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How to not miss alveolar echinococcosis in hepatic lesions suspicious for cholangiocellular carcinoma



Hepatic alveolar echinococcosis (AE) resembles intrahepatic cholangiocarcinoma (ICC) on radiological imaging. The purpose of this study was to identify criteria to discriminate AE from ICC with CT and MR Imaging.


One hundred and sixteen imaging studies of 94 patients (CT n = 65; MRI n = 51) diagnosed with AE (n = 55) or ICC (n = 39) were retrospectively reviewed by two blinded radiologists for lesion features including enhancement pattern and matrix composition. A consensus read was conducted in cases of disagreement. Uni- and multivariate logistic regression with bootstrapping were used for analysis.


Using CT, no or septal enhancement and calcification yielded the highest values of sensitivity/specificity (90.9%/90.6% and 81.8%/96.9%) for AE. Using MRI, no or septal enhancement and cystic components achieved the highest sensitivity/specificity (90.9%/100.0% and 84.8%/66.7%) for AE. Multivariate logistic regression identified the following strong independent predictors for AE: for MRI, no or septal enhancement (odds ratio [OR] 322.4; p < 0.001); for CT, no or septal enhancement and calcification (OR 35.9 and 42.5; p < 0.001 and p < 0.01, respectively). No or septal enhancement and calcification demonstrated the highest interreader agreement (>90%).


Enhancement characteristics and matrix calcifications offer the strongest discriminating potential between AE and ICC with a high sensitivity, specificity, and interreader agreement.

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  1. Czermak BV, Akhan O, Hiemetzberger R, et al. (2008) Echinococcosis of the liver. Abdom Imaging 33(2):133–143. doi:10.1007/s00261-007-9331-0

    Article  PubMed  Google Scholar 

  2. Stojkovic M, Mickan C, Weber TF, Junghanss T (2015) Pitfalls in diagnosis and treatment of alveolar echinococcosis: a sentinel case series. BMJ Open Gastroenterol 2(1):e000036. doi:10.1136/bmjgast-2015-000036

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  3. Didier D, Weiler S, Rohmer P, et al. (1985) Hepatic alveolar echinococcosis: correlative US and CT study. Radiology 154(1):179–186. doi:10.1148/radiology.154.1.3880602

    Article  CAS  PubMed  Google Scholar 

  4. Bresson-Hadni S, Delabrousse E, Blagosklonov O, et al. (2006) Imaging aspects and non-surgical interventional treatment in human alveolar echinococcosis. Parasitol Int 55(Suppl):S267–272. doi:10.1016/j.parint.2005.11.053

    Article  PubMed  Google Scholar 

  5. Kantarci M, Bayraktutan U, Karabulut N, et al. (2012) Alveolar echinococcosis: spectrum of findings at cross-sectional imaging. Radiographics 32(7):2053–2070. doi:10.1148/rg.327125708

    Article  PubMed  Google Scholar 

  6. Madhusudhan KS, Srivastava DN, Dash NR, et al. (2014) Alveolar echinococcosis of the liver: a diagnostic problem in a nonendemic area. Curr Probl Diagn Radiol . doi:10.1067/j.cpradiol.2014.09.001

    Google Scholar 

  7. Mittal PK, Moreno CC, Kalb B, et al. (2014) Primary biliary tract malignancies: MRI spectrum and mimics with histopathological correlation. Abdom Imaging . doi:10.1007/s00261-014-0300-0

    PubMed  Google Scholar 

  8. Rozanes I, Acunas B, Celik L, Minareci O, Gokmen E (1992) CT in lobar atrophy of the liver caused by alveolar echinococcosis. J Comput Assist Tomogr 16(2):216–218

    Article  CAS  PubMed  Google Scholar 

  9. Maetani Y, Itoh K, Watanabe C, et al. (2001) MR imaging of intrahepatic cholangiocarcinoma with pathologic correlation. Am J Roentgenol 176(6):1499–1507. doi:10.2214/ajr.176.6.1761499

    Article  CAS  Google Scholar 

  10. Brunetti E, Kern P, Vuitton DA, Writing Panel for the W-I (2010) Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop 114(1):1–16. doi:10.1016/j.actatropica.2009.11.001

    Article  PubMed  Google Scholar 

  11. Torgerson PR, Schweiger A, Deplazes P, et al. (2008) Alveolar echinococcosis: from a deadly disease to a well-controlled infection. Relative survival and economic analysis in Switzerland over the last 35 years. J Hepatol 49(1):72–77. doi:10.1016/j.jhep.2008.03.023

    Article  PubMed  Google Scholar 

  12. Zeng C, Newcomer SR, Glanz JM, et al. (2013) Bias correction of risk estimates in vaccine safety studies with rare adverse events using a self-controlled case series design. Am J Epidemiol 178(12):1750–1759. doi:10.1093/aje/kwt211

    Article  PubMed  Google Scholar 

  13. Firth D (1993) Bias reduction of maximum likelihood estimates. Biometrika 80(1):27–38

    Article  Google Scholar 

  14. McHugh ML (2012) Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 22(3):276–282

    Article  Google Scholar 

  15. Torgerson PR, Keller K, Magnotta M, Ragland N (2010) The global burden of alveolar echinococcosis. PLoS Negl Trop Dis 4(6):e722. doi:10.1371/journal.pntd.0000722

    PubMed Central  Article  PubMed  Google Scholar 

  16. Kodama Y, Fujita N, Shimizu T, et al. (2003) Alveolar echinococcosis: MR findings in the liver. Radiology 228(1):172–177. doi:10.1148/radiol.2281020323

    Article  PubMed  Google Scholar 

  17. Lee WJ, Lim HK, Jang KM, et al. (2001) Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses. Radiographics 21 Spec No: S97-S116. doi:10.1148/radiographics.21.suppl_1.g01oc12s97

  18. Coskun A, Ozturk M, Karahan OI, et al. (2004) Alveolar echinococcosis of the liver: correlative color Doppler US, CT, and MRI study. Acta Radiol 45(5):492–498

    Article  CAS  PubMed  Google Scholar 

  19. Katranci N, Elmas N, Yilmaz F, Mentes A (1999) Correlative CT, MRI and histological findings of hepatic Echinococcus alveolaris: a case report. Comput Med Imaging Graph 23(3):155–159

    Article  CAS  PubMed  Google Scholar 

  20. Azizi A, Blagosklonov O, Lounis A, et al. (2015) Alveolar echinococcosis: correlation between hepatic MRI findings and FDG-PET/CT metabolic activity. Abdom Imaging 40(1):56–63. doi:10.1007/s00261-014-0183-0

    Article  PubMed  Google Scholar 

  21. Choi BI, Lee JM, Han JK (2004) Imaging of intrahepatic and hilar cholangiocarcinoma. Abdom Imaging 29(5):548–557. doi:10.1007/s00261-004-0188-1

    CAS  PubMed  Google Scholar 

  22. Ros PR, Buck JL, Goodman ZD, Ros AM, Olmsted WW (1988) Intrahepatic cholangiocarcinoma: radiologic-pathologic correlation. Radiology 167(3):689–693. doi:10.1148/radiology.167.3.2834769

    Article  CAS  PubMed  Google Scholar 

  23. Vuitton DA, Guerret-Stocker S, Carbillet JP, et al. (1986) Collagen immunotyping of the hepatic fibrosis in human alveolar echinococcosis. Z Parasitenkd 72(1):97–104

    Article  CAS  PubMed  Google Scholar 

  24. Curvo-Semedo L, Brito JB, Seco MF, et al. (2010) The hypointense liver lesion on T2-weighted MR images and what it means. Radiographics 30(1):e38. doi:10.1148/rg.e38

    Article  PubMed  Google Scholar 

  25. Lim JH (2003) Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings. Am J Roentgenol 181(3):819–827. doi:10.2214/ajr.181.3.1810819

    Article  Google Scholar 

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Correspondence to J. Mueller.

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Mueller, J., Stojkovic, M., Berger, A.K. et al. How to not miss alveolar echinococcosis in hepatic lesions suspicious for cholangiocellular carcinoma. Abdom Radiol 41, 221–230 (2016).

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  • Alveolar echinococcosis
  • Cholangiocarcinoma
  • Calcification
  • Enhancement
  • Computed tomography
  • Magnetic resonance imaging