From the Departments of Radiology (H.J.K., J.M.L., J.H.Y., J.K.H.) and Pathology (K.L., H.K.), Seoul National University Hospital, Seoul, Korea; Department of Radiology, Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, 03080, Korea (H.J.K., J.M.L., J.H.Y., J.K.H.); and Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea (J.M.L., J.K.H.).
Radiology. 2020 Oct;297(1):108-116. doi: 10.1148/radiol.2020200115. Epub 2020 Aug 4.
Background Perfluorobutane (PFB) and sulfur hexafluoride (SHF) have different physiologic characteristics, but it is unclear whether hepatocellular carcinomas (HCCs) show similar wash-in and washout patterns to both contrast agents at US. Purpose To investigate Contrast-Enhanced US Liver Imaging Reporting and Data System (LI-RADS) version 2017 HCC categorization by comparing PFB-enhanced US and SHF-enhanced US in participants at high risk for HCC. Materials and Methods In this prospective study conducted from February to August 2019, participants at high risk for HCC with treatment-naive hepatic observations (≥1 cm) categorized as LR-3, LR-4, LR-5, or LR-M (intermediate probability of HCC, probable HCC, definitely HCC, and probably malignant but not HCC specific, respectively) on cross-sectional images were screened. They underwent same-day PFB-enhanced US and SHF-enhanced US. Arterial phase hyperenhancement (APHE), washout time and degree, and echogenicity in the Kupffer phase (PFB-enhanced US) were evaluated and categorized by the operator using CEUS LI-RADS, who referred to the radiologist who performed the contrast-enhanced US, and by a reviewer. Diagnostic performance was analyzed using the McNemar test. Results Fifty-nine participants were evaluated (43 with HCC, 10 with non-HCC malignancies, six with benign findings). Nonrim APHE was identically observed in 95% (41 of 43, operator) or 88% (38 of 43, reviewer) of HCCs with both contrast agents. Among 43 HCCs, late (≥60 seconds) and mild washout were more frequent with PFB-enhanced US (34 with operator, 33 with reviewer) than with SHF-enhanced US (24 with operator, 26 with reviewer) ( = .04 or = .12). The washout time for HCCs was later at PFB-enhanced US (median, 101 seconds ± 11) than at SHF-enhanced US (median, 84 seconds ± 5; = .04). Sensitivity (34 of 43; 79%; 95% confidence interval [CI]: 64%, 90%) was higher with PFB-enhanced US than with SHF-enhanced US (23 of 43; 54%; 95% CI: 38%, 67%; = .01). Specificity was 100% (95% CI: 79%, 100%) with both. Hypoenhancement in the Kupffer phase was more common in malignant (49 of 53 [92%] for both operator and reviewer) than in benign (two of six [33%] for operator, one of six [16%] for reviewer) lesions. Conclusion On the basis of the Contrast-Enhanced US Liver Imaging Reporting and Data System version 2017 algorithm, noninvasive US diagnosis of hepatocellular carcinoma by using perfluorobutane-enhanced US had higher diagnostic performance than sulfur hexafluoride-enhanced US, without loss of specificity. © RSNA, 2020 See also the editorial by Kim and Jang in this issue.
背景 全氟丁烷（PFB）和六氟化硫（SHF）具有不同的生理特性，但尚不清楚肝细胞癌（HCC）在超声检查中是否显示出与这两种对比剂相似的增强和廓清模式。
目的 本研究旨在通过比较 PFB 增强超声和 SHF 增强超声，探讨高危 HCC 患者的对比增强超声肝脏影像报告和数据系统（LI-RADS）版本 2017 HCC 分类。
材料与方法 本前瞻性研究于 2019 年 2 月至 8 月进行，纳入经横断面图像分类为 LR-3、LR-4、LR-5 或 LR-M（分别为 HCC 低度、中度、高度及可能恶性但非 HCC 特异性的可能性）的治疗前存在肝脏观察（≥1cm）且存在 HCC 高危因素的患者。所有患者均接受同日的 PFB 增强超声和 SHF 增强超声检查。操作人员使用 CEUS LI-RADS 评估和分类动脉期高增强（APHE）、廓清时间和程度以及 Kupffer 期（PFB 增强超声）的回声强度，并参考进行对比增强超声的放射科医生和一名审核员的意见。采用 McNemar 检验分析诊断性能。
结果 共评估了 59 名患者（43 例 HCC，10 例非 HCC 恶性肿瘤，6 例良性病变）。两种对比剂均显示 95%（41/43，操作人员）或 88%（38/43，审核员）的 HCC 为非环形 APHE。在 43 例 HCC 中，PFB 增强超声显示晚期（≥60 秒）和轻度廓清更为常见（操作人员 34 例，审核员 33 例），而 SHF 增强超声显示晚期廓清更为常见（操作人员 24 例，审核员 26 例； =.04 或 =.12）。PFB 增强超声 HCC 的廓清时间较 SHF 增强超声更长（中位数 101 秒±11）（ =.04）。PFB 增强超声的敏感性（34/43；79%，95%置信区间：64%，90%）高于 SHF 增强超声（23/43；54%，95%置信区间：38%，67%； =.01）。两种方法的特异性均为 100%（95%置信区间：79%，100%）。操作人员和审核员均认为 Kupffer 期低增强更常见于恶性病变（49/53 [92%]），而良性病变中低增强更为少见（操作人员 2/6 [33%]，审核员 1/6 [16%]）。
结论 根据对比增强超声肝脏影像报告和数据系统 2017 版算法，使用全氟丁烷增强超声进行 HCC 的无创性诊断，其诊断性能优于六氟化硫增强超声，且特异性无损失。
