Associations of Ultrasound LI-RADS Visualization Score With Examination-, Sonographer-, and Radiologist-Factors: Retrospective Assessment in Over 10,000 Examinations.

Background: When performing ultrasound (US) for hepatocellular carcinoma (HCC) screening, numerous factors may impair hepatic visualization, potentially lowering sensitivity. US LI-RADS includes a visualization score as a technical adequacy measure. Objective: To identify associations between examination-, sonographer-, and radiologist-level factors and the visualization score in liver US HCC screening. Methods: This retrospective study included 6598 patients (3979 men, 2619 women; mean age, 58 years) at risk for HCC who underwent a total of 10,589 liver US examinations performed by 91 sonographers and interpreted by 50 radiologists. Visualization scores (A: no or minimal limitations; B: moderate limitations; C: severe limitations) were extracted from clinical reports. Patient location [emergency department (ED), inpatient, outpatient], sonographer and radiologist liver US volumes during the study period (<50, 50-500, >500 examinations), and radiologist practice pattern (ultrasound, abdominal, community, interventional) were recorded. Associations with visualization scores were explored. Results: Frequencies of visualization scores were 71.5%, 24.2%, and 4.2% for A, B, and C, respectively. Scores varied significantly (p<.001) between examinations performed in ED patients (59.7%, 33.1%, and 7.2%), inpatients (59.7%, 33.1%, and 7.2%), and outpatients (76.9%, 20.3%, and 2.9%). Scores also varied significantly (p<.001) by sonographer volume (<50 examinations: 58.4%, 33.7%, and 7.9%; >500 examinations: 72.9%, 22.5%, and 4.6%); reader volume (<50 examinations: 62.9%, 29.9%, and 7.1%; >500 examinations: 67.3%, 28.0%, and 4.7%); and reader practice pattern (ultrasound: 74.5%, 21.3%, and 4.3%; abdominal: 67.0%, 28.1%, and 4.8%; community: 75.2%, 21.9%, and 2.9%; interventional: 68.5%, 24.1%, and 7.4%). In multivariable analysis, independent predictors of score C were patient location [ED/inpatient: odds ratio (OR)=2.62; p=<.001] and sonographer volume (<50: OR=0.1.55; p=.01). Among sonographers performing >50 examinations, the percentage of outpatient examinations with score C ranged from 0.8% to 5.4%; 9/33 were above the upper 95% CI (3.2%). Conclusion: The US LI-RADS visualization score may identify factors impacting quality of HCC screening examinations and identify outlier sonographers in terms of poor examination quality. The approach also highlights potential systematic biases among radiologists in their quality assessment process. Clinical Impact: These findings may be applied to guide targeted quality improvement efforts and establish best practices and performance standards for screening programs.

[1]  Ranjit S. Chima,et al.  Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) Visualization Score: a reliability analysis on inter-reader agreement , 2021, Abdominal Radiology.

[2]  J. Marrero,et al.  International Liver Cancer Association (ILCA) White Paper on Biomarker Development for Hepatocellular Carcinoma. , 2021, Gastroenterology.

[3]  E. Tapper,et al.  Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis. , 2020, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[4]  J. Byun,et al.  Validation of US Liver Imaging Reporting and Data System Version 2017 in Patients at High Risk for Hepatocellular Carcinoma. , 2019, Radiology.

[5]  M. O'Boyle,et al.  ACR Ultrasound Liver Reporting and Data System: Multicenter Assessment of Clinical Performance at 1 Year. , 2019, Journal of the American College of Radiology : JACR.

[6]  M. O'Boyle,et al.  Role of US LI-RADS in the LI-RADS Algorithm. , 2019, Radiographics : a review publication of the Radiological Society of North America, Inc.

[7]  Yu Shen,et al.  Hepatocellular Carcinoma Screening Is Associated With Increased Survival of Patients With Cirrhosis , 2019, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[8]  M. Abecassis,et al.  Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases , 2018, Hepatology.

[9]  P. Schirmacher,et al.  EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. , 2018, Journal of hepatology.

[10]  J. Marrero,et al.  Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis. , 2018, Gastroenterology.

[11]  Jasmin A. Tiro,et al.  An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis , 2017, Hepatology.

[12]  J. Marrero,et al.  Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis , 2017, Alimentary pharmacology & therapeutics.

[13]  M. Zoli,et al.  Factors that affect efficacy of ultrasound surveillance for early stage hepatocellular carcinoma in patients with cirrhosis. , 2014, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[14]  Amit G. Singal,et al.  Early Detection, Curative Treatment, and Survival Rates for Hepatocellular Carcinoma Surveillance in Patients with Cirrhosis: A Meta-analysis , 2014, PLoS medicine.

[15]  William M. Lee,et al.  Detection of Hepatocellular Carcinoma at Advanced Stages Among Patients in the HALT-C Trial: Where Did Surveillance Fail? , 2013, The American Journal of Gastroenterology.

[16]  K. Maturen,et al.  US LI-RADS: ultrasound liver imaging reporting and data system for screening and surveillance of hepatocellular carcinoma , 2017, Abdominal Radiology.