Contrast-enhanced intraoperative ultrasound for hepatocellular carcinoma: high sensitivity of diagnosis and therapeutic impact

Contrast-Enhanced Intraoperative Ultrasound of the Liver

Contrast-enhanced intraoperative ultrasound (CE-IOUS) is a relatively new but valuable tool that is increasingly used as an adjunct to computed tomography, MRI, and IOUS for patients undergoing liver surgery. CE-IOUS has an important role in 2 main settings: the discrimination of indeterminate lesions detected in cirrhotic livers by conventional IOUS and in the detection of colorectal liver metastasis that may be overlooked by other imaging modalities. The intraoperative nature of the imaging and interpretation allows for CE-IOUS to directly affect surgical decision-making that may importantly affect patient outcomes.

Protocol of Kupffer phase whole liver scan for metastases: A single-center prospective study

Introduction

As the presence of hepatic metastases is very important to cancer patients' clinical stage which would directly affect the selection and application of anti-cancer treatments. Although conventional ultrasound is commonly performed as a screening tool, most of the examinations have relatively poor sensitivity and specificity for detecting liver metastases. Contrast-enhanced ultrasound (CEUS) with Sonazoid has been reported to have the advantage of the diagnosis and therapeutic support of focal hepatic lesions and its specific Kupffer phase whole liver scan (KPWLS) is believed to be sensitive to detect liver metastases. And the purpose of this study is to determine the number, size, location and diagnosis of metastatic lesions, and to compare the results with conventional ultrasound and contrast-enhanced computed tomography (CECT), thus to clarify the application value, indications of Sonazoid-CEUS in screening liver metastasis.

Methods and analysis

Kupffer phase whole liver scan for metastases (KPWLSM) is a self-control, blind map-reading, single-center, prospective superiority trial. Approved by the institutional review committee, the study period is planned to be from 1 January 2022 to 31 December 2025. Our study will include 330 patients with history of malignant tumors that cling to metastasize to liver. All patients will undergo the examinations of conventional ultrasound, Sonazoid-CEUS, and contrast-enhanced magnetic resonance imaging (CEMRI), and 65 of them should have additional CECT scans. The primary endpoint is the comparative analysis of the numbers of detected liver metastatic lesions among Sonazoid-CEUS, conventional ultrasound and CECT in screening liver metastases. Subjective conditions of patient after injection of Sonazoid will be followed up 3 and 30 days after KPWLSM, and any short-term and long-term adverse events are to be recorded with telephone interviews.

Ethics and dissemination

This study has been granted by the Ethics Committee of Shanghai Jiao Tong University Affiliated Sixth People's Hospital (Approval No: 2021-197). When the KPWLSM is completed, we will publish it in an appropriate journal to promote further widespread use.

Registration

Trial Registration Number and Date of Registration: Chinese Clinical Trial Registry, ChiCTR2100054385, December 16, 2021.

Contrast-Enhanced Intraoperative Ultrasonography with Kupffer Phase May Change Treatment Strategy of Metastatic Liver Tumors - A Single-Centre Prospective Study

Aim

To compare the diagnostic performance of contrast-enhanced intraoperative ultrasonography (CE-IOUS) with Kupffer phase in metastatic liver tumours.

Methods

Twenty-seven consecutive patients with liver metastasis were prospectively recruited from November 2019 to July 2020 in the Department of HPB, Beijing Hospital. MRI and Contrast Enhanced Ultrasonography (CEUS) were obtained preoperatively, and the diagnosis was made by radiologists independently and blindly. Intraoperative ultrasonography (IOUS) and CE-IOUS with Sonazoid were done by the same sophisticated surgeon and sonographer and Kupffer phase was used to detect lesions. The sensitivity and specificity to detect lesions were compared between different radiologic methods. Then, the changes in treatment strategy due to CE-IOUS with Sonazoid were analysed.

Results

Twenty-seven patients were included. In MRI, 91 lesions were detected with sensitivity 93.3% (70/75) and specificity 68.8% (11/16). In CEUS, it was 97.1% (68/70) and 86.7% (13/15) in 85 lesions. Meanwhile, in the Kupffer phase in CE-IOUS, 99 lesions were found and 8 new lesions were discovered in 7 cases, with sensitivity 97.5% (80/82) and specificity 94.1% (16/17). The four imaging methods showed no statistic significance in sensitivity and specificity in detecting lesions (Cochran’s Q 10.825, P=0.055). Treatment strategies were altered in 7 patients, 6 achieved R0 resection or ablation, and 1 patient changed from planned R0 resection to palliative surgery.

Conclusion

CE-IOUS may play a similar or even better role than other radiological methods in diagnosing liver metastasis. The CE-IOUS using Sonazoid demonstrated a high sensitivity and specificity for finding occult metastases intraoperatively and changing the treatment strategy.

Current role of intraoperative ultrasonography in hepatectomy

Hepatectomy had a high mortality rate in the previous decade because of inadequate techniques, intraoperative blood loss, liver function reserve misdiagnoses, and accompanying postoperative complications. However, the development of several modalities, including intraoperative ultrasonography (IOUS), has made hepatectomy safer. IOUS can provide real-time information regarding the tumor position and vascular anatomy of the portal and hepatic veins. Systematic subsegmentectomy, which leads to improved patient outcomes, can be performed by IOUS in open and laparoscopic hepatectomy. Although three-dimensional (3D) computed tomography and gadoxetic acid-enhanced magnetic resonance imaging have been widely used, IOUS and contrast-enhanced IOUS are important modalities for risk analyses and making decisions regarding resectability and operative procedures because of the vital anatomical information provided and high sensitivity for liver tumors, including "disappearing" liver metastases. Intraoperative color Doppler ultrasonography can be used to delineate the vascular anatomy and evaluate the blood flow volume and velocity in hepatectomy patients and recipients of deceased- and living-donor liver transplantation after vessel reconstruction and liver positioning. For liver surgeons, IOUS is an essential technique to perform highly curative hepatectomy safely, although recent advances have also been made in virtual modalities, such as real-time virtual sonography with 3D visualization.

Des-gamma-carboxy prothrombin affects the survival of HCC patients with marginal liver function and curative treatment: ACRoS1402

PURPOSE

Considering the initial treatment of hepatocellular carcinoma (HCC), the best prognostic index for Child-Pugh classes B and C (CP-BC) patients has not been yet established. This study aimed to elucidate the risk factors for disease-free survival (DFS) and overall survival (OS) in multicenter patients with a poor liver functional reserve after curative treatment.

METHODS

Between April 2000 and April 2014, 212 CP-BC patients who received treatment in five high-volume centers in Japan were included in this study. CP-B and C patients were 206 and 6, respectively. Cox proportional hazard regression analyses for DFS and OS were performed to estimate the risk factors.

RESULTS

The mean observation time was 1132 days. Mean Child-Pugh score and indocyanine green retention rate at 15 min were 7.5 and 31.5%, respectively. Histological chronic hepatitis and liver cirrhosis were observed in 20% and 74% patients, respectively. In the multivariate analysis, the risk factors for DFS were des-gamma-carboxy prothrombin (DCP) [hazard ratio (HR), 1.6; P = 0.012] and treatment without liver transplantation. Moreover, DCP was identified as an independent risk factor for OS (HR, 1.7; P = 0.01). Tumor size, number, tumor thrombus, Milan criteria, liver cirrhosis, and treatment without liver transplantation were not identified as risk factors for OS. The 5-year OS in patients with high serum DCP levels (< 90 mAU/mL) was significantly better than that in those with low serum DCP levels (P = 0.003).

CONCLUSIONS

Serum DCP value before treatment predicted both DFS and OS in CP-BC patients with HCC.

Contrast-enhanced US with Perfluorobutane(Sonazoid) used as a surveillance test for Hepatocellular Carcinoma (HCC) in Cirrhosis (SCAN): an exploratory cross-sectional study for a diagnostic trial

Background

Ultrasonography (US) is widely used as a standard surveillance tool for patients who are at a high risk of having hepatocellular carcinoma (HCC); however, conventional B-mode US appears to be insufficient in order to ensure the early detection of HCC. Perfluorobutane allows very stable Kupffer phase imaging for at least 60 min, which is tolerable for examinations of the entire liver. The purpose of our study is to evaluate the added value of contrast-enhanced US using perfluorobutane to that of conventional B-mode US as an HCC surveillance tool for patients with liver cirrhosis.

Methods/Design

SCAN (Sonazoid-US for surveillance of hepatoCellulArcarciNoma) is a prospective, multi-institutional, diagnostic trial using an intra-individual comparison design in a single arm of patients. This study was approved by our five institutional review board and informed consent was obtained from all participating. We obtained consent for publication of these data (contrast enhanced US images, CT or MRI images, laboratory findings, age, sex) from all participating patients. All patients will undergo conventional B-mode US immediately followed by contrast-enhanced US. The standardized case report forms will be completed by operating radiologists after B-mode US and contrast-enhanced US, respectively. If any lesion(s) is detected, the likelihood of HCC will be recorded. The primary endpoints are a detection rate of early-stage HCC and a false referral rate of HCC. Intra-individual comparison using Mcnemar’s test will be performed between B-mode US and contrast-enhanced US. The study will include 523 patients under HCC surveillance in five medical institutions in Korea.

Discussion

SCAN is the first study to investigate the efficacy of contrast-enhanced US in surveillance using two reciprocal endpoints specialized for the evaluation of a surveillance test. SCAN will provide evidence regarding whether patients can truly benefit from contrast-enhanced US in terms of the detection of early stage HCC while avoiding additional unnecessary examinations. In addition to the study protocol, we elaborate on potentially debatable components of SCAN, including the design of an intra-individual comparison study, study endpoints, composite reference standards, and indefinite imaging criteria regarding the likelihood of HCC.

Trial registration

The date of trial registration (ClincalTrials.gov: NCT02188901) in this study is July 3, 2014. The last patient enrolled in August 30, 2016 and follow up to see the primary end point is still ongoing. All authors have no other relationships/conditions/circumstances that present a potential conflict of interest of relationships. Our study protocol has undergone peer-review by the funding body (GE Healthcare). No other relationships/conditions/circumstances that present a potential conflict of interest. Also, we clearly stated in the 'competing interests' section of my manuscript.

Role of contrast-enhanced ultrasonography with Sonazoid for hepatocellular carcinoma: evidence from a 10-year experience

Hepatocellular carcinoma (HCC) represents primary liver cancer. Because the development of HCC limits the prognosis as well as the quality of life of the patients, its management should be properly conducted based on an accurate diagnosis. The liver is the major target organ of ultrasound (US), which is the simple, non-invasive, and real-time imaging method available worldwide. Microbubble-based contrast agents are safe and reliable and have become popular, which has resulted in the improvement of diagnostic performances of US due to the increased detectability of the peripheral blood flow. Sonazoid (GE Healthcare, Waukesha, WI, USA), a second-generation contrast agent, shows the unique property of accumulation in the liver and spleen. Contrast-enhanced US with Sonazoid is now one of the most frequently used modalities in the practical management of liver tumors, including the detection and characterization of the nodule, evaluation of the effects of non-surgical treatment, intraoperative support, and post-treatment surveillance. This article reviews the 10-year evidence for contrast-enhanced US with Sonazoid in the practical management of HCC.

Real-time contrast-enhanced sonographically guided biopsy or radiofrequency ablation of focal liver lesions using perflurobutane microbubbles (sonazoid): value of Kupffer-phase imaging

OBJECTIVES

To evaluate the utility of Kupffer-phase imaging by real-time contrast-enhanced sonography using the perflurobutane microbubble contrast agent Sonazoid (GE Healthcare, Oslo, Norway) in guiding biopsy or radiofrequency (RF) ablation of focal liver lesions.

METHODS

A total of 75 patients (mean age, 59.7 years) who were referred for percutaneous biopsy (n = 42) or RF ablation (n = 33) were included in the study. Grayscale sonography and contrast-enhanced sonography using Sonazoid were performed in all patients before the procedure. The conspicuity of each targeted liver lesion on grayscale sonography, vascular-phase contrast-enhanced sonography, and Kupffer-phase contrast-enhanced sonography was graded using a 5-point scale. Lesion detection rates were calculated, and the conspicuity of the lesions among the imaging modalities was compared. The technical success of the procedures was also assessed.

RESULTS

The procedures were conducted in 66 patients (biopsy in 41 and RF ablation in 25) under real-time guidance by Kupffer-phase contrast-enhanced sonography. Lesion detection rates were 77.3% (58 of 75), 84.0% (63 of 75), and 92.0% (69 of 75) on grayscale sonography, vascular-phase contrast-enhanced sonography, and Kupffer-phase contrast-enhanced sonography, respectively, and were significantly different among the 3 modalities (P= .034). Overall, lesion conspicuity was significantly increased on vascular-phase and Kupffer-phase contrast-enhanced sonography compared to grayscale sonography (P < .001). Technical success rates for the procedures were 95.2% (40 of 42) for biopsy and 69.7% (23 of 33) for RF ablation.

CONCLUSIONS

Kupffer-phase imaging by contrast-enhanced sonography using Sonazoid increases the conspicuity of the liver lesions compared to grayscale sonography, and it is useful for real-time guidance of percutaneous biopsy or RF ablation of focal liver lesions.

A novel approach to patient self-monitoring of sonographic examinations using a head-mounted display

OBJECTIVES

Patients' use of a head-mounted display during their sonographic examinations could provide them with information about their diseases in real time and might help improve "patient-centered care." We conducted this prospective study to evaluate the feasibility of a modern head-mounted display for patient self-monitoring of sonographic examinations.

METHODS

In November and December 2013, 58 patients were enrolled. Patients wore a head-mounted display (HMZ-T2; Sony Corporation, Tokyo, Japan) during their sonographic examinations and watched their own images in real time. After the sonographic examinations, the patients completed a questionnaire, in which they evaluated the utility of the head-mounted display, their understanding of their diseases, their satisfaction with using the head-mounted display, and any adverse events. Until November 26, 2013, patients' names were requested on the questionnaire; after that date, the questionnaire was changed to be anonymous.

RESULTS

Of the 58 patients, 56 (97%) elected to participate in this study. The head-mounted display was reported to have good image quality by 42 patients (75%) and good wearability by 39 (70%). Thirty-six patients (64%) reported they had deepened their understanding of their diseases. There were no major complications, and only 2 patients (4%) had mild eye fatigue. There was no significant association between questionnaire results and patient characteristics. None of the questionnaire results changed significantly after the questionnaire was made anonymous.

CONCLUSIONS

The use of a modern head-mounted display by patients during sonographic examinations provided good image quality with acceptable wearability. It could deepen their understanding of their diseases and help develop patient-centered care.

Does the preoperative alpha-fetoprotein predict the recurrence and mortality after hepatectomy for hepatocellular carcinoma without macrovascular invasion in patients with normal liver function?

AIM

It has been highly controversial whether elevated serum α-fetoprotein (AFP) level before hepatectomy predicts recurrence and mortality of patients with hepatocellular carcinoma (HCC) or not. This study is to identify whether the index predicts recurrence and mortality after hepatectomy in HCC.

METHODS

Of 568 consecutive patients, 342 with normal liver function (Child-Pugh score, 5) and no macrovascular invasion were enrolled between April 2000 and March 2013. Multivariate analysis was performed to identify risk factors for disease-free survival (DFS) and overall survival (OS).

RESULTS

In multivariate analysis, the elevated serum AFP level was an independent risk factor for DFS (hazard ratio [HR], 1.9; P < 0.0001) and OS (HR, 2.0; P < 0.0001). Histological hepatic venous tumor thrombus was also an independent risk factor for DFS (HR, 2.6; P < 0.0001) and OS (HR, 2.5; P = 0.001). Anatomical resection decreases the risk factor for recurrence after hepatectomy (HR, 0.6; P = 0.003), though it did not decrease the risk for OS (P = 0.3). At 5 years, DFS rates were 42% and 21% (P < 0.0001) and OS rates were 75% and 46% among patients with low and high AFP levels, respectively (P < 0.0001). The area under the receiver-operator curves (AUROC) of serum AFP and des-γ-carboxy prothrombin were 0.65 and 0.58 for DFS and 0.65 and 0.57 for OS, respectively. Tumor size was the best predictor of microvascular invasion (AUROC, 0.70, P < 0.0001).

CONCLUSION

Serum AFP was a highly reliable index for DFS and OS.

Contrast-enhanced ultrasonography: advance and current status in abdominal imaging

In the field of contrast-enhanced ultrasonography (US), contrast agents are classified as either first- or second-generation agents depending on the gas within the microbubbles. In the case of first-generation contrast agents, a high-mechanical-index technique is used and only intermittent scanning is possible due to the early destruction of the microbubbles during the scanning. The use of second-generation contrast agents in a low-mechanical-index technique enables continuous scanning. Besides the detection and characterization of focal liver lesions, contrastenhanced US is helpful in the monitoring of radiofrequency ablation therapy and in the targeting step of an US-guided biopsy. Recently, there has been a demand for new criteria to evaluate the treatment response obtained using anti-angiogenic agents because morphologic criteria alone may not reflect the treatment response of the tumor and contrast-enhanced US can provide quantitative markers of tissue perfusion. In spite of the concerns related to its cost-effectiveness, contrast-enhanced US has the potential to be more widely used as a complimentary tool or to substitute the current imaging modalities in some occasions.

Alcohol consumption and recurrence of non-B or non-C hepatocellular carcinoma after hepatectomy: a propensity score analysis

BACKGROUND

The aim of this study was to identify factors related to the recurrence of non-B or non-C (NBNC) hepatocellular carcinoma (HCC).

STUDY DESIGN

Between April 2000 and March 2012, out of 621 consecutive HCC patients at our institution, 543 who underwent initial hepatectomy and had no extrahepatic metastases were enrolled in the study. Multivariate analysis were performed to identify risk factors for poor disease-free survival (DFS).

RESULTS

The 5-year DFS rate of NBNC (34 %) was better than that of hepatitis virus B (30 %, P = 0.011) and hepatitis virus C (21 %, P < 0.0001), significantly. Multivariate analysis revealed NBNC [hazard ratio (HR), 0.5; 95 % CI, 0.4-0.8; P < 0.0001)] to be an independent factor for DFS rate. We constructed a propensity score matching model with the 543 patients, and the 5-year DFS rates with and without severe alcohol liver disease (ALD) were 31.6 and 47.5 %, respectively (P = 0.013). In the 163 NBNC patients, severe ALD, mild ALD, and no ALD were seen in 35, 56, and 72 patients, respectively. Multivariate analysis revealed a vascular invasion into the hepatic vein (HR, 3.3; 95 % CI, 1.7-6.3; P < 0.0001) and severe ALD (HR, 2.0; 95 % CI, 1.1-3.6; P = 0.020) to be independent risk factors for poor DFS. By propensity score matching between mild and severe ALD, the 5-year DFS rates with severe and mild ALD were 26 and 50 %, respectively (P = 0.035).

CONCLUSIONS

The prognoses of NBNC patients were better than those of patients with viral infections. Among the NBNC patients, preoperative excessive alcohol intake decreased DFS rate of HCC occurrence after surgery.

Clinical application of a modern high-definition head-mounted display in sonography

Because of the remarkably improved image quality and wearability of modern head-mounted displays, a monitoring system using a head-mounted display rather than a fixed-site monitor for sonographic scanning has the potential to improve the diagnostic performance and lessen the examiner's physical burden during a sonographic examination. In a preclinical setting, 2 head-mounted displays, the HMZ-T2 (Sony Corporation, Tokyo, Japan) and the Wrap1200 (Vuzix Corporation, Rochester, NY), were found to be applicable to sonography. In a clinical setting, the feasibility of the HMZ-T2 was shown by its good image quality and acceptable wearability. This modern device is appropriate for clinical use in sonography.