Contrast-enhanced ultrasound: Improving the preoperative staging of hepatocellular carcinoma and guiding individual treatment

Table 1 Demographic and clinical data of 69 patients and pathologic data of tumors

	Total	S-group	L-group	P value
Clinical data
Age (mean ± SD) (yr)	53.0 ± 11.8	52.69 ± 10.22	53.0 ± 13.88	0.82
Gender (Male/Female)	55:14	32:8	23:6	0.59
HBsAg (Positive/Negative)	63:6	37:3	26:3	0.69
AFP level ( ≤ 20/> 20 ng/mL)	19:50	14:26	5:24	0.17
Mean interval between two images (mean ± SD) (d)	7.88 ± 3.74	7.90 ± 3.36	7.86 ± 3.68	0.97
Mean MELD score (mean ± SD)	4.90 ± 2.81	4.92 ± 2.65	4.87 ± 3.06	0.94
Child-Pugh
Class A	69	40	29
Pathologic data
Mean nodule size (mean ± SD) (cm)	5.49 ± 3.48	3.07 ± 1.12	8.80 ± 2.81	< 0.01
Tumor number (1/2/3)1
Without CEUS	58:9:2	33:5:2	25:4	0.65
With CEUS	57:9:3	36:3:1	21:6:2	0.20
Tumor characteristics
Degree of differentiation (Well/Moderate/Poor)	6:35:28	4:20:16	2:15:12	0.70
Micro-vascular invasion (Positive/Negative)	20:49	8:32	12:17	0.065
Mean Ishak score (mean ± SD)	4.94 ± 1.31	5.30 ± 1.14	4.45 ± 1.38	0.007

¹Indicates that tumor number was documented before surgery. S-group: The “Smaller group” (≤ 5 cm in diameter); L-group: The “Larger-group” (> 5 cm in diameter). HBsAg: Hepatitis B surface antigen; AFP: Alpha-fetoprotein; CEUS: Contrast-enhanced ultrasound.

Table 2 Sensitivity, specificity, accuracy and positive predictive value, negative predictive value for contrast-enhanced computed tomography/magnetic resonance imaging, contrast-enhanced ultrasound, intraoperative ultrasound, contrast-enhanced ultrasound + computed tomography and/or magnetic resonance imaging

	Sensitivity	Specificity	Accuracy	PPV	NPV
CE-CT or MRI	78.7%a	72.7%b	77.2%	89.2%	54.6%
CEUS	89.4%	97.0%bd	91.3%	98.8%	76.2%
IOUS	89.4%	69.7%b	84.3%	89.4%	69.7%
CEUS + CE-CT/MRI	89.4%	100%	92.1%f	100%	76.7%

^aP < 0.05 vs CEUS, IOUS and CEUS + CE-CT/MRI;

^bP< 0.01 vs CEUS + CE-CT/MRI;

^dP < 0.01 vs CE-CT/MRI and IOUS;

^fP < 0.01 vs CT/MRI and IOUS. PPV: Positive predictive value; NPV: Negative predictive value; CEUS: Contrast-enhanced ultrasound; IOUS: Intraoperative ultrasound; CE-CT: Contrast-enhanced computed tomography; MRI: Magnetic resonance imaging.

Table 3 Tumor node metastasis stage of tumors without contrast-enhanced ultrasound, with contrast-enhanced ultrasound and by pathology

	TNM					Pathology
	I	II	IIIA	IIIB	IIIC	Right	Wrong
Without CEUS	56	7	4	2		46	23
With CEUS12	50	4	8	7		61	8
Pathology	49	4	7	9	1

¹P = 0.002 vs without CEUS about accuracy of TNM stage;

²P = 0.977 vs CEUS and pathology about TNM stage. CEUS: Contrast-enhanced ultrasound; TNM: Tumor node metastasis.

Table 4 Sensitivity, specificity, accuracy and positive predictive value, negative predictive value for contrast-enhanced computed tomography/magnetic resonance imaging, contrast-enhanced ultrasound, intraoperative ultrasound in the S-group

	Sensitivity	Specificity	Accuracy	PPV	NPV
CE-CT or MRI	84.0%	69.6%	79.5%	85.7%	66.7%
CEUS	90.0%	100.0%	93.2%	100%	82.2%
IOUS	94.0%	78.3%	89.1%	90.4%	85.7%
CEUS + CE-CT/MRI	90.0%	100%	93.2%	100%	82.2%

S-group: the “Smaller group” (≤ 5 cm in diameter). PPV: Positive predictive value; NPV: Negative predictive value; CEUS: Contrast-enhanced ultrasound; IOUS: Intraoperative ultrasound; CE-CT: Contrast-enhanced computed tomography; MRI: Magnetic resonance imaging.

Table 5 Sensitivity, specificity, accuracy and positive predictive value, negative predictive value for contrast-enhanced computed tomography/magnetic resonance imaging, contrast-enhanced ultrasound, intraoperative ultrasound in the L-group

	Sensitivity	Specificity	Accuracy	PPV	NPV
CE-CT or MRI	72.7%	80.0%	82.4%	89.2%	44.0%
CEUS	88.6%	90.0%	88.9%	98.8%	64.3%
IOUS	84.1%	50.0%	77.8%	88.1%	41.7%
CEUS + CE-CT/MRI	86.4%	100%	90.7%	100%	66.7%

L-group: the “Larger-group” (> 5 cm in diameter). PPV: Positive predictive value; NPV: Negative predictive value; CEUS: Contrast-enhanced ultrasound; IOUS: Intraoperative ultrasound; CE-CT: Contrast-enhanced computed tomography; MRI: Magnetic resonance imaging.

Table 6 Surgical strategies changed according to contrast-enhanced ultrasound findings

	1 segment	1 segments	3 segments	Right liver	Left liver	Right 3 segment	Left 3 segment	Liver transplantation
Without CEUS	7	22	8	13	5	12	1	11
With CEUS	10	22	7	13	5	10	1	11

¹This patient accepted TACE, and then accepted liver transplantation 2 mo later. CEUS: Contrast-enhanced ultrasound; TACE: transcatheter arterial chemoembolization.