Diagnostic value of color parametric imaging and contrast-enhanced ultrasound in the differentiation of hepatocellular adenoma and well-differentiated hepatocellular carcinoma.

PURPOSE: To investigate the differential diagnostic value of computer-aided color parametric imaging (CPI) and contrast-enhanced ultrasound (CEUS) in hepatocellular adenoma (HCA) and well-differentiated hepatocellular carcinoma (wHCC). METHOD: A total of 38 patients who underwent CEUS and were pathologically diagnosed with HCA (10 cases) and wHCC (28 cases) were reviewed retrospectively. The differences between the radiological features of HCA and wHCC were compared by two readers, blinded to the final diagnosis. RESULTS: (a) Sonographic features: on gray-scale ultrasound, halo sign was more common in wHCC than in HCA (60.7% vs. 10.0%, p = 0.009). On CEUS, hyper- or isoenhancement was more common in HCA in the portal phase (90.0% vs. 50.0%; p = 0.022). On CPI mode, HCA was inclined toward centripetal enhancement (60.0% vs. 14.3% p = 0.010). HCA was characterized by the presence of pseudocapsule enhancement (50.0% vs. 14.3%; p = 0.036). Quantitative analysis showed that the arrival time of HCA was earlier than that of wHCC (12.4 ± 3.7 s vs. 15.9 ± 3.2 s; p = 0.006). (b) Interobserver agreement was improved by using CPI compared with CEUS. The diagnostic sensitivity, specificity, and accuracy of the combination were 80.0%, 85.7%, and 84.2%, respectively. CONCLUSIONS: CEUS combined with CPI can provide effective information for the differential diagnosis of HCA and wHCC, especially for the non-experienced radiologists.

Value of intra-operative Doppler sonographic measurements in predicting post-operative anastomotic leakage in rectal cancer: a prospective pilot study.

BACKGROUND: Anastomotic leakage is a serious surgical complication in rectal cancer; however, effective evaluation methods for predicting anastomotic leakage individual risk in patients are not currently available. This study aimed to develop a method to evaluate the risk of leakage during surgery. METHODS: The 163 patients with rectal cancer, who had undergone anterior resection and low-ligation procedures for Doppler sonographic hemodynamic measurement from April 2011 to January 2015 in Peking University Cancer Hospital, were prospectively recruited. A predictive model was constructed based on the associations between anastomotic leakage and alterations in the anastomotic blood supply in the patients, using both univariate and multivariate statistical analyses, as well as diagnostic methodology evaluation, including Chi-square test, logistic regression model, and receiver operating characteristic curve. RESULTS: The overall anastomotic leakage incidence was 9.2% (15/163). Doppler hemodynamic parameters whose reduction was significantly associated with anastomotic leakage were peak systolic velocity, pulsatility index, and resistance index. The areas under the receiver operating characteristic curve of residual rates of peak systolic velocity, pulsatility index, and resistance index in predicting anastomotic leakage were 0.703 (95% confidence interval [CI]: 0.552-0.854), 0.729 (95% CI: 0.579-0.879), and 0.689 (95% CI: 0.522-0.856), respectively. The predictive model revealed that the patients with severely reduced blood-flow signal exhibited a significantly higher incidence rate of anastomotic leakage than those with sufficient blood supply (19.6% vs. 3.7%, P = 0.003), particularly the patients with low rectal cancer (25.9% vs. 3.9%, P = 0.007) and those receiving neoadjuvant chemoradiotherapy (32.1% vs. 3.7%, P = 0.001), independent of prophylactic ileostoma. Multivariate analysis revealed that insufficient blood supply of the anastomotic bowel was an independent risk factor for anastomotic leakage (odds ratio: 10.37, 95% CI: 2.703-42.735, P = 0.001). CONCLUSION: Based on this explorative study, Doppler sonographic hemodynamic measurement of the anastomotic bowel presented potential value in predicting anastomotic leakage.

Diagnostic Value of Arrival Time Parametric Imaging Using Contrast-Enhanced Ultrasonography in Superficial Enlarged Lymph Nodes.

OBJECTIVE: The aim of this study was to evaluate the value of arrival-time parametric imaging for differential diagnosis of superficial enlarged lymph nodes. METHODS: Patients with lymphadenopathy who received contrast-enhanced ultrasonography (CEUS) and biopsy were included in this study. Following CEUS, a prototype software of the arrival-time parametric imaging system was used to analyze the video footage. Arrival-time patterns during the arterial phase were evaluated. The quantitative parameters including arrival time of periphery, arrival time of center, and the travel time (△T) were calculated. RESULTS: A total of 145 lymph nodes were analyzed. Arrival-time parametric imaging showed that 80.3% of metastatic lymph nodes and 68.4% of lymphoid tuberculosis presented a centripetal perfusion pattern, 76.5% of lymphoma showed complete homogeneous enhancement, and 81.2% of reactive lymph nodes had centrifugal patterns. The arrival time of periphery (sec) of metastatic lymph nodes was substantially earlier than that of lymphoma (11.0 ± 3.1 versus 12.6 ± 3.6; P < .05). The arrival time of center (sec) of metastatic lymph nodes was obviously later than that of lymphoma and reactive lymph nodes (13.4 ± 3.3 versus 10.5 ± 2.9 and 10.6 ± 1.5; P < .05). The travel time (△T) (sec) in metastatic lymph nodes was substantially longer than in reactive lymph nodes and lymphoma (4.2 ± 2.1 versus 2.3 ± 1.6 and 2.9 ± 2.5; P < .05). At a △T cutoff value of 2.75 seconds (using the receiver operating characteristic curve), the sensitivity and specificity in differentiating metastatic lymph nodes from benign lymph nodes (lymphoid tuberculosis and reactive lymph nodes) were 78.9% and 64.7%, respectively. CONCLUSIONS: Enhanced patterns and parameters of arrival-time parametric imaging during CEUS could provide more information for the differential diagnosis of enlarged superficial lymph nodes.

Diagnostic Value of Contrast-Enhanced Ultrasonography and Time-Intensity Curve in Differential Diagnosis of Cervical Metastatic and Tuberculous Lymph Nodes.

OBJECTIVES: To evaluate the diagnostic value of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of tuberculous and metastatic lymph nodes. METHODS: Nineteen cervical tuberculous lymph nodes and 43 cervical metastatic lymph nodes were investigated. The CEUS perfusion patterns and parameters of time-intensity curve (TIC) were analyzed. Diagnostic accuracy and consistency of two physicians were compared before and after CEUS and TIC analysis. RESULTS: Conventional ultrasonography showed no significant differences between tuberculous and metastatic lymph nodes. Concentric enhancement at the arterial phase of CEUS occurred in 15 of 19 (78.9%) tuberculous lymph nodes and 42 of 43 (97.7%) metastatic lymph nodes (P < .05). For the TIC curve, a steep descending curve with an apparent notch was commonly found in tuberculous lymph nodes (13 of 16). Although a shallow descending curve was common (40 of 43) in metastatic lymph nodes, most did not have a notch on the curve (39 of 43) (P < .01). The k-value and the peak intensity (PI) value of tuberculous lymph nodes were significantly higher and the △PI value was significantly lower than that of metastatic lymph nodes (P < .05, respectively). Kappa values for the diagnosis consistency of the two physicians before and after CEUS and TIC analysis were 0.582 and 0.761, respectively. Diagnostic accuracy before and after CEUS and TIC analysis was 47.4% (28 of 59) and 96.6% (57 of 59), respectively (P < .001). CONCLUSIONS: Contrast-enhanced ultrasonography with TIC analysis is helpful in differentiating tuberculous from metastatic lymph nodes.

Effects of Gray-Scale Ultrasonography Immediate Post-Contrast on Characterization of Focal Liver Lesions.

This study compared the imaging features of conventional gray scale ultrasound (US) before and after contrast-enhanced ultrasound (CEUS) for focal liver lesions and 22 evaluated the role of US post-CEUS in characterizing liver lesions. 126 patients with 158 focal liver lesions underwent CEUS and US post-CEUS examination and entered this study. There were 74 hepatocellular carcinomas (HCC), 43 hepatic metastases, and 41 hemangiomas. Imaging features of US pre-CEUS and US post-CEUS were analyzed offsite by two blinded experienced radiologists to evaluate size, boundary, echogenicity, internal texture, posterior acoustic enhancement, spatial resolution, and contrast resolution. In the end with pathological and clinical evidence, the diagnostic accuracy rate of US pre-CEUS was 53.8% (85/158 lesions), lower than that of CEUS (88.0%, 139/158 lesions); with the complementation of US post-CEUS the rate rose to 93.0% (147/158 lesions). US post-CEUS could improve the visibility of typical structures of focal liver lesions and might provide important complementary information for CEUS diagnosis. It also increases the visibility of small liver lesions compared with US pre-CEUS and helps to guide local interventional procedure.

Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography.

AIM: To investigate the diagnostic value for the diagnosis of small (1-2 cm) hepatic nodules detected by surveillance ultrasound in patients with cirrhosis using contrast-enhanced ultrasound (CEUS) compared with that of contrast-enhanced helical computed tomography (CECT). METHODS: Seventy-two liver cirrhosis patients with 103 small hepatic nodules (1-2 cm) detected by surveillance ultrasound were enrolled in the present study. All patients underwent CEUS with SonoVue as well as CECT. Nodules which appeared by contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CECT were diagnosed as malignant (hepatocellular carcinoma [HCC]). Histopathology obtained from biopsy or surgery served as the gold standard. RESULTS: According to the above diagnostic criteria, the sensitivity (i.e. rate of correct diagnosis of HCC) was 91.1% (51/56 HCC) for CEUS and the specificity (i.e. the rate of correct exclusion of HCC) was 87.2% (41/47 regenerative nodules [RN]).Therefore, the diagnostic accuracy of CEUS was 89.3% (92/103 all nodules). Using the same diagnostic criteria, the sensitivity, specificity and accuracy of CECT were 80.4% (45/56 HCC), 97.9% (46/47 RN), and 88.4% (91/103 all nodules). Overall, there was no significant difference between CEUS and CECT in the diagnostic confidence of small hepatic nodules. Eighty-six nodules (45 HCC and 41 RN) were correctly diagnosed by both modalities and six (five HCC and one RN) were misdiagnosed by both. CONCLUSION: The ability of CEUS in the characterization of small nodules (1-2 cm) detected by surveillance US in patients with liver cirrhosis is similar to that of CECT.

Focal liver lesions: can SonoVue-enhanced ultrasound be used to differentiate malignant from benign lesions?

OBJECTIVE: To evaluate whether contrast-enhanced ultrasound (CEUS) with SonoVue could differentiate malignant focal liver lesions (FLLs) from benign lesions and provide lesion type diagnoses. MATERIALS AND METHODS: Four hundred fifty-six patients with 554 FLLs were examined by CEUS with SonoVue using low mechanical index, nonlinear imaging techniques. Each lesion was characterized by 2 independent off-site readers as malignant or benign and given specific lesion type diagnosis, if possible, both at baseline ultrasound (US) and after SonoVue administration (CEUS). The final diagnosis was achieved by histopathology obtained from biopsy or surgical specimens, or by typical manifestation on contrast-enhanced CT or MRI. RESULTS: The diagnostic accuracies of the 2 readers were 41.9% and 35.2% for baseline US, which improved significantly to 87.2% and 87.9% for CEUS (P < 0.05). Interreader agreement also increased with CEUS compared with baseline US (ê value changed from 0.49 to 0.77). The accuracy for lesion type diagnosis was 38.4% and 32.5% for baseline US, which increased to 77.6% and 78.0% for CEUS (P < 0.05). CONCLUSIONS: CEUS with SonoVue improves differentiation between malignant and benign FLLs, and also provides improved lesion type (differential) diagnosis.

[The assessment of wall invasion of rectal carcinoma: correlation of endoluminal ultrasonographic and pathologic findings].

OBJECTIVE: To evaluate the accuracy of endoluminal ultrasonography (ELUS) in the preoperative assessment of wall invasion of rectal carcinoma and analyze its influencing factors. METHODS: ELUS was performed preoperatively in 117 patients with rectal carcinoma, in which no preoperative treatment was given. The results of ELUS were correlated with operative and pathologic findings according to the TNM classification. We observed the following factors and analyzed their impact on the accuracy of ELUS: tumor location, the depth of the tumor invasion, and the inflammatory cell infiltration and fibrosis peritumor. RESULTS: The overall accuracy of ELUS in T stage was 76.9% (90/117). The sensitivity of ELUS for pT(1), pT(2), pT(3) and pT(4) carcinoma was 87.5% (7/8), 51.7% (15/29), 85.7% (60/70), 80% (8/10), respectively. Misdiagnosis occurred in 27 cases, of which 14 cases were overstaged and 13 cases were understaged. The sensitivity for pT(2) carcinoma was the lowest; 14 cases were misdiagnosed, of them 13 cases were overstaged. Overstaging with ELUS for pT(2) carcinoma occurred mainly in these cases in which inflammatory cell infiltration, fibrosis or tumor involved more than one-third of muscularis propria. 13 cases were understaged, of which tumors in 7 cases were located in superior segment of rectum and 4 cases with obviously rectal stenosis. When tumor was located in middle or lower segment of rectum, misdiagnostic rate was 18.5% (17/92); while tumor was located in superior segment of rectum, misdiagnostic rate was 40% (10/25), and differences were statistically significant between two groups in misdiagnostic rate (P = 0.024). CONCLUSION: Although ELUS in the preoperative assessment of wall invasion of rectal carcinoma is useful, it is difficult to avoid overstaging and understaging of ELUS. The overstaging is an important unfavourable factor in assessing the invasion depth of pT(2) carcinoma with ELUS, and the depth of tumor invasion muscularis propria, and the depth of inflammatory cell infiltration and fibrosis might be responsible for overstaging. Obviously rectal stenosis and tumor being located in the superior segment of rectum might cause understaging.

The role of contrast-enhanced sonography of focal liver lesions before percutaneous biopsy.

OBJECTIVE: The objective of our study was to evaluate the clinical utility of performing contrast-enhanced sonography before percutaneous biopsy of focal liver lesions. SUBJECTS AND METHODS: One hundred eighty-six patients with focal liver lesions detected on either sonography or contrast-enhanced CT were randomly divided into two groups: a group who underwent contrast-enhanced sonography and another who underwent unenhanced sonography. The contrast-enhanced sonography group (79 patients, 129 lesions) underwent SonoVue-enhanced sonography before biopsy, and the unenhanced sonography group (107 patients, 143 lesions) did not undergo contrast-enhanced sonography before biopsy. Conventional sonography was used in all patients to guide the biopsy procedures. The pathologic diagnosis was considered definitive and final if the biopsy result was malignant. If the initial biopsy result was benign or negative for malignancy, then the result was either confirmed or denied on the basis of contrast-enhanced CT, MRI, angiography, serum alpha-fetoprotein level, or clinical follow-up over a period of 6 months. In some patients with suspected malignancy, biopsy was repeated when considered necessary during the follow-up. The diagnostic accuracy of the initial biopsy was defined as the percentage of the total number of lesions that were correctly diagnosed at the initial biopsy. The difference in diagnostic accuracy between the two groups was analyzed to evaluate the value of performing contrast-enhanced sonography before biopsy. RESULTS: Of the 129 lesions in the contrast-enhanced sonography group, 28 (21.7%) were benign and 101 (78.3%) were malignant. Of the 143 lesions in the unenhanced sonography group, 36 (25.2%) were benign and 107 (74.8%) were malignant. There was no significant difference in the distribution of malignant and benign lesions in these two groups (p > 0.05). There was no statistically significant difference in the distribution of lesions by size between the contrast-enhanced and unenhanced sonography groups (chi(2) = 0.619, p > 0.05). The diagnostic accuracy of the initial biopsy was significantly higher in the contrast-enhanced sonography group than in the unenhanced sonography group (95.3% vs 87.4%, respectively; p < 0.05). The diagnostic accuracy of the initial biopsy for malignant lesions < or = 2.0 cm was also significantly higher in the contrast-enhanced sonography group than in the unenhanced sonography group (97.1% vs 78.8%, respectively; p < 0.05). No major complications occurred in our study except one case of pneumothorax in the unenhanced sonography group. CONCLUSION: Contrast-enhanced sonography before percutaneous focal liver lesion biopsy improved the diagnostic accuracy of the procedure by providing important intralesional information for differentiating viable, denaturalized, or necrotic tissue; consequently, by providing more accurate information about the site of biopsy even in lesions < or = 2.0 cm, contrast-enhanced sonography before biopsy reduced the number of puncture attempts.

The role of contrast-enhanced ultrasound on the diagnosis of small hepatocellular carcinoma (

BACKGROUND: This study aimed to investigate the diagnostic value of contrast-enhanced ultrasound (CEUS) of small hepatocellular carcinomas (HCC) (

Evaluation of primary malignancies of the liver using contrast-enhanced sonography: correlation with pathology.

OBJECTIVE: Our purpose was to investigate the correlation of contrast-enhanced sonographic patterns with the histopathology of primary malignancies of the liver. MATERIAL AND METHODS: Of the 318 contrast-enhanced sonographic examinations performed between April and September 2004, 95 patients with 117 lesions confirmed by surgery or biopsy pathology were reviewed in this study. We analyzed the enhancement time and patterns according to the types and degrees of pathologic differentiation. RESULTS: All 65 moderately to poorly differentiated hepatocellular carcinomas (HCCs) enhanced in the arterial phase, and 96.9% (63 lesions) of them quickly washed out in the portal venous phase. All 32 well-differentiated HCCs enhanced in the arterial phase, and 50.0% (16 lesions) washed out slowly during the late phase. The washout time of the two differentiated types was significantly different (p < 0.05). Seventy-five percent of the clear cell carcinomas (12/16) enhanced in the arterial phase, 25% (4/16) did not enhance until the portal venous phase, and 31.3% (5/16) of the clear cell carcinomas washed out slowly during the late phase. The enhancement and washout times of clear cell carcinomas were significantly different than those of moderately to poorly differentiated HCCs (p < 0.05). All four intrahepatic cholangiocarcinomas presented the same patterns as moderately to poorly differentiated HCCs: enhanced in the arterial phase and quickly washed out in the portal venous phase. Among the 72 lesions enhanced homogeneously, 46 lesions (63.9%) were smaller than 3 cm. Thirty-seven lesions (82.2%) of the 45 lesions that enhanced heterogeneously were larger than 3 cm (including the four cholangiocarcinomas). Larger lesions were mainly less differentiated. There were significant differences in tumor sizes in regard to cellular differentiations and types. CONCLUSION: Our study showed that the enhancement manifestations of primary malignancies of the liver are related to pathologic types and grades. Contrast-enhanced sonograms may provide the histopathologic information for malignant tumors of the liver.

[Application of contrast-enhanced ultrasound to increase the diagnostic rate of liver tumor by biopsy].

OBJECTIVE: To evaluate the clinical utility of contrast-enhanced ultrasound (CEUS) in percutaneous liver biopsy of focal liver lesions. METHODS: Two hundred and eleven patients with unidentified space occupying lesions in liver, 112 males and 74 females, aged 52 (16-78), were randomly divided into 2 groups: CEUS group in which 96 cases with 149 lesions underwent liver biopsy with 21-18 gauge needles directed by real time grey CEUS, and routine ultrasound (US) group in which 115 patients with 153 lesions underwent biopsy guided by conventional ultrasonography. There was no significant difference in the size of lesions between these 2 groups. There were 75 minute malignant lesions with the size of < or = 2.0 cm (24.8%) in 67 patients, 12.9% in the CEUS group and 11.9% in the US group. Obtainment of adequate specimen for pathological examination meant successful biopsy. Definite diagnosis was made by the combination of the results of pathological examination, CEUS, CT, MRI, angiography, serum alpha-fetoprotein, and 3 to 6-month follow-up. RESULTS: The proportion of no more than 2 puncture attempts in the CEUS group was 33/19, significantly higher than that in the US group (8/153, P = 0.0007). The biopsy success rate of the CEUS group was 98.7%, significantly higher than that of the US group (91.5%, P = 0.0096). The accurate diagnosis rate of the CEUS group was 96.0%, significantly higher than that of the US group (87.6%, P = 0.0165). The accurate diagnosis rate of malignant lesions with the size of < or = 2.0 cm in the CEUS group was 97.4%, significantly higher than that in the US group (80.6%, P = 0.0473). Among the 112 confirmed malignant lesions in the US group 15 had been diagnosed as benign by pathological examination of the biopsy specimens with a false negative rate of 13.4%. The relevant patients underwent CEUS-guided biopsy again and 14 of the 15 lesions were confirmed as malignant finally and the size of 6 of the 14 lesions was < or = 2.0 cm. Except for one case of pneumothorax in the US group no major complication occurred. CONCLUSION: Biopsy guided by CEUS is more accurate in location and diagnosis of malignant lesions and minute tumors in the liver, thus increasing the success rate of biopsy and the confirmed diagnosis rate of malignant lesions.

[Early diagnosis of small hepatocellular carcinoma by new contrast-enhanced ultrasound technique].

OBJECTIVE: To investigate the diagnostic value of contrast-enhanced ultrasound (CEUS) enhancement patterns of hepatocellular carcinoma (HCC) smaller than 2 cm. METHODS: From 392 cases with focal liver lesions undergoing CEUS with SonoVue and Contrast Tuned Imaging (CnTI) technique, thirty six cirrhotic patients with thirty eight HCCs with histopathological diagnosis were retrospectively analyzed in this study. Surgery or needle biopsy was performed within fifteen days after CEUS. Twenty two tumors were finally diagnosed as moderately differentiated HCC, twelve as well differentiated HCC, and four as clear cell carcinomas using Edmondson Grade system. The enhancement patterns of different histopathological HCCs were analyzed. RESULTS: Before CEUS, only 16 lesions (42.1%) were diagnosed as malignant or possibly malignant. After CEUS, 38 HCCs were enhanced in different degrees following contrast administration,of which, all the 22 moderately differentiated HCCs presented typical "fast-in and fast-out" pattern with fast enhancement in arterial phase and then a quick wash-out in the parenchymal phase. Nine (75.0%) of the 12 well differentiated HCCs presented "fast-in and slow-out" pattern. One of the 4 clear cell carcinomas presented "fast-in and fast-out", one presented "fast-in and slow-out" and the other 2 presented "slightly slow-in and slow-out" pattern. According to the enhancement patterns, 76.3% (29 tumors) were considered as malignant, while 18.4% (7 tumors) as possibly malignant, only 5.3% (2 tumors smaller than 1.5 cm) could not be diagnosed by CEUS. CONCLUSION: The identification of different enhancement patterns of various histological types of small HCCs could improve the diagnostic ability of ultrasound in cirrhotic liver. CEUS might be also helpful in detecting small HCCs. Thus CEUS could be a complementary method of enhanced CT and other imaging methods in early diagnosis of HCCs.