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The diagnostic and economic impact of contrast imaging technique in the diagnosis of small hepatocellular carcinoma in cirrhosis
  1. Angelo Sangiovanni1,*,
  2. Matteo A Manini1,
  3. Massimo Iavarone1,
  4. Raffaella Romeo1,
  5. Laura V Forzenigo2,
  6. Mirella Fraquelli3,
  7. Sara Massironi3,
  8. Cristina Della Corte1,
  9. Guido Ronchi1,
  10. Maria Grazia Rumi1,
  11. Piero Biondetti2,
  12. Massimo Colombo1
  1. 1 1st Div Gastroenterology, Fond. IRCCS Maggiore Hospital, MA.R.E., University of Milan, Italy;
  2. 2 Div of Radiology, Fond. IRCCS Maggiore Hospital, MA.R.E., University of Milan, Italy;
  3. 3 2nd Div Gastroenterology, Fond. IRCCS Maggiore Hospital, MA.R.E., University of Milan, Italy
  1. Correspondence to: Angelo Sangiovanni, First Division of Gastroenterology, Fondazione IRCCS Maggiore Hospital, MA.R.E., University of Milan, Via F. Sforza 35, Milan, 20122, Italy; angelo.sangiovanni{at}


Background: Contrast-enhanced ultrasound (CE-US), contrast computerized tomography (CT)-scan and gadolinium dynamic magnetic resonance (MRI), are recommended for the characterization of liver nodules detected during surveillance of cirrhotics with US.

Aim: To assess sensitivity, specificity, diagnostic accuracy and economic impact of all possible sequential combinations of contrast imaging techniques in cirrhotic patients with 1-2 liver nodules undergoing US surveillance.

Patients/Methods: 64 patients with 67 de-novo liver nodules (55 with 1-2 cm) were consecutively examined by CE-US, CT, MRI and a fine-needle biopsy (FNB) as diagnostic standard. Undiagnosed nodules were re-biopsied; non malignant nodules underwent enhanced imaging follow-up. The typical radiological feature of hepatocellular carcinoma (HCC) was arterial phase hypervascularization followed by portal/venous phase wash-out.

Results: HCC was diagnosed in 44 (66%) nodules (2 < 1cm, 34 1-2 cm, 8 > 2cm). The sensitivity of CE-US, CT, and MRI for 1-2 cm HCC was 26%, 44% and 44%, with 100% specificity, the typical vascular pattern of HCC being identified in 22 (65%) by a single technique vs 12 (35%) by at least two coincidental techniques (p=0.028). Compared to the cheapest dual examination (CE-US + CT), the cheapest single technique stepwise imaging diagnostic of HCC was equally expensive (€26,440 vs 28,667), but led to 23% reduction of FNB procedures (p=0.031).

Conclusions: In cirrhotics with a 1-2 cm nodule detected during surveillance, a single imaging technique showing a typical contrast pattern confidently permits the diagnosis of HCC, reducing thereby the need for FNB examinations.

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