title: Impact of contrast-enhanced ultrasonography in a tertiary clinical practice.
abstract: OBJECTIVE
  The purpose of this study was to assess the impact of contrast-enhanced ultrasonography (CEUS) of the liver in a tertiary clinical practice.
  
  
  METHODS
  One thousand forty consecutive CEUS examinations performed over 30 months for mass characterization were reviewed to determine their source, accuracy, and clinical impact.
  
  
  RESULTS
  Two hundred seventy-five (26.4%) of 1040 examinations were motivated by incidental detection of a mass at routine ultrasonography; 765 (73.6%) were clinical referrals, most often for characterization of a mass in a high-risk patient scanned for hepatoma surveillance or characterization of an indeterminate mass after prior imaging. Clinician referrals increased from 57 in the first 6 months after CEUS introduction to 158 in the last 6 months of the study. Surveillance scans yielded 78 confirmed hepatocellular carcinomas characterized on CEUS at the time of identification. Contrast-enhanced ultrasonography was accurate in 233 (89.2%) of 261 with histologic proof, including 208 malignant lesions. Clinical impact included reduced referrals for other imaging in 226 (21.7%) of 1040 patients, decreased time to diagnosis in 390 (37.5%), and successful guidance for ablation therapy in 26 (2.5%). A positive change in management occurred in 182 (17.5%) of 1040, including alteration of a previous diagnosis, a diagnosis made by CEUS after indeterminate prior imaging, and a diagnosis upstaged by CEUS. Negative impacts included delayed management in 8 (0.8%) small hepatocellular carcinomas misdiagnosed as benign lesions and wrong management of a solitary sclerotic hemangioma, in a high-risk patient for hepatoma, misdiagnosed as a malignant tumor on CEUS, computed tomography, and magnetic resonance imaging, leading to its surgical removal.
  
  
  CONCLUSIONS
  Contrast-enhanced ultrasonography has a positive impact on clinical management, providing rapid, accurate diagnosis of incidentally detected masses and resolving nodules on surveillance scans and indeterminate masses on other imaging.
authors.affiliation: Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Bina
authors.initials: B
authors.lastname: Lanka
authors.forename: Hyun-Jung
authors.initials: HJ
authors.lastname: Jang
authors.forename: Tae Kyoung
authors.initials: TK
authors.lastname: Kim
authors.forename: Peter N
authors.initials: PN
authors.lastname: Burns
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Wilson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D019091:Critical Pathways / Q000706:statistics & numerical data*; D005260:Female; D005466:Fluorocarbons; D006801:Humans; D008113:Liver Neoplasms / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014463:Ultrasonography / Q000706:statistics & numerical data*
chemical_list: D003287:Contrast Media; D005466:Fluorocarbons; C042852:perflutren