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Indeterminate Focal Liver Lesions Incidentally Discovered at Gray-Scale US: Role of Contrast-Enhanced Sonography

Bartolotta, Tommaso Vincenzo MD, PhD*; Taibbi, Adele MD*; Midiri, Massimo MD*; Matranga, Domenica PhD*; Solbiati, Luigi MD†; Lagalla, Roberto MD*

Investigative Radiology:
doi: 10.1097/RLI.0b013e3181f44184
Original Article

Objectives: To assess the role of contrast-enhanced ultrasound (CEUS) in the characterization of focal liver lesions (FLLs) incidentally discovered but indeterminate at gray-scale ultrasound (US).

Materials and Methods: One hundred forty-two consecutive patients with 174 FLLs (169 benign and 5 malignant) incidentally discovered but indeterminate at gray-scale US, underwent CEUS after the administration of SonoVue. Two readers independently reviewed CEUS scans and: (1) classified each lesion as malignant or benign on a 5-point scale of confidence by means of definite diagnostic criteria; (2) provided if possible a specific diagnosis; (3) were requested if further imaging was needed for lesion characterization. Sensitivity, specificity, and areas under the receiver-operating characteristic curve (Az) as well as interobserver agreement were calculated.

Results: At CEUS, both readers correctly differentiated benign from malignant lesions in 168 of 174 (96.5%) cases (P < 0.0001). A specific correct diagnosis was provided in 123 of 174 (70.7%) and 127 of 174 (72.9%) cases for reader 1 and 2, respectively (P < 0.0001). A further imaging study to characterize the lesion after CEUS was requested in 67 cases (38.5%) for reader 1 (P < 0.001) and 46 cases (26.4%) for reader 2 (P < 0.001). Receiver-operating characteristic analysis after CEUS revealed Az value of 1 for both readers and sensitivity and specificity values of 100% and 97.04% for reader 1 and 100% and 96.45 for reader 2 respectively (P < 0.0001). Inter-reader agreement at CEUS was good (weighted k = 0.779).

Conclusion: CEUS improves the diagnostic performance of radiologists in the characterization of indeterminate FLLs incidentally discovered at US and reduces the need for further radiologic work-up.

Author Information

From the *Department of Radiology, University of Palermo, Palermo, Italy; and †Department of Radiology, General Hospital, Busto Arsizio Varese, Italy.

Received September 12, 2009; accepted for publication (after revision) July 18, 2010.

Each author certifies that he or she did not receive any funds for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and other(s).

Reprints: Tommaso Vincenzo Bartolotta, MD, PhD, Via Del Carabiniere 32, 90146 Palermo, Italy. E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.