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Figure 4. The globular-like progressive centripetal arterial filling of hemangioma

Figure 5. In A and B, an HCC presents arterial hyperenhancement and late and mild washout with respect to the surrounding liver; on
the contrary, in C and D, a malignant lesion of probable metastatic nature shows rim hyperenhancement together with early and marked
wash-out. HCC: hepatocellular carcinoma; APHE: arterial phase hyperenhancement; LR: Liver Imaging Reporting and Data System (LI-
RADS); LR-M: LI-RADS malignancy

precise information with respect to MDCT/MRI. Obviously, as a counterpart, the global vision of the entire
abdomen is lost, such that CEUS is not appropriate for tumor staging. In return, it can clearly depict key
details such as the progressively centripetal and globular arterial hyperenhancement typical of hemangiomas
(CEUS LR-1) [Figure 4], or the peripheral hyperenhanced rim visible in the early venous phase which is
diagnostic of intrahepatic cholangiocarcinoma (CEUS LR-M), the early (< 60 s) and complete wash-out
typical of metastases or of intrahepatic cholagiocarcinoma (CEUS LR-M) and which unequivocally differs
from late (> 60 s) and partial wash-out which are diagnostic of HCC (CEUS LR-5) [Figure 5].

These are only some examples given in order to emphasize that CEUS has great potential to help adjudicate
the right diagnosis, not only in the event of hepatic nodules of uncertain nature and as a complementary
diagnostic tool after MDCT/MRI, but also as a first post-contrast examination of an observation of
uncertain nature made at ultrasound (i.e., distinction between real nodule vs. fat sparing area/accumulation).
In many situations CEUS can define the real nature of a lesion with high sensibility and specificity and
can avoid an unneeded biopsy or, on the contrary, guide in its realization, in the presence of a hepatic