Could Contrast-Enhanced Ultrasound with Perfluorobutane Provide a Viable Option for Diagnosing Hepatocellular Carcinoma?

Emerging research showed the combination of contrast-enhanced ultrasound (CEUS) with perfluorobutane and modified 2017 LI-RADS criteria had comparable sensitivity, specificity, and accuracy to current magnetic resonance imaging (MRI) and computed tomography (CT) approaches to detecting hepatocellular carcinoma (HCC) lesions.

Is it time to reassess first-line imaging for the detection of hepatocellular carcinoma (HCC) in high-risk patients?

In a recent study published in the American Journal of Roentgenology, researchers compared contrast-enhanced ultrasound (CEUS) with perfluorobutane and modified 2017 Liver Reporting and Data System (LI-RADS) criteria versus contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) with 2018 LI-RADS criteria. The study population consisted of 171 patients deemed to be high-risk for HCC.

The use of CEUS with perfluorobutane had equivalent sensitivity (92.1 percent), specificity (87.1 percent) and accuracy rates (90.6 percent) in detecting HCC lesions as CT and MRI (89.5 percent, 84.2 percent, and 87.7 percent, respectively), according to the study. The study authors also noted LI-RADS category concordance between the two diagnostic approaches on 139 of 171 cases, including 99 LR-5 assessments.

“Given the favorable performance compared with the current preferred tests of contrast-enhanced CT and contrast-enhanced MRI, the findings support the application of modified CEUS criteria using perfluorobutane for characterizing focal liver lesions as HCC in high-risk patients,” explained Jianhua Zhou, M.D., Ph.D, who is affiliated with the Department of Ultrasound at the Sun Yat-Sen University Cancer Center in Guangzhou, China, and colleagues.

While acknowledging a low detection rate for washout in the past that contributed to CECU’s significantly lower sensitivity rate for detecting HCC in comparison to MRI and CT, the study authors suggested the use of perfluorobutane for assessment of a Kupffer defect has enhanced the sensitivity of CEUS for HCC. Zhou and colleagues found that 98.2 percent of HCCs had a Kupffer phase defect on CEUS in comparison to 95.6 percent of HCCs revealing a non-peripheral washout on MRI or CT, and 86.8 percent of HCCs showing a portal-venous or late phase washout pattern on CECU.

“The findings indicate the potential impact of selecting perfluorobutane as the contrast agent for CEUS to allow lesion characterization in the Kupffer phase,” added Zhou and colleagues.

In regard to study limitations, the authors acknowledged the inherent limitations with a small sample size and retrospective design. They noted the possibility of selection bias due to potential confounding factors with the study. Zhou and colleagues also pointed out the study was performed in an area with a high prevalence of chronic hepatitis B, which may prevent extrapolation of the findings for patients at high risk for HCC due to risk factors such as cirrhosis and hepatitis C.