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Sbeit W, Kadah A, Mahamid M, Pellicano R, Mari A, Khoury T. A State-of-the-Art Review on the Evolving Utility of Endoscopic Ultrasound in Liver Diseases Diagnosis. Diagnostics (Basel) 2020; 10:diagnostics10080512. [PMID: 32717886 PMCID: PMC7459648 DOI: 10.3390/diagnostics10080512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Liver diseases are amongst the most common diseases worldwide and manifest as a parenchymatic and/or biliary injury due to several causes as well as focal liver lesions, ranging from benign to malignant ones. The diagnosis of liver diseases is based mainly on biochemical and advanced imaging studies and, when required, on liver biopsy. Endoscopic ultrasound (EUS), which combines endoscopy and ultrasonography, is one of the main examination techniques used in gastroenterology as it is applied to evaluate abnormalities in the lumen of the upper and lower gastrointestinal tract and to define pancreatic and hepato-biliary features, often in chronic patients. Given its high spatial resolution and its proximity to the liver, EUS is gaining popularity in the diagnostic work up of liver diseases. This is a comprehensive overview of the current literature on the diagnostic indications for EUS use in patients with liver diseases. We performed a MEDLINE\PubMed and Embase search, and all articles that were relevant, after reviewing abstracts, were assessed and the full text was analyzed to extract data regarding technical success, diagnostic yield, bioptic characteristics, and complications rate. EUS-guided imaging and biopsy techniques in liver diseases have shown consistent favorable promising results among the reports through the literature, with an excellent diagnostic yield and safety profile, especially in the context of focal lesions and portal hypertension. The application of EUS in the diagnosis of liver diseases is a promising technique and should be considered as a first-line therapeutic option in selected cases.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
| | - Mahmud Mahamid
- Department of Gastroenterology, Sharee Zedek Medical Center, Jerusalem 9103102, Israel;
| | | | - Amir Mari
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Gastroenterology and Endoscopy Units, The Nazareth Hospital, EMMS, Nazareth 16100, Israel;
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel; (W.S.); (A.K.)
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
- Gastroenterology and Endoscopy Units, The Nazareth Hospital, EMMS, Nazareth 16100, Israel;
- Correspondence: ; Tel.: +972-509870611
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Lu Q, Zhang XL, Han H, Huang BJ, Ding H, Wang WP. Value of Perfusion Parameters for Differentiating Hepatocellular Carcinoma and Liver Metastasis With Hypervascularity and a Normal Hepatic Background on Contrast-Enhanced Ultrasound Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2601-2608. [PMID: 30697787 DOI: 10.1002/jum.14957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To retrospectively evaluate the value of contrast-enhanced ultrasound (CEUS) perfusion parameters in the differential diagnosis of hepatocellular carcinomas (HCCs) and metastatic liver tumors (MLTs) with hypervascularity. METHODS Sixty-seven HCCs and 55 MLTs with arterial homogeneous/heterogeneous hyperenhancement on CEUS imaging and a normal liver background were included in this retrospective study. Six CEUS perfusion parameters were compared between HCCs and MLTs with different sizes and HCC differentiations: rise time (RT), time to peak (TTP), mean transit time, wash-out time (WT), maximum intensity (IMAX), and area under the curve (AUC). The area under the receiver operating characteristic curve (AUROC) was determined to compare the diagnostic efficacy of the parameters. RESULTS The RT, TTP, and WT were significant longer and the IMAX and AUC were significantly higher in HCCs than in MLTs. In distinguishing between HCCs and MLTs, the AUROC was highest for the WT (0.922; sensitivity, 85.1%; specificity, 89.6%); the AUC and IMAX had the second and third highest AUROCs (AUC: 0.855; sensitivity, 76.1%; specificity, 80.6%; IMAX: 0.827; sensitivity, 76.1%; specificity, 77.6%). The AUROC was lowest for the TTP and RT (TTP: 0.719; sensitivity, 70.1%; specificity, 61.2%; RT: 0.707; sensitivity, 67.2%; specificity, 65.7%). In HCCs, both the tumor size and degree of differentiation affected the IMAX, AUC, and WT. In MLTs, perfusion parameters were not influenced by the tumor size. CONCLUSIONS In HCCs and MLTs with hypervascularity and a normal liver background on CEUS imaging, various CEUS perfusion parameters, including IMAX, AUC, WT, RT, and TTP, differed significantly between tumor types. The WT may be the most useful parameter for differentiating between these tumors.
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Affiliation(s)
- Qing Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xiao-Long Zhang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Hong Han
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bei-Jian Huang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Ding
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
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Lincke T, Zech CJ. Liver metastases: Detection and staging. Eur J Radiol 2017; 97:76-82. [PMID: 29153371 DOI: 10.1016/j.ejrad.2017.10.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 09/27/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
The liver is more often involved with metastatic disease than primary liver tumors. The accurate detection and characterization of liver metastases are crucial since patient management depends on it. The imaging options, mainly consisting of contrast-enhanced ultrasound (CEUS), multidetector computed tomography (CT), magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI), extra-cellular contrast media and liver-specific contrast media as well as positron emission tomography/computed tomography (PET/CT), are constantly evolving. PET/MRI is a more recent hybrid method and a topic of major interest concerning liver metastases detection and characterization. This review gives a brief overview about the spectrum of imaging findings and focus on an update about the performance, advantages and potential limitations of each modality as well as current developments and innovations.
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Affiliation(s)
- Therese Lincke
- Clinic of Radiology und Nuclear Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Christoph J Zech
- Clinic of Radiology und Nuclear Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
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Urnauer S, Müller AM, Schug C, Schmohl KA, Tutter M, Schwenk N, Rödl W, Morys S, Ingrisch M, Bertram J, Bartenstein P, Clevert DA, Wagner E, Spitzweg C. EGFR-targeted nonviral NIS gene transfer for bioimaging and therapy of disseminated colon cancer metastases. Oncotarget 2017; 8:92195-92208. [PMID: 29190908 PMCID: PMC5696174 DOI: 10.18632/oncotarget.21028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023] Open
Abstract
Liver metastases present a serious problem in the therapy of advanced colorectal cancer (CRC), as more than 20% of patients have distant metastases at the time of diagnosis with less than 5% being cured. Consequently, new therapeutic approaches are of major need together with high-resolution imaging methods that allow highly specific detection of small metastases. The unique combination of reporter and therapy gene function of the sodium iodide symporter (NIS) may represent a promising theranostic strategy for CRC liver metastases allowing non-invasive imaging of functional NIS expression and therapeutic application of 131I. For targeted NIS gene transfer polymers containing linear polyethylenimine (LPEI), polyethylene glycol (PEG) and the epidermal growth factor receptor (EGFR)-specific ligand GE11 were complexed with human NIS DNA (LPEI-PEG-GE11/NIS). Tumor specificity and transduction efficiency were examined in high EGFR-expressing LS174T metastases by non-invasive imaging using 18F-tetrafluoroborate (18F-TFB) as novel NIS PET tracer. Mice that were injected with LPEI-PEG-GE11/NIS 48 h before 18F-TFB application showed high tumoral levels (4.8±0.6% of injected dose) of NIS-mediated radionuclide uptake in comparison to low levels detected in mice that received untargeted control polyplexes. Three cycles of intravenous injection of EGFR-targeted NIS polyplexes followed by therapeutic application of 55.5 MBq 131I resulted in marked delay in metastases spread, which was associated with improved animal survival. In conclusion, these preclinical data confirm the enormous potential of EGFR-targeted synthetic polymers for systemic NIS gene delivery in an advanced multifocal CRC liver metastases model and open the exciting prospect of NIS-mediated radionuclide therapy in metastatic disease.
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Affiliation(s)
- Sarah Urnauer
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Andrea M Müller
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Christina Schug
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Kathrin A Schmohl
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Mariella Tutter
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Nathalie Schwenk
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Wolfgang Rödl
- Department of Pharmacy, Center of Drug Research, Pharmaceutical Biotechnology, LMU Munich, Munich, Germany
| | - Stephan Morys
- Department of Pharmacy, Center of Drug Research, Pharmaceutical Biotechnology, LMU Munich, Munich, Germany
| | - Michael Ingrisch
- Department of Clinical Radiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Jens Bertram
- Department of Nuclear Medicine, Radiopharmacy, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Dirk-André Clevert
- Department of Clinical Radiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Ernst Wagner
- Department of Pharmacy, Center of Drug Research, Pharmaceutical Biotechnology, LMU Munich, Munich, Germany
| | - Christine Spitzweg
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
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Lekht I, Nayyar M, Luu B, Guichet PL, Ho J, Ter-Oganesyan R, Katz M, Gulati M. Intra-arterial contrast-enhanced ultrasound (IA CEUS) for localization of hepatocellular carcinoma (HCC) supply during transarterial chemoembolization (TACE): a case series. Abdom Radiol (NY) 2017; 42:1400-1407. [PMID: 28008454 DOI: 10.1007/s00261-016-1016-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transarterial chemoembolization (TACE) is a proven catheter-based locoregional therapy for treatment of hepatocellular carcinoma (HCC). Drug-eluting bead TACE involves delivering micrometer-sized particles preloaded with doxorubicin directly to the tumor via its arterial blood supply and results in vascular embolization with intra-tumoral drug release. Effective therapy requires mapping of the tumor arterial supply, which in some cases cannot be accomplished with conventional angiographic techniques alone. Contrast-enhanced ultrasound (CEUS) is an imaging technique which utilizes microbubble contrast agents to demonstrate blood flow and tissue perfusion, enabling tumor visualization in real time. CEUS with intravenous contrast administration is well established for evaluation of HCC. Intra-arterial (IA) CEUS, on the other hand, is an emerging technique that allows more selective evaluation of the arterial supply to the tumor. The three cases in this report illustrate the utility of intra-procedural IA CEUS during TACE. Specifically, IA CEUS aided TACE in cases where the HCC showed poor arterial enhancement, an extrahepatic arterial supply, and a portal venous supply, respectively.
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Abbas FM, Julie BM, Sharma A, Halawa A. “Contrast nephropathy” in renal transplantation: Is it real? World J Transplant 2016; 6:682-688. [PMID: 28058218 PMCID: PMC5175226 DOI: 10.5500/wjt.v6.i4.682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/26/2016] [Accepted: 10/24/2016] [Indexed: 02/05/2023] Open
Abstract
The risk of contrast-induced nephropathy (CIN) in renal transplant recipients is increased in diabetics, patients with impaired basal kidney function, patients in shock, patients presenting with acute emergency and in old age recipients. Approximately one-third of all hospitalized patients with acute kidney injury is attributed to CIN. In the United States, it is the third leading cause of hospital-acquired renal failure. Therefore, efforts should be directed to minimize CIN-related morbidity and mortality as well as to shorten hospital stay. While the role of peri-procedural prophylactic hydration with saline is unequivocal; the use of acetyl cysteine is not based on robust evidence. The utility of theophylline, aminophylline, calcium channel blockers, natriuretic peptide, and diuretics does not have proven role in attenuating CIN incidence. We aim to analyze the evidence for using various protocols in published literature to limit CIN-associated morbidity and mortality, particularly during surveillance of the renal allograft survival.
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Kong WT, Ji ZB, Wang WP, Cai H, Huang BJ, Ding H. Evaluation of Liver Metastases Using Contrast-Enhanced Ultrasound: Enhancement Patterns and Influencing Factors. Gut Liver 2016; 10:283-7. [PMID: 26586554 PMCID: PMC4780459 DOI: 10.5009/gnl14324] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS To evaluate the enhancement patterns of liver metastases and their influencing factors using dynamic contrast-enhanced ultrasound (CEUS). METHODS A total of 240 patients (139 male and 101 female; 58.5 ± 11.2 years of age) diagnosed with liver metastases in our hospital were enrolled in this study to evaluate tumor characteristics using CEUS. A comparison of enhancement patterns with tumor size and primary tumor type was performed using the chi-square test. The differences between quantitative variables were evaluated with the independent-sample t-test and one-way analysis of variance. RESULTS The enhancement patterns of liver metastases on CEUS were categorized as diffuse homogeneous hyperenhancement (133/240, 55.4%), rim-like hyperenhancement (80/240, 33.3%), heterogeneous hyperenhancement (10/240, 4.2%), and isoenhancement (17/240, 7.1%). There were significant differences in the enhancement patterns during the arterial phase based on the nodule size (p=0.001). A total of 231 of the nodules showed complete washout during the portal phase, and 237 nodules were hypoenhanced during the delayed phase. The washout time was correlated with tumor vascularity, with a longer washout time observed in hypervascular metastases compared to hypovascular metastases (p=0.033). CONCLUSIONS Diffuse homogeneous hyperenhancement followed by rapid washout was the most common enhancement pattern of liver metastases on CEUS and was affected by the nodule size and tumor vascularity. Small metastases were prone to show diffuse homogeneous hyperenhancement. Hypervascular metastases showed a significantly longer washout time compared to hypovascular metastases.
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Affiliation(s)
- Wen-Tao Kong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng-Biao Ji
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Cai
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bei-Jian Huang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Ding
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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Wang D, Zong Y, Yang X, Hu H, Wan J, Zhang L, Bouakaz A, Wan M. Ultrasound Contrast Plane Wave Imaging Based on Bubble Wavelet Transform: In Vitro and In Vivo Validations. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:1584-1597. [PMID: 27067280 DOI: 10.1016/j.ultrasmedbio.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 01/08/2016] [Accepted: 02/04/2016] [Indexed: 06/05/2023]
Abstract
The aim of the study described here was to develop an ultrasound contrast plane wave imaging (PWI) method based on pulse-inversion bubble wavelet transform imaging (PIWI) to improve the contrast-to-tissue ratio of contrast images. A pair of inverted "bubble wavelets" with plane waves was constructed according to the modified Herring equation. The original echoes were replaced by the maximum wavelet correlation coefficients obtained from bubble wavelet correlation analysis. The echoes were then summed to distinguish microbubbles from tissues. In in vivo experiments on rabbit kidney, PIWI improved the contrast-to-tissue ratio of contrast images up to 4.5 ± 1.5 dB, compared with that obtained in B-mode (p < 0.05), through use of a pair of inverted plane waves. The disruption rate and infusion time of microbubbles in PIWI-based PWI were then quantified using two perfusion parameters, area under the curve and half transmit time estimated from time-intensity curves, respectively. After time-intensity curves were denoised by detrended fluctuation analysis, the average area under the curve and half transit time of PIWI-based PWI were 55.94% (p < 0.05) and 20.51% (p < 0.05) higher than those of conventional focused imaging, respectively. Because of its high contrast-to-tissue ratio and low disruption of microbubbles, PIWI-based PWI has a long infusion time and is therefore beneficial for transient monitoring and perfusion assessment of microbubbles circulating in vessels.
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Affiliation(s)
- Diya Wang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Yujin Zong
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Xuan Yang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Hong Hu
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Jinjin Wan
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Lei Zhang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Ayache Bouakaz
- UMR Inserm U930, Université François Rabelais, Tours, France
| | - Mingxi Wan
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China.
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Gulati M, King KG, Gill IS, Pham V, Grant E, Duddalwar VA. Contrast-enhanced ultrasound (CEUS) of cystic and solid renal lesions: a review. ACTA ACUST UNITED AC 2016; 40:1982-96. [PMID: 25588715 DOI: 10.1007/s00261-015-0348-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Incidentally detected renal lesions have traditionally undergone imaging characterization by contrast-enhanced computer tomography (CECT) or magnetic resonance imaging. Contrast-enhanced ultrasound (CEUS) of renal lesions is a relatively novel, but increasingly utilized, diagnostic modality. CEUS has advantages over CECT and MRI including unmatched temporal resolution due to continuous real-time imaging, lack of nephrotoxicity, and potential cost savings. CEUS has been most thoroughly evaluated in workup of complex cystic renal lesions, where it has been proposed as a replacement for CECT. Using CEUS to differentiate benign from malignant solid renal lesions has also been studied, but has proven difficult due to overlapping imaging features. Monitoring minimally invasive treatments of renal masses is an emerging application of CEUS. An additional promising area is quantitative analysis of renal masses using CEUS. This review discusses the scientific literature on renal CEUS, with an emphasis on imaging features differentiating various cystic and solid renal lesions.
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Affiliation(s)
- Mittul Gulati
- Department of Radiology, Keck USC School of Medicine, 1500 San Pablo Street, 2nd Floor Imaging, Los Angeles, CA, 90033, USA,
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Lampe A, Duddalwar VA, Djaladat H, Aron M, Gulati M. Contrast-enhanced ultrasound findings of post-transplant lymphoproliferative disorder in a transplanted kidney: A case report and literature review. J Radiol Case Rep 2015; 9:26-34. [PMID: 26629291 DOI: 10.3941/jrcr.v9i10.2602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Post-transplant lymphoproliferative disorder occurs in approximately one percent of kidney transplant recipients. We evaluated a seventy-seven year-old man with a solid mass in his transplant kidney. On contrast enhanced ultrasound, the mass enhanced but remained persistently hypovascular throughout exam. The enhancement pattern of the mass differed from that typical of clear cell renal cell carcinoma, the main differential diagnosis. Final pathology after partial nephrectomy confirmed post-transplant lymphoproliferative disorder. This is the first report of contrast enhanced ultrasound findings in a renal mass diagnosed as post-transplant lymphoproliferative disorder. Contrast enhanced ultrasound has a promising role in imaging of renal masses, particularly relevant in transplant patients due to the lack of nephrotoxicity.
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Affiliation(s)
- Alyssa Lampe
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vinay A Duddalwar
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Hooman Djaladat
- Department of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Manju Aron
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mittul Gulati
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Allard CB, Coret A, Dason S, Tajzler C, Shayegan B, Matsumoto ED, Kapoor A. Contrast-enhanced Ultrasonography for Surveillance of Radiofrequency-ablated Renal Tumors: A Prospective, Radiologist-blinded Pilot Study. Urology 2015; 86:1174-8. [PMID: 26123518 DOI: 10.1016/j.urology.2015.04.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/03/2015] [Accepted: 04/25/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To prospectively evaluate the performance of contrast-enhanced ultrasonography (CEUS) for surveillance after radiofrequency ablation (RFA) of small renal masses by comparing CEUS to the contrast-enhanced computed tomography (CECT), the current gold standard. PATIENTS AND METHODS Patients underwent surveillance after RFA of small renal masses (≤4 cm) consisting of CECT scans at 3 and 6 months and every 6 months thereafter. Participants additionally underwent ≥1 CEUS within 90 days before CECT. Percutaneous biopsy was performed for lesions suspicious for recurrence on CECT. Independent, blinded radiologists interpreted CEUS and CECT scans. Intermodality agreement was evaluated with the kappa coefficient. RESULTS In total, 37 pairs of CEUS and CECT scans were performed. Median tumor size was 2.5 cm (range, 1.4-4.0 cm). Median follow-up from RFA to CEUS was 25 months. Renal tumor recurrences were diagnosed by CECT in 3 patients and confirmed histopathologically by percutaneous biopsy; 34 CECT scans were negative for recurrence. The diagnostic rate of CEUS was 94.6%; 2 CEUS scans were nondiagnostic because of patient body habitus. Among diagnostic CEUS scans, tumor enhancement was present in 3 and absent in 32. We observed perfect concordance between CEUS and CECT (=1.0; P <.0001). CONCLUSION This is the first prospective study incorporating radiologist blinding to evaluate CEUS for RFA surveillance. Our findings suggest CEUS may ultimately be incorporated into RFA surveillance protocols. The operator dependency of CEUS is a possible barrier to its widespread adoption. These findings justify larger studies with longer follow-up.
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Affiliation(s)
- Christopher B Allard
- Division of Urology, Massachusetts General Hospital & Brigham and Women's Hospital, Boston, MA
| | - Alexander Coret
- Department of Radiology, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Shawn Dason
- Department of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Camilla Tajzler
- Department of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Bobby Shayegan
- Department of Urology, McMaster University, Hamilton, Ontario, Canada
| | | | - Anil Kapoor
- Department of Urology, McMaster University, Hamilton, Ontario, Canada.
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Role of intra-operative contrast-enhanced ultrasound (CEUS) in robotic-assisted nephron-sparing surgery. J Robot Surg 2015; 9:1-10. [PMID: 25722751 PMCID: PMC4333307 DOI: 10.1007/s11701-015-0496-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 01/16/2015] [Indexed: 12/11/2022]
Abstract
This review examines studies of intra-operative contrast-enhanced ultrasound (CEUS) and its emerging role and advantages in robotic-assisted nephron-sparing surgery. Contrast-enhanced ultrasound is a technology that combines the use of second-generation contrast agents consisting of microbubbles with existent ultrasound techniques. Until now, this novel technology has aided surgeons with procedures involving the liver. However, with recent advances in the CEUS technique and the introduction of robotics in nephron-sparing surgery, CEUS has proven to be efficacious in answering several clinical questions with respect to the kidneys. In addition, the introduction of the microbubble-based contrast agents has increased the image quality and signal uptake by the ultrasound probe. This has led to better, enhanced scanning of the macro and microvasculature of the kidneys, making CEUS a powerful diagnostic modality. This imaging method is capable of further lowering the learning curve and warm ischemia time (WIT) during robotic-assisted nephron-sparing surgery, with its increased level of capillary perfusion and imaging. CEUS has the potential to increase the sensitivity and specificity of intra-operative images, and can significantly improve the outcome of robotic-assisted nephron-sparing surgery by increasing the precision and diagnostic insight of the surgeon. The purpose of this article is to review the practical and potential uses of CEUS as an intra-operative imaging technique during robotic-assisted nephron-sparing surgery.
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Hudson JM, Williams R, Karshafian R, Milot L, Atri M, Burns PN, Bjarnason GA. Quantifying vascular heterogeneity using microbubble disruption-replenishment kinetics in patients with renal cell cancer. Invest Radiol 2014; 49:116-23. [PMID: 24220251 DOI: 10.1097/rli.0000000000000003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The purposes of this study were to establish the physiological interpretation of the shape parameter of the dynamic contrast-enhanced ultrasound (DCE-US) lognormal perfusion model and to evaluate the clinical significance of the parameter in a sample of patients undergoing antiangiogenic therapy for metastatic renal cell carcinoma (mRCC). MATERIALS AND METHODS The physiological interpretation of the lognormal shape parameter was explored using computer simulations of disruption-replenishment in fractal models of the microcirculation generated by a piecewise iterative algorithm in MATLAB. Architectural variety was accomplished by introducing random perturbations to the diameter, length, and branching angles to the growing vascular tree. The shape parameter was extracted from the time-intensity curves and compared with the transit time distributions calculated directly from the simulations. Dynamic contrast-enhanced ultrasound data were obtained from 31 consenting patients with mRCC being treated with antiangiogenic therapy. Lognormal parameters related to the blood volume, mean flow speed, and vascular morphology/heterogeneity extracted before, during, and after therapy were correlated with progression-free survival (PFS). Cox proportional hazard ratios were calculated alongside receiver operator characteristics for different combinations of the vascular parameters to determine their ability to distinguish patients who would progress early (less than the median PFS) versus late (greater than the median PFS). RESULTS The lognormal shape parameter correlated strongly to the width of the transit time distribution calculated directly from the simulations, and by extension, to the morphology/heterogeneity of the microvascular network (Spearman r = 0.80, P < 0.001, n = 28). Shorter time to progression was predicted by higher baseline heterogeneity (P = 0.003) and a reduction in tumor blood volume less than 43% (P = 0.002) after 2 weeks of treatment. Combining baseline parameters with changes that occur shortly after starting treatment increased the sensitivity and specificity of DCE-US to identify which patients would progress/resist therapy early versus late compared with when the vascular parameters were considered in isolation. CONCLUSIONS The DCE-US shape parameter from the lognormal perfusion model is representative of microvascular morphology/heterogeneity and may be used to noninvasively characterize the vascular architecture of cancer lesions. A more abnormal flow distribution at baseline predicts for poorer outcome for patients treated with antiangiogenic therapy for metastatic renal cell cancer. Combining pretreatment and on-treatment measurements of vascularity can improve the performance of DCE-US to predict which patients will progress earlier versus later when on antiangiogenic therapy for mRCC.
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Affiliation(s)
- John M Hudson
- From the *Department of Medical Biophysics, University of Toronto; †Imaging Research, Sunnybrook Research Institute; ‡Department of Physics, Ryerson University; §Medical Imaging, Sunnybrook Health Sciences Centre; ∥Department of Medical Imaging, Toronto General Hospital; and ¶Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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Cantisani V, Grazhdani H, Fioravanti C, Rosignuolo M, Calliada F, Messineo D, Bernieri MG, Redler A, Catalano C, D’Ambrosio F. Liver metastases: Contrast-enhanced ultrasound compared with computed tomography and magnetic resonance. World J Gastroenterol 2014; 20:9998-10007. [PMID: 25110428 PMCID: PMC4123379 DOI: 10.3748/wjg.v20.i29.9998] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/23/2013] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
The development of ultrasound contrast agents with excellent tolerance and safety profiles has notably improved liver evaluation with ultrasound (US) for several applications, especially for the detection of metastases. In particular, contrast enhanced ultrasonography (CEUS) allows the display of the parenchymal microvasculature, enabling the study and visualization of the enhancement patterns of liver lesions in real time and in a continuous manner in all vascular phases, which is similar to contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance imaging. Clinical studies have reported that the use of a contrast agent enables the visualization of more metastases with significantly improved sensitivity and specificity compared to baseline-US. Furthermore, studies have shown that CEUS yields sensitivities comparable to CT. In this review, we describe the state of the art of CEUS for detecting colorectal liver metastases, the imaging features, the literature reports of metastases in CEUS as well as its technique, its clinical role and its potential applications. Additionally, the updated international consensus panel guidelines are reported in this review with the inherent limitations of this technique and best practice experiences.
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Kondo T, Maruyama H, Sekimoto T, Shimada T, Takahashi M, Chiba T, Kanai F, Yokosuka O, Yamaguchi T. Natural history of postvascular-phase iso-enhanced lesions on the sonogram in chronic liver diseases. J Gastroenterol Hepatol 2014; 29:165-72. [PMID: 24224484 DOI: 10.1111/jgh.12449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM This study examined the natural history of postvascular-phase iso-enhanced lesions (PIELs) on contrast-enhanced sonograms to determine the potential risk and predictive factors for developing hepatocellular carcinoma (HCC) in chronic liver diseases. METHODS This prospective study included 87 PIELs on contrast-enhanced sonograms (postvascular-phase: 10 min post-injection of perflubutane microbubbles) in 72 patients with chronic liver diseases (45 males and 27 females; age 65.0 ± 10.8y; PIEL diameter 12.5 ± 4.2 mm). The PIELs were followed up by ultrasound/contrast-enhanced ultrasound, computed tomography, or magnetic resonance imaging at 3 to 6 months intervals. RESULTS Twenty patients developed HCCs during the study period (median, 22.0 months). The cumulative risk of HCC occurrence was 7.9% at 1 year and 36.0% at 3 years. The presence of coexistent HCC (hazard ratio [HR], 4.975; 95% confidence interval [CI], 1.729-14.316; P = 0.003) and alpha-fetoprotein > 20 ng/mL (HR, 4.104; 95% CI, 1.621-10.392; P = 0.003) were significant factors for the risk of HCC occurrence. Fourteen of these lesions were diagnosed as HCCs that developed from iso-enhanced lesions. Cumulative HCC occurrence rates from PIEL > 14 mm was 23.5% at 1 year and 46.3% at 3 years. Cox regression analysis showed that PIEL > 14 mm (HR, 6.780; 95% CI, 2.060-22.32; P = 0.002) and alpha-fetoprotein > 20 ng/mL (HR, 4.892; 95% CI, 1.559-15.350; P = 0.007) were statistically significant factors for HCC occurrence. CONCLUSIONS Patients with coexistent HCC, alpha-fetoprotein > 20 ng/mL, or PIEL > 14 mm should be carefully monitored because of the high potential for HCC occurrence.
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Affiliation(s)
- Takayuki Kondo
- Department of Gastroenterology and Hepatology, Chiba University Graduate School of Medicine, Chiba, Japan
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Contrast enhanced ultrasound of the kidneys: what is it capable of? BIOMED RESEARCH INTERNATIONAL 2013; 2013:595873. [PMID: 24455707 PMCID: PMC3884609 DOI: 10.1155/2013/595873] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 09/22/2013] [Accepted: 09/30/2013] [Indexed: 12/20/2022]
Abstract
One of the many imaging uses of contrast enhanced ultrasound (CEUS) is studying a wide variety of kidney pathology, due to its ability to detect microvascular blood flow in real time without affecting renal function. CEUS enables dynamic assessment and quantification of microvascularisation up to capillary perfusion. The objective of this paper is to briefly refresh basic knowledge of ultrasound (US) contrast agents' physical properties, to study technical details of CEUS scanning in the kidneys, and to review the commonest renal indications for CEUS, with imaging examples in comparison to baseline unenhanced US and computed tomography when performed. Safety matters and limitations of CEUS of the kidneys are also discussed.
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Alzaraa A, Gravante G, Chung WY, Al-Leswas D, Morgan B, Dennison A, Lloyd D. Contrast-enhanced ultrasound in the preoperative, intraoperative and postoperative assessment of liver lesions. Hepatol Res 2013; 43:809-19. [PMID: 23745715 DOI: 10.1111/hepr.12044] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 12/04/2012] [Accepted: 12/10/2012] [Indexed: 12/12/2022]
Abstract
The use of contrast agents (CA) with liver ultrasound (US) has gained recently an established role for the diagnosis of various hepatic diseases due to their safety, high versatility and low costs (contrast-enhanced ultrasound: CEUS). The purpose of this review is to provide a state-of-the-art summary of the available evidence for their use in the characterization of focal liver lesions. A published work search was conducted for all preclinical and clinical studies involving CA on hepatic US imaging. CEUS increases the sensitivity for lesion detection and the specificity to differentiate between benign and malignant diseases due to the enhanced visualization of the tumor microcirculation. Results achieved seem at least equivalent to those of spiral computed tomography or magnetic resonance imaging. The association of CA with intraoperative ultrasound has changed the surgical approach in 25% of patients and guarantees complete ablations by a single session in most of them. CEUS provides detailed information about tumor vasculature, improves the preoperative characterization and therefore the therapeutic strategy, and can evaluate the intraoperative completeness of the ablation.
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Affiliation(s)
- Ahmed Alzaraa
- Department of General Surgery, William Harvey Hospital, Ashford
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Warren-Smith CMR, Andrew S, Mantis P, Lamb CR. Lack of associations between ultrasonographic appearance of parenchymal lesions of the canine liver and histological diagnosis. J Small Anim Pract 2012; 53:168-73. [DOI: 10.1111/j.1748-5827.2011.01184.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Utility of contrast-enhanced ultrasonography for qualitative imaging of atherosclerosis in Watanabe heritable hyperlipidemic rabbits: initial experimental study. Jpn J Radiol 2010; 28:656-62. [DOI: 10.1007/s11604-010-0487-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 07/07/2010] [Indexed: 12/27/2022]
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Hypervascular liver masses on contrast-enhanced ultrasound: the importance of washout. AJR Am J Roentgenol 2010; 194:977-83. [PMID: 20308500 DOI: 10.2214/ajr.09.3375] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The objective of our study was to determine the role of negative enhancement (washout), its presence and timing, in the differential diagnosis of hypervascular liver masses on contrast-enhanced ultrasound. MATERIALS AND METHODS One-hundred forty-six hypervascular liver lesions (mean size, 3.9 cm; range, 1.0-17.0 cm) were evaluated with contrast-enhanced ultrasound over a 6-month period. Seventy-four were benign (29 hemangiomas, 31 focal nodular hyperplasia [FNH] lesions, seven adenomas, five inflammatory lesions, two other) and 72, malignant (41 hepatocellular carcinomas [HCCs], 25 metastases, six other). Two independent reviewers retrospectively recorded the presence and timing of washout in the portal venous phase, observing until 4 minutes after injection, of a contrast agent (perflutren microspheres). Diagnoses were confirmed by histopathology (n = 68) or clinicoradiologic follow-up (n = 78). Timing of washout was compared between types of lesion using Fisher's exact test. RESULTS Washout occurred in both benign (27/74, 36%) and malignant (70/72, 97%) lesions but was more frequently seen in malignancy (p < 0.001) (kappa = 0.91). Metastases showed more rapid washout than HCCs (p < 0.001): 20 of 25 metastases showed washout by 30 seconds after injection and 23 of 41 HCCs, later than 75 seconds. All malignant lesions without washout were HCCs (2/41). Among the benign lesions, all five inflammatory lesions showed rapid washout before 75 seconds and six of seven adenomas showed washout, mostly later than 75 seconds (5/6). Washout also occurred in hemangiomas (6/29) and FNH lesions (9/31), mostly later than 75 seconds after injection (12/15). CONCLUSION Hypervascular malignant lesions show washout except infrequent cases of HCC. Rapid washout characterizes metastases, whereas HCCs show variable, often slow, washout. However, washout is not unique to malignancy and may be seen in benign lesions.
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Arfelli F, Rigon L, Menk RH. Microbubbles as x-ray scattering contrast agents using analyzer-based imaging. Phys Med Biol 2010; 55:1643-58. [DOI: 10.1088/0031-9155/55/6/008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Wu H, Lu Q, Luo Y, He XL, Zeng Y. Application of contrast-enhanced intraoperative ultrasonography in the decision-making about hepatocellular carcinoma operation. World J Gastroenterol 2010; 16:508-12. [PMID: 20101780 PMCID: PMC2811807 DOI: 10.3748/wjg.v16.i4.508] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the detection and differentiation ability of contrast-enhanced intraoperative ultrasonography (CE-IOUS) in hepatocellular carcinoma (HCC) operations.
METHODS: Clinical data of 50 HCC patients were retrospective analyzed. The sensitivity, specificity, false negative and false positive rates of contrast enhanced magnetic resonance imaging (CE-MRI), IOUS and CE-IOUS were calculated and compared. Surgical strategy changes due to CE-IOUS were analyzed.
RESULTS: Lesions detected by CE-MRI, IOUS and CE-IOUS were 60, 97 and 85 respectively. The sensitivity, specificity, false negative rate, false positive rate of CE-MRI were 98.2%, 98.6%, 98.6%, 60.0%, respectively; for IOUS were 50.0%, 90.9%, 1.8%, 1.4%, respectively; and for CE-IOUS were 1.4%, 40.0%, 50.0%, 9.1%, respectively. The operation strategy of 9 (9/50, 18.0%) cases was changed according to the results of CE-IOUS.
CONCLUSION: Compared with CE-MRI, CE-IOUS performs better in detection and differentiation of small metastasis and regenerative nodules. It plays an important role in the decision-making of HCC operation.
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Larsen LPS. Role of contrast enhanced ultrasonography in the assessment of hepatic metastases: A review. World J Hepatol 2010; 2:8-15. [PMID: 21160951 PMCID: PMC2998950 DOI: 10.4254/wjh.v2.i1.8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 09/17/2009] [Accepted: 09/24/2009] [Indexed: 02/06/2023] Open
Abstract
Contrast enhanced ultrasonography (CEUS) has improved both the detection and characterization of focal liver lesions. It is now possible to evaluate in real time the perfusion of focal liver lesions in the arterial, portal and late contrast phases, and thus to characterize focal liver lesions with high diagnostic accuracy. As a result, CEUS has taken a central diagnostic role in the evaluation of focal liver lesions that are indeterminate upon computed tomography (CT) and magnetic resonance imaging. The combined use of second generation contrast agents and low mechanical index techniques is essential for the detection of liver metastases, and it now allows the examination of the entire liver in both the portal and late phases. Several studies have shown that using CEUS instead of conventional ultrasonography without contrast agents significantly improves sensitivity in detection of liver metastases. Furthermore, the detection rate with CEUS seems to be similar to that of CT. This review describes the clinical role of CEUS in detecting liver metastases, including details about examination techniques, features of metastases observed with CEUS, and clinical results and guidelines.
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Affiliation(s)
- Lars Peter Skovgaard Larsen
- Lars Peter Skovgaard Larsen, Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, Aarhus 8000 C, Denmark
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Kanemoto H, Ohno K, Nakashima K, Takahashi M, Fujino Y, Nishimura R, Tsujimoto H. Characterization of canine focal liver lesions with contrast-enhanced ultrasound using a novel contrast agent-sonazoid. Vet Radiol Ultrasound 2009; 50:188-94. [PMID: 19400467 DOI: 10.1111/j.1740-8261.2009.01515.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Contrast-enhanced ultrasound using Sonazoid, a novel contrast medium with a liver-specific Kupffer phase, was evaluated in canine focal liver lesions Twenty-five dogs with a liver mass were given intravenous Sonazoid, and the enhancement pattern in the arterial, portal, and parenchymal phase was characterized. An enhancement defect in the lesion in the parenchymal phase was observed in all malignant lesions, whereas only one of nine benign lesions had a filling defect. The diagnostic value of the presence of a filling defect for malignancy was statistically significant (100% sensitivity, 88.9% specificity, 94.1% positive predictive value, 100% negative predictive value), and was equal to that of hypoenhancement in the portal or delayed phase. The defect pattern (clear or irregular defect) was dependent (P < 0.05) on the types of malignancy (i.e., hepatocellular carcinoma and other types of malignancies). In the arterial phase, five of the six hepatocellular carcinomas had hypervascularity, whereas no other lesion was characterized by hypervascularity. In some dogs, additional lesions that could not be observed with conventional B-mode ultrasonography were detected in the parenchymal phase. The enhancement pattern of Sonazoid, especially in the parenchymal phase, has potential as a diagnostic tool for canine focal liver lesions.
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Affiliation(s)
- Hideyuki Kanemoto
- Department of Veterinary Internal Medicine, Graduate School of Agricultural and Life Sciences, University of Tokyo, Tokyo, Japan.
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Abstract
Hepatocellular carcinoma (HCC) is one of the commonest cancers worldwide, particularly in parts of the developing world, and is increasing in incidence. This article reviews the current modalities employed for the diagnosis of HCC, including serum markers, radiological techniques and histological evaluation, and summarises international guidelines for the diagnostic approach to HCC.
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Nishida M, Koito K, Hirokawa N, Hori M, Satoh T, Hareyama M. Does contrast-enhanced ultrasound reveal tumor angiogenesis in pancreatic ductal carcinoma? A prospective study. ULTRASOUND IN MEDICINE & BIOLOGY 2009; 35:175-185. [PMID: 18845377 DOI: 10.1016/j.ultrasmedbio.2008.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2007] [Revised: 08/04/2008] [Accepted: 08/12/2008] [Indexed: 05/26/2023]
Abstract
The purpose of this study is to evaluate tumor vascularity of pancreatic carcinoma noninvasively by contrast-enhanced ultrasound (US) and clarify the diagnostic value of tumor vascularity in subjects with nonresectable advanced pancreatic carcinoma. The study was approved by our institutional review board and written informed consent was obtained from all subjects. Twenty-seven subjects with advanced pancreatic ductal carcinoma were treated by chemoradiotherapy. Contrast-enhanced US, US guided biopsies and dynamic computed tomography (CT) were performed before and after the therapy. We assigned the intratumoral enhancement pattern of US as an enhanced ultrasound (EU) score, from 1 to 4, according to the degree of enhancement area. Intratumoral microvessel density (IMD) and average vessel diameter (AVD) were calculated by means of CD 34 immunostaining. Vascular endothelial growth factor (VEGF) staining was graded on a scale of 1 to 3. EU scores before chemoradiotherapy were compared with IMD, AVD, VEGF, histological grading and hepatic metastasis. After the therapy, local treatment response was evaluated by dynamic CT calculating the maximum area of the tumor, by comparing it with its size in pre- therapy. Subjects who had at least a 50% or more decrease of tumor size lasting more than 4 wk were estimated as partial response (PR), more than a 50% of increase progressive disease (PD) and if neither PR nor PD criteria were met, they were classified as stabled disease (SD). Next, EU scores were compared with IMD, AVD, VEGF and treatment response. Statistically significant differences were evaluated by Pearson's correlation, post-hoc, Spearman's rank correlation, Wilcoxon rank sum and Student's t-test. A p < 0.05 was defined as being statistically significant. Before the therapy, the EU score and IMD were significantly correlated (r = 0.50, p < 0.02), as was VEGF (r = 0.45, p < 0.05). The EU score and AVD were negatively correlated (r = - 0.56, p < 0.02). Significant correlation was found between the EU score and histological grading (p < 0.004). The EU score was higher in subjects who had hepatic metastasis compared with subjects who had no hepatic metastasis (p < 0.05). After chemoradiotherapy, 14 subjects exhibited PR, while 13 showed SD. None of the subjects showed PD. The EU score was smaller in PR than SD (p < 0.05). The EU score significantly decreased after the therapy in PR (p < 0.01) but not in SD. IMD and AVD did not significantly decrease in either PR or SD; however, VEGF decreased significantly in PR (p < 0.01) but not in SD. Contrast-enhanced US could reveal tumor vascularity of pancreatic ductal carcinoma and could be potentially useful to evaluate treatment effect of subjects who receive chemoradiotherapy. Further investigation will be needed to prove the usefulness of contrast-enhanced US.
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Affiliation(s)
- Mutsumi Nishida
- Radiation Oncology, Imaging and Diagnosis, Sapporo Medical University Graduate School of Medicine, Sapporo, Japan.
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Lu Q, Luo Y, Yuan CX, Zeng Y, Wu H, Lei Z, Zhong Y, Fan YT, Wang HH, Luo Y. Value of contrast-enhanced intraoperative ultrasound for cirrhotic patients with hepatocellular carcinoma: A report of 20 cases. World J Gastroenterol 2008; 14:4005-10. [PMID: 18609684 PMCID: PMC2725339 DOI: 10.3748/wjg.14.4005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in partial hepatectomy for cirrhotic patients with hepatocellular carcinoma (HCC).
METHODS: From January 2007 to September 2007, a total of 20 consecutive cirrhotic patients with HCC scheduled to undergo partial hepatectomy were studied. Preoperative contrast enhanced computer tomography (CT) and/or magnetic resonance (MR) scans were performed within 1-2 wk before operation. Intraoperative ultrasound (IOUS) and CE-IOUS were carried out after mobilization of the liver. Lesions on precontrast and postcontrast scans were counted and mapped. CE-IOUS was performed with intravenous injection of ultrasound contrast agents SonoVue (Bracco Imaging, Milan, Italy). Arterial, portal and late phases of contrast enhancement were recorded and analyzed. Nodules showing arterial phase hyper-enhancing and/or hypo-enhancing in late parenchymal phase were considered malignant and removed surgically. Ultrasound-guided biopsy and ethanol ablation would be an option if the nodule could not be removed surgically. Newly detected nodules on IOUS showing iso-enhancement in both arterial and late phases were considered benign. These nodules were either removed surgically if they were close to the main lesion or followed by examinations of alpha-fetoprotein (AFP) level and ultrasound and/or CT/MR every 3 mo.
RESULTS: IOUS found 41 nodules in total, among which 17 (41.46%) were newly detected compared to preoperative imaging. Thirty-three nodules were diagnosed malignant by CE-IOUS, including one missed by IOUS. The sensitivity and specificity of CE-IOUS on detecting HCC nodules are 100% (33/33 and 100% (9/9), respectively. Nine nodules were considered benign by CE-IOUS, four was confirmed at histology and five by follow-up. CE-IOUS changed the surgical strategy in 35% (7/20) of patients and avoid unnecessary intervention in 30% (6/20) of patients.
CONCLUSION: CE-IOUS is a useful means to charac-terize the nodules detected by IOUS in cirrhotic liver, to find isoechoic HCC nodules which can not be shown on IOUS and to improve the accuracy of conventional IOUS, thus it can be used as an essential tool in the surgical treatment of cirrhotic patients with HCC.
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Morin SH, Lim AK, Cobbold JF, Taylor-Robinson SD. Use of second generation contrast-enhanced ultrasound in the assessment of focal liver lesions. World J Gastroenterol 2008. [PMID: 18023084 DOI: 10.3748/wjg.13.5963] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ultrasound (US) is often the first imaging modality employed in patients with suspected focal liver lesions. The role of US in the characterisation of focal liver lesions has been transformed with the introduction of specific contrast media and the development of specialized imaging techniques. Ultrasound now can fully characterise the enhancement pattern of hepatic lesions, similar to that achieved with contrast enhanced multiphasic computed tomography (CT) and magnetic resonance imaging (MRI). US contrast agents are safe, well-tolerated and have very few contraindications. Furthermore, real-time evaluation of the vascularity of focal liver lesions has become possible with the use of the newer microbubble contrast agents. This article reviews the enhancement pattern of the most frequent liver lesions seen, using the second generation US contrast media. The common pitfalls for each type of lesion are discussed. The recent developments in US contrast media and specific imaging techniques have been a major advance and this technique, in view of the intrinsic advantages of US, will undoubtedly gain popularity in the years to come.
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Morin SH, Lim AK, Cobbold JF, Taylor-Robinson SD. Use of second generation contrast-enhanced ultrasound in the assessment of focal liver lesions. World J Gastroenterol 2008; 13:5963-70. [PMID: 18023084 PMCID: PMC4250875 DOI: 10.3748/wjg.v13.45.5963] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ultrasound (US) is often the first imaging modality employed in patients with suspected focal liver lesions. The role of US in the characterisation of focal liver lesions has been transformed with the introduction of specific contrast media and the development of specialized imaging techniques. Ultrasound now can fully characterise the enhancement pattern of hepatic lesions, similar to that achieved with contrast enhanced multiphasic computed tomography (CT) and magnetic resonance imaging (MRI). US contrast agents are safe, well-tolerated and have very few contraindications. Furthermore, real-time evaluation of the vascularity of focal liver lesions has become possible with the use of the newer microbubble contrast agents. This article reviews the enhancement pattern of the most frequent liver lesions seen, using the second generation US contrast media. The common pitfalls for each type of lesion are discussed. The recent developments in US contrast media and specific imaging techniques have been a major advance and this technique, in view of the intrinsic advantages of US, will undoubtedly gain popularity in the years to come.
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Morin SH, Lim AK, Cobbold JF, Taylor-Robinson SD. Use of second generation contrast-enhanced ultrasound in the assessment of focal liver lesions. World J Gastroenterol 2007. [PMID: 18023084 DOI: dx.doi.org/10.3748/wjg.13.5963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ultrasound (US) is often the first imaging modality employed in patients with suspected focal liver lesions. The role of US in the characterisation of focal liver lesions has been transformed with the introduction of specific contrast media and the development of specialized imaging techniques. Ultrasound now can fully characterise the enhancement pattern of hepatic lesions, similar to that achieved with contrast enhanced multiphasic computed tomography (CT) and magnetic resonance imaging (MRI). US contrast agents are safe, well-tolerated and have very few contraindications. Furthermore, real-time evaluation of the vascularity of focal liver lesions has become possible with the use of the newer microbubble contrast agents. This article reviews the enhancement pattern of the most frequent liver lesions seen, using the second generation US contrast media. The common pitfalls for each type of lesion are discussed. The recent developments in US contrast media and specific imaging techniques have been a major advance and this technique, in view of the intrinsic advantages of US, will undoubtedly gain popularity in the years to come.
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Jang HJ, Kim TK, Burns PN, Wilson SR. Enhancement patterns of hepatocellular carcinoma at contrast-enhanced US: comparison with histologic differentiation. Radiology 2007; 244:898-906. [PMID: 17709836 DOI: 10.1148/radiol.2443061520] [Citation(s) in RCA: 224] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To retrospectively compare the arterial and portal venous phase enhancement patterns of hepatocellular carcinoma (HCC) at contrast material-enhanced ultrasonography (US) with the degree of HCC histologic differentiation. MATERIALS AND METHODS This study was approved by the research ethics board, and informed consent was obtained. The study population included 112 consecutive patients (91 men, 21 women; aged 25-86 years) with 112 histologically proved HCCs: 23 well differentiated, 77 moderately differentiated, and 12 poorly differentiated. All underwent continuous real-time low-mechanical-index contrast-enhanced US from wash-in of contrast material to 300 seconds by using a blood-pool microbubble agent. Initial image interpretation included arterial enhancement, dysmorphic intratumor arteries, and presence and time of negative enhancement (washout). Enhancement patterns were compared with histologic differentiation by using the Fisher exact test. RESULTS In the arterial phase, 97 of 112 (87%) HCCs showed hypervascularity, with a significantly higher proportion in moderately differentiated HCCs (74 of 77, 96%) when compared with well- (14 of 23, 61%; P<.001) and poorly differentiated HCC (nine of 12, 75%; P<.004). Eight of 112 (7%) were isovascular and seven (6%) were hypovascular. Dysmorphic arteries were seen in 81 (72%) HCCs. Of 97 hypervascular tumors, only 42 (43%) showed typical washout by 90 seconds. Late washout appeared in 25 (26%) HCCs in the 91-180 seconds phase and in 21 (22%) in the 181-300 seconds phase. The remaining nine showed no washout up to 300 seconds and seven (78%) were well-differentiated HCCs. CONCLUSION Moderately differentiated HCC generally shows classic enhancement features, while well- and poorly differentiated tumors account for most atypical variations. Extended observation in the portal phase is important as late washout occurs with slightly more frequency than washout in the conventionally defined portal venous phase.
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Affiliation(s)
- Hyun-Jung Jang
- Department of Medical Imaging, University of Toronto, Toronto General Hospital, 585 University Ave, Toronto, ON, Canada M5G 2N2.
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Maruyama H, Matsutani S, Okugawa H, Kobayashi S, Yoshizumi H, Ebara M, Saisho H. Microbubble disappearance-time is the appropriate timing for liver-specific imaging after injection of Levovist. ULTRASOUND IN MEDICINE & BIOLOGY 2006; 32:1809-15. [PMID: 17169692 DOI: 10.1016/j.ultrasmedbio.2006.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 06/13/2006] [Accepted: 06/22/2006] [Indexed: 05/13/2023]
Abstract
Contrast enhancement in the portal vein was repeatedly observed at 1 min intervals with wide-band Doppler ultrasonography in 152 consecutive patients (132 with liver cirrhosis and HCC, 20 controls), 5 min after the injection of Levovist. The duration time of contrast enhancement in the portal vein (microbubble disappearance-time; MD-T) was measured in all patients and contrast-enhanced appearances were compared between the 5 min phase and MD-T phase in 68 HCC nodules. MD-T in patients with liver cirrhosis (572.4 +/- 117.9 s) was significantly longer than in controls (481.6 +/- 89.3 s, p < 0.05). MD-T was prolonged in patients with Child B and C compared with Child A (p < 0.05). The contrast-enhanced appearances between the two phases were different in 30 of 68 HCC nodules (44.1%), showing positive enhancement in the 5 min phase and negative enhancement in the MD-T phase. The proposed MD-T may become an essential factor for the evaluation of liver-specific sonograms.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Maruyama H, Matsutani S, Kondo F, Yoshizumi H, Kobayashi S, Okugawa H, Ebara M, Saisho H. Ring-shaped appearance in liver-specific image with Levovist: a characteristic enhancement pattern for hypervascular benign nodule in the liver of heavy drinkers. Liver Int 2006; 26:688-94. [PMID: 16842325 DOI: 10.1111/j.1478-3231.2006.01286.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIMS The aim was to clarify the features of contrast-enhanced ultrasound (CEUS) with Levovist for diagnosis of hypervascular benign nodules in the liver of heavy drinkers. PATIENTS AND METHODS Seven heavy drinkers with hypervascular nodules in the liver were studied. Findings of CEUS with Levovist (wide-band Doppler, 7/7), contrast-enhanced computed tomography (CECT, 7/7) and magnetic resonance imaging (MRI, 5/7) were compared for one nodule in each patient. RESULTS Diagnosis of all seven nodules on CECT was HCC, whereas pathological results were HCC for four nodules and benign lesion for three nodules. The former four showed compatible findings for HCC on CEUS (4/4) and MRI (2/4). However, the latter three showed characteristic liver-specific sonograms with a ring-shaped appearance--peripheral enhancement with a central non-enhanced area. Two of the three nodules showed decreased signal-intensity in the periphery on SPIO-enhanced MRI. CONCLUSIONS The ring-shaped appearance on liver-specific sonograms with Levovist may be a useful sign for the differential diagnosis of hypervascular benign nodule from HCC in heavy drinkers.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Medicine and Clinical Oncology, Chiba University Graduate School of Medicine, Chiba, Japan.
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Quaia E, Palumbo A, Rossi S, Degobbis F, Cernic S, Tona G, Cova M. Comparison of visual and quantitative analysis for characterization of insonated liver tumors after microbubble contrast injection. AJR Am J Roentgenol 2006; 186:1560-70. [PMID: 16714644 DOI: 10.2214/ajr.05.0527] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The objective of our study was to compare diagnostic performance of visual and quantitative analysis for the characterization of liver tumors insonated at low transmit power after microbubble contrast agent injection. SUBJECTS AND METHODS This series comprised 166 liver tumors (1-5 cm in diameter) in 166 patients (99 men, 67 women; mean age +/- SD, 58 +/- 11 years) scanned at low transmit power (mechanical index: 0.1-0.14) after sulfur hexafluoride-filled microbubble injection. Digital cine clips recorded at the arterial phase (10-40 sec after contrast injection) and late phase (100-300 sec) were analyzed to characterize liver tumors as benign or malignant. Visual analysis was performed by three independent blinded reviewers who evaluated enhancement patterns at the arterial phase and subjective tumor conspicuity at the late phase. Quantitative analysis of videotape intensity (VI: gray-scale levels, 0-255) was performed to calculate objective tumor conspicuity at the late phase: (VI(tumor) - VI(liver)) / VI(liver). RESULTS Characteristic enhancement patterns were observed in malignant tumors (peripheral rimlike) and benign tumors (peripheral nodular or central and spoke-wheel-shaped). Malignant (n = 95) versus benign (n = 71) tumors differed for subjective (median value: -1 vs 1, respectively) and objective conspicuity at the late phase (-0.6 vs 0.15, respectively; p = 0.001, Mann-Whitney U test) due to persistent microbubble uptake in benign tumors. Diagnostic performance of visual (odds ratio: reviewer 1 = 4.28, reviewer 2 = 10.18, reviewer 3 = 9.56) and quantitative (odds ratio: 89.33) analyses differed significantly in the characterization of liver tumors (p = 0.01, chi-square test). CONCLUSION Quantitative analysis revealed higher diagnostic performance than visual analysis to characterize liver tumors insonated at low transmit power after microbubble contrast agent injection.
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Affiliation(s)
- Emilio Quaia
- Department of Radiology, University of Trieste, Cattinara Hospital, Strada di Fiume 447, Trieste 34149, Italy.
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Ogawa S, Kumada T, Toyoda H, Ichikawa H, Kawachi T, Otobe K, Hibi T, Takeshima K, Kiriyama S, Sone Y, Tanikawa M, Hisanaga Y, Yamaguchi A, Isogai M, Kaneoka Y, Washizu J. Evaluation of pathological features of hepatocellular carcinoma by contrast-enhanced ultrasonography: comparison with pathology on resected specimen. Eur J Radiol 2006; 59:74-81. [PMID: 16545532 DOI: 10.1016/j.ejrad.2006.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 02/06/2006] [Accepted: 02/06/2006] [Indexed: 12/23/2022]
Abstract
Features of hepatocellular carcinoma (HCC) observed by contrast-enhanced ultrasonography (CEUS) were compared to pathological features of corresponding resected HCC specimens, to evaluate the ability of CEUS to depict the pathological features of HCC. We investigated 50 HCC nodules that were treated by surgical resection. All nodules had been examined by CEUS with intravenous contrast agent (Levovist) before surgery. CEUS findings were divided into three phases for evaluation and classification of enhancement patterns: two vascular phases (arterial phase and portal venous phase) and the delayed phase. Pathological examination focused on differentiation and on the presence or absence of a tumor capsule, intratumoral septum, and intratumoral necrosis. All 21 nodules that showed a linear or annular vessel around the tumor margin in the arterial phase had capsular formation. Of the 27 nodules that showed heterogeneous perfusion in the portal venous phase, 21 (77.8%) had an intratumoral septum and 23 (85.2%) showed intratumoral necrosis. All nodules that were depicted as a defect with an unclear margin in the delayed phase were well-differentiated HCCs, whereas all nodules that were depicted as a defect with a clear margin were moderately or poorly differentiated HCCs. From our observations, the arterial, portal venous, and delayed phases of CEUS could reflect different pathological aspects of HCC. Some pathological characteristics of HCC might be evaluated preoperatively and non-invasively, by means of combined analysis of three phases of CEUS findings.
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Affiliation(s)
- Sadanobu Ogawa
- Department of Imaging Diagnosis, Ogaki Municipal Hospital, Ogaki, Japan
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Fraile Moreno E, Cruz Díaz A. [Diagnostic imaging in liver pathology]. Rev Clin Esp 2005; 205:97-8. [PMID: 15811274 DOI: 10.1157/13072963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
BACKGROUND The ability of colour Doppler, power Doppler and echo-enhanced Doppler imaging to detect the blood flow in liver metastases from colorectal cancer was investigated. An evaluation was then made to determine whether the flow pattern could be used as an indication of disease elsewhere. METHODS Forty-two patients with hepatic metastases from colorectal cancer were examined, 8 of whom had local recurrence of their colorectal cancer. Seventy-seven liver metastases were evaluated with colour Doppler and power Doppler, and the presence or absence of a Doppler signal in the halo or centre was noted. Forty-three of these metastases were further examined after contrast media echo-enhancement. RESULTS Signals from the peripheral halo were detected by colour Doppler imaging in 34% of the metastases, and in 77% by power Doppler (P < 0.001). Use of contrast media enhanced the power Doppler detection rate to 98% (P < 0.005). Central signals were detected by power Doppler in 12 patients, 8 (66%) of whom also had local recurrence. Thirty patients had neither local recurrence nor central signals, as detected by power Doppler (P < 0.001). CONCLUSION The results indicate that the halo in liver metastases corresponds to the vascular flow. There seems to be an association between metastases showing a central power Doppler flow and local tumour recurrence.
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