Liver focal lesions and hepatocellular carcinoma in cirrhotic patients: from screening to diagnosis.

This short review aims at pointing out the role of ultrasonography (US) as a valuable means for an early detection of liver focal lesions in cirrhotic patients. Among these lesions which may be benign and malignant, hepatocellular carcinoma (HCC) finds its place with an incidence in cirrhotic patients becoming higher as the time passes from the onset of cirrhosis. US is of fundamental importance in the regular screening of subjects with viral cirrhosis because of its sensitivity in evaluating focal lesions (79-82%); however, it is not yet the most valuable method for the diagnosis of HCC for which other diagnostic techniques are needed such as CT (Computerized Tomography), MR (Magnetic Resonance) and the US-guided fine-needle biopsy. In fact, the echo-structure of HCC varies with its dimensions and may mimic that of one of many other liver focal lesions. Lately, some new sonographic techniques have become available that can allow a more accurate investigation of HCC. Among them, the "Tissue Harmonic" and the "Pulse Inversion Imaging" techniques provide a better definition of the grey-scale image thus improving the conspicuity of focal lesions. Color and Power Doppler techniques, while allowing an accurate observation of the lesion vascularization, integrate the sonographic appearance of HCC. The enhancement of the US color Doppler signal obtainable by using echographic contrast agents, represents a further progress for a detailed observation of the focal lesions' micro-vascularization and, thus, for the HCC identification. Further advancements in terms of improvement of the image quality and characterization of the focal lesion are to be expected from the use of "Tissue Harmonic" and "Pulse Inversion Imaging" techniques associated with echographic contrast agents. However, the diagnosis of HCC still rests on the incontrovertible histological evidence obtained by echo-guided fine-needle biopsy.

[Glucagon test for Doppler sonography measurement of portal flow in chronic HCV infections] / Il test al glucagone nello studio eco-Doppler del flusso portale nell'infezione cronica da HCV.

Purpose - To evaluate whether Doppler sonography measurement of portal flow velocity (PFV) after glucagon injection can be useful in assessing the severity of liver damage in chronic HCV infection. Methods - Forty-five patients (32 males and 13 females; mean age 54.1 14.8 years) with biochemical (raised serum ALT levels), virological (positive serum HCV RNA test) and histological (liver biopsy) evidence of chronic HCV infection were included in the study. According to hepatitis staging (degree of liver fibrosis), as assessed by Knodell histological activity index, patients were divided into three groups: group 1 (n.=17), with no or mild fibrosis (fibrosis score: 0-1); group 2 (n.=11), with severe fibrosis (score: 3); and group 3 (n.=17), with liver cirrhosis (score: 4). For sonographic measurements of PFV, a Doppler ultrasound multi-purpose equipment and a convex 3.5 MHz probe were used. All patients were examined after an 8-hour fast, in supine position, 10 min before (baseline), as well as 5 and 10 min after, intravenous administration of 1 mg of glucagon chloride (Novo Nordisk). Statistical analysis was performed by ANOVA test, Bonferroni t test and Spearman rank correlation test. Results - No significant differences were found in mean basal PFV of group 1 (19.4 2.4 cm/sec), group 2 (20.1 3.6 cm/sec) and group 3 (17.5 3.7 cm/sec) (p > 0.05). Five minutes after glucagon injection, all the three groups showed a significant increase in PFV (25.6 4.8,23.7 4.0 and 19.5 5.0 cm/sec, respectively; p < 0.05 vs baseline). The peak increase in PFV after glucagon injection was significantly higher in group 1 (7.9 3.7 cm/sec; 40.7% of basal value) than in group 2 (4.5 3.9 cm/sec; 22.4%) (p < 0.05) and in group 3 (2.7+2.3 cm/sec; 15.4%) (p < 0.05). A significant (p< 0.001) inverse correlation was also found between the patients fibrosis scores and peak increments of PFV induced by glucagon. Conclusions - In some patients with chronic HCV infection, Doppler sonography measurement of PFV after glucagon injection can be useful, in combination with other non invasive ultrasound investigations, both in staging of liver disease and in monitoring the progression of liver histological damage.