5 by adding ancillary features (AFs) in the CEUS LI-RADS v2017 algorithm for the diagnosis of definite HCC. This retrospective single- center study included 143 patients with 191 FLL detected by abdominal ultrasound from a total of 823 consecutive patients. The risk factors were liver cirrhosis of any etiology and non-cirrhotic HBV patients. Diagnosis was established either through histopathology or based on CT/MRI scan. CEUS recordings were assessed by an EFSUMB level 3 sonographer, with more than 10 years experience in CEUS and who was blinded to clinical data and to the final diagnosis. All lesions have been categorized according to the CEUS LI-RADS® described by The American College of Radiology scheme. The AFs were taken into account. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated. PPV for primitive malignancy (LR-4 + LR-5) was 95.7% (95CI%: 90.7–98%), with 88.07% sensitivity, 89.3% specificity and 88.4% accuracy for HCC (95CI%: 82.8–92.6%). LR4 + LR5 had 81.8% sensitivity for HCCs over 2 cm (n = 127), and 78.57% sensitivity for HCCs less than 2 cm (n = 14). Both sensitivity and accuracy of LR-4 + LR-5 for the diagnosis of definite HCC considerably raised to 88.07% and 88.4%, unlike the sensitivity and accuracy for LR-5 of only 60.45% and 69%, respectively. NPV also improved (73.4% vs. 46.6%), while similar high PPVs (95.7% vs. 96.2%) and quite similar specificity (89.3% vs. 93.6%) were maintained. Higher sensitivity than estimated for the diagnosis of HCCs smaller than 2 cm was achieved for CEUS LR-4 and LR-5. The use of AFs might improve the overarching goal of CEUS LR-5 + LR-4 diagnosis of high specificity for HCC and exclusion of non-HCC malignancy, despite the size of the lesion. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) is one of the neoplasms with a growing incidence. Only a limited number of studies evaluated the diagnostic performance of CEUS LI-RADS. Clinical utility of ancillary features (AFs) in CEUS LI-RADS is yet to be established. We assessed the diagnostic yield of CEUS LI-RADS and AFs in HCC. To our knowledge, this is the first blind study of CEUS application in assessing focal liver lesions (FLL) by using the LI-RADS algorithm and AFs. We retrospectively included patients with risk factors for HCC with newly diagnosed FLL, hospitalized between January 2016 and December 2019 in the Gastroenterology Department of Emergency County Hospital of Craiova, Romania. All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. CEUS AFs in favor of benignity were size reduction or stability >2 years of the tumor. The malignancy aspects were: definite growth, nodule in nodule architecture and mosaic architecture, favoring HCC in particular. Diagnostic accuracy of CEUS was calculated. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule in nodule architecture. From the total of 141 HCC cases, 118 of them (83.6%) were correctly classified as HCC diagnosis, as follows: 81 tumors (57.4%)—definitely HCC (LR-5) and 37 tumors (26.2%)—probably HCC (LR-4). In 13 cases (9.21%), CEUS characteristics indicated malignant lesions, but not necessarily HCC (LR-M); 3 cases (2.12%) were classified as intermediate probability of malignancy (LR-3); none of them was incorrectly diagnosed as benign. The LR-5 category was 96.2% (95% CI: 89.4–98.7%) predictive (PPV) of HCC, with one case of misdiagnosis for cholangiocarcinoma. CEUS LR-5 sensitivity for HCC was 60.4% and specificity was 93.6%. Regarding the LR-4 category, PPV was 94.8%, with only 26.2% sensitivity, whereas for LR-3 the PPV was 41.02%, with only 2% sensitivity. CEUS LIRADS algorithm including AFs remains an excellent diagnostic tool for HCC. [ABSTRACT FROM AUTHOR]

Contrast-enhanced ultrasound (CEUS) has similar performance to computed tomography (CT) or MRI in the diagnosis of hepatic hemangioma [1]. We propose an ultrasound-based diagnostic algorithm for hepatic hemangioma that is easy to use and is cost-effective [2,3]. The study included 204 patients, examined between January 2019-January 2021 in the outpatient setting, diagnosed anteriorly or during the same examination with a focal liver mass. The patients were divided into three groups. Asymptomatic patients, without liver or oncological disease, in whom ultrasound identified a focal liver lesion below 3 cm with homogeneous hyperechoic appearance, with sharp margins and posterior enhancement, an absent halo sign, without intra-tumoral vessels at color Doppler, were assigned to the first group. These characteristics directed the diagnosis toward hepatic hemangioma and further investigations were unnecessary. If ultrasound showed a lesion with features other than those described or if a liver mass was detected in oncological patients or in those with underlying liver disease, CEUS was performed (second group). A typical aspect in contrast ultrasound (peripheral and globular enhancement on arterial phase followed by a central enhancement on delayed phases) guided the diagnosis to liver hemangioma. If the appearance in CEUS was atypical, the patient was referred for further investigations (CT, MRI) (third group). The first two groups were subject to follow-up one year after the diagnosis. From all the examined patients, 30 were assigned to the first group. At the 1-year follow-up, 25 presented no changes in lesion characteristics and did not require further investigations. For the 5 remaining patients in this group, ultrasound follow-up indicated tumor size progression and CEUS was performed. In all these cases, CEUS revealed the typical characteristics of hepatic hemangioma. The second group included 45 patients with typical hemangioma findings on CEUS. Due to the stationary appearance of the lesions at the 1-year follow-up, subsequent investigations were not pursued. 129 patients included in the third group required further imagistic evaluation. The diagnostic algorithm of liver hemangioma is applicable to the adult patient in countries where the hepatologist has an ultrasonography system equipped with CEUS software in the consulting room. [ABSTRACT FROM AUTHOR]