Super-resolution ultrasound imaging of intranodal lymphatic sinuses for predicting sentinel lymph node metastasis in breast cancer: a preliminary study
September 26, 2025Role of elastography and dynamic contrast-enhanced ultrasound in the evaluation of pancreas transplantation rejection
December 16, 2025Arterial-Washout Temporal Profiling in CEUS LI-RADS: A Diagnostic Algorithm for Reducing Hepatocellular Carcinoma Misclassification
| Background | CEUS achieves a diagnostic accuracy for HCC comparable to that of contrast-enhanced CT, although lower than that of multiparametric or combined MRI approaches . To increase diagnostic standardization, the CEUS LI-RADS was introduced in 2017 for patients at risk for HCC. While widely adopted, its LR-M category has demonstrated suboptimal performance, with many HCCs misclassified as non-HCC malignancies. |
| Authors |
Wang Y, Zhu Z, Zhu M, Wu S.
|
| Journal |
Radiol Imaging Cancer. 2026;8(1):e250259. doi: 10.1148/ rycan.250259.
|
| Objectives |
To determine whether combining the arterial phase onset time to washout onset time interval (AWTI) with washout onset time improves the accuracy of CEUS Liver LI-RADS and reduces the incidence of hepatocellular carcinoma (HCC) being misclassified as LR-M.
|
| Methods | CEUS and clinical data from patients with focal liver lesions (FLLs), collected between January 2019 and October 2024, were retrospectively analyzed. The AWTI was calculated for all FLLs with washout < 60 seconds. A revised classification was proposed: (a) washout < 45 seconds + AWTI < 21 seconds for LR-M; and (b) washout ≥ 45 seconds + AWTI ≥ 21 seconds for LR-5. Diagnostic performance of the revised classification was compared with that of the standard LI-RADS with washout < 60 seconds (and ≥60 seconds). |
| Results |
The study included 352 patients each with one FLL. Among HCCs, 75.9% exhibited washout ≥ 60 seconds. In contrast, 75.0% of intrahepatic cholangiocarcinomas and 52.0% of metastatic liver carcinomas, demonstrated washout < 45 seconds. Among FLLs classified as LR-5, 92.6% were HCCs; among FLLs classified as LR-M, 41.8% were HCCs. The optimal AWTI cutoff to distinguish LR-M from LR-5 was 21 seconds. The revised LR-M (washout < 45 seconds+ AWTI < 21 seconds) significantly increased the PPV to 92.6% (P < .05). The revised LR-5 (washout ≥ 45 seconds + AWTI ≥ 21 seconds) significantly improved the sensitivity and NPV to 89.0% and 87.0%, respectively (both P < .05). The diagnostic accuracy and AUC were 88.4% and 0.88, respectively, despite slight decreases in the specificity and positive predictive value.
|
| Conclusions | Using washout time and arterial phase onset to washout onset time interval thresholds improved contrast-enhanced US LiRads categorization by reducing HCC misclassification as category LR-M and improving LR-5 diagnostic performance. |
| Key points | In this retrospective study of 352 patients with focal liver lesions evaluated using CEUS , the LI-RADS misclassified 41.8% of HCCs as category LR-M.
A revised LR-5 criterion defined as washout time ≥ 45 seconds and AWTI ≥ 21 seconds significantly improved sensitivity and PPV for HCC to 89.0% and 87.0%, respectively (both P < .05). |
| Link (DOI) | https://dx.doi.org/10.1148/rycan.250259. |
| Ultrasound speciality | Contrast sonography |
Short-Review by:
Prof. Dr. Zeno Sparchez
Department of Ultrasound
Institute for Gastroenterology and Hepatology
University of Medicine and Pharmacy
Cluj Napoca, Romania
Strengths:
a) Integrating the AWTI: Measuring the interval between the start of the arterial phase and the start of washout accounts for individual variations in contrast circulation and retention times, providing a more precise temporal assessment.
b) Using a stricter threshold for LR-M: By requiring washout to occur even earlier (less than 45 seconds) and with a short AWTI (less than 21 seconds) for the LR-M category, the algorithm more accurately identifies non-HCC malignancies (e.g., intrahepatic cholangiocarcinomas or metastases) which tend to wash out very quickly
c) Improving sensitivity for LR-5: Conversely, using a longer washout time (≥ 45 seconds) in combination with a longer AWTI (≥ 21 seconds) for LR-5 categorization increases the sensitivity for true HCCs, many of which have a more prolonged contrast retention compared to other malignancies.
Weaknesses:
a) Strict anclusion criteria and imbalanced cohort: Many FLL cases were excluded due to strict criteria, leading to a final cohort that was predominantly HCC cases. This imbalance may limit how broadly the study’s findings can be applied to other populations or lesion types .
b) Small sample sizes and selection Bias: The limited number of non-HCC malignancies and atypical benign FLLs in the study group may have introduced selection bias and reduced statistical power for those specific subgroups .
c) Lack of interobserver agreement Assessment: The researchers did not perform an assessment of how consistent different observers were when determining “wash-in” and “washout” onset times and AWTI (Arterial Wash-In Time Index).
d) No External Validation
Personally thinking:
