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Giorgio et al. Hepatoma Res 2019;5:20 I http://dx.doi.org/10.20517/2394-5079.2019.05 Page 7 of 9

additional liver lesions. This advantage was demonstrated when IOCEUS was compared to preoperative
MRI, as well as to preoperative CEUS. According to results of Huf et al. , in 27 % of their cases IOCEUS
[45]
allowed the detection of further liver lesions not detected preoperatively. Such detection of further lesions
modified the treatment planning and resection was extended if necessary.

CONCLUSION
Today, CEUS plays an essential role in the clinical recognition of small nodules arising de novo or recurrent
in cirrhotic livers at risk for HCC. The advantages of CEUS over CT/MRI are unique and are represented
by: the high sensitivity in depiction of arterial hypervascularity of HCC; the better demonstration of rapid
washout for non-HCC malignant nodules; the very late washout of HCC.

In 2016, SonoVue was approved for the first time in the United States for the diagnostic imaging of liver
tumors in adults and children. It is undisputable that this approval represents a milestone for CEUS .
[46]
In clinical practice, CEUS demands are constantly increasing in Europe, Asia and Canada (and we are
hoping also in USA after the FDA approval) in the Hepatology Units and not only (see Gastroenteroly Units,
Infectious disease Units, Internal Medicine Units and Surgical Units).

It is undoubtable that the most important benefit of CEUS is based on the fact that physicians can perform
CEUS soon after the detection on conventional US of a new nodule during surveillance of cirrhotic patients.
Thanks to this technique, physicians can immediately exclude typical benignancy, non-HCC malignant
nodules such as ICC and, mainly, in case of CEUS recognition of early HCC, physicians can define a rapid
therapeutic work-up choosing among liver transplantation, resection or ablation.

DECLARATIONS
Authors’ contributions
Design of the work, data analysis and interpretation: Giorgio A
Data acquisition, material support: Giorgio A, Gatti P, Matteucci P, Giorgio V
Wrote the manuscript: Giorgio A, Giorgio V

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2019.

REFERENCE
1. Van Malenstein H, van Pelt J, Verslype C. Molecular classification of hepatocellular carcinoma anno 2011. Eur J Cancer 2011;47:1789-97.