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However, the heterogeneous imaging characteristics of HAE lesions present significant challenges to accurate diagnosis. To improve diagnostic reliability, this study compared the performance of two established ultrasound classification systems: the\n                      <jats:italic>Echinococcus multilocularis<\/jats:italic>\n                      National Health Commission Classification-Ultrasound (EMNHCC-US) and the\n                      <jats:italic>E. multilocularis<\/jats:italic>\n                      Ulm Classification-Ultrasound (EMUC-US).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>This study compared EMUC-US and EMNHCC-US systems in 169 HAE cases (179 lesions) and 99 non-HAE controls. Both systems identified heterogeneous echotexture as a universal feature but differed in lesion categorization and diagnostic performance. Inter-observer agreement was moderate for EMUC-US (\u03ba\u2009=\u20090.57) and substantial for EMNHCC-US (\u03ba\u2009=\u20090.73). The EMUC-US system included atypical patterns such as metastasis-like, found in 10.6% of cases, and ossified lesions, found in 6.1%. This contributed to its high sensitivity of 96.7% and a negative predictive value (NPV) of 90.3%. The EMNHCC-US system focused on advanced patterns, identifying infiltration in 49.7% of cases and liquefactive necrosis in 31.8%. It demonstrated superior specificity of 94.2% and a positive predictive value of 95.5%. Receiver operating characteristic analysis confirmed a better overall discriminative ability for EMNHCC-US, with an area under curve of 0.88 compared to 0.72 for EMUC-US. Sensitivity analysis revealed that EMUC-US maintained a near-perfect NPV of approximately 100% across all prevalence levels. In contrast, EMNHCC-US offered a higher PPV in high-prevalence settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The EMUC-US and EMNHCC-US systems share core features, but EMUC-US includes smaller, atypical lesions (e.g., ossification, metastasis-like), enhancing early HAE detection with higher sensitivity and NPV, ideal for screening. EMNHCC-US focuses on advanced lesions, offering high specificity for confirmation. They are complementary: EMUC-US for sensitive screening, EMNHCC-US for specific diagnosis. Together, they enable a stratified strategy, optimizing case identification and clinical decisions despite lesion heterogeneity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical Abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1186\/s40249-025-01402-9","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:01:39Z","timestamp":1768780899000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Diagnostic performance comparison of two ultrasound classification systems for hepatic alveolar echinococcosis: a single-center retrospective study"],"prefix":"10.1186","volume":"15","author":[{"given":"Yifei","family":"Wang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiaojiao","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wu","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaofei","family":"Zhong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yongzhong","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diming","family":"Cai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"issue":"7","key":"1402_CR1","doi-asserted-by":"publisher","first-page":"1139","DOI":"10.1016\/j.cmi.2025.01.034","volume":"31","author":"B Lundstr\u00f6m-Stadelmann","year":"2025","unstructured":"Lundstr\u00f6m-Stadelmann B, Rostami A, Frey CF, Torgerson PR, Riahi SM, Bagheri K, et al. 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