Role of computed tomographic arterial portography and intraoperative ultrasound in the evaluation of patients for resectability of hepatic lesions

Imaging of Hepatic Metastases

BACKGROUND

Imaging plays an important role not only in screening, evaluating, staging, and monitoring disease, but also in surveillance following tumor ablation. Advances in imaging techniques have increased our ability to detect and characterize focal liver lesions, resulting in improvements in diagnostic capability and improved monitoring of liver metastases. This has led to increased interest in both hepatic imaging and image-guided hepatic interventions.

METHODS

Several imaging options are reviewed according to their effective application, notably computed tomography (CT), CT during arterial portography, ultrasound, magnetic resonance imaging, positron emission tomography, and integrated PET/CT imaging.

RESULTS

Although there are exceptions regarding imaging options based on patient selection and on institution preference and expertise, multidetector helical CT scanning remains the dominant modality in the evaluation of suspected hepatic metastases, and for preoperative planning, treatment monitoring, and posttreatment follow-up.

CONCLUSIONS

Ultimately, the choice of imaging modality must be based not only on the patient and the clinical situation, but also on the imaging expertise within each institution.

Intraoperative ultrasonography in open and laparoscopic abdominal surgery: an overview

This article reviews the current state of intraoperative ultrasonography in open surgery (IOUS) and laparoscopic surgery (LUS). The review is based on extensive study of data published (Pubmed search) and on 25 years of personal experience with intraoperative ultrasonography. The main application areas of IOUS and LUS and its use during liver, biliary tract, and pancreatic surgery are discussed. The benefits and limitations as well as future expectations with regard to the existing and emerging applications also are discussed. New developments in ultrasound technology and the increasing experience of surgeons in ultrasonography secure the future for IOUS and LUS.

Intraoperative ultrasound

Intraoperative ultrasound (IOUS) can provide various diagnostic information that is otherwise not available, and can guide or assist various surgical procedures in real time. With refinement of equipment, IOUS is currently used in a wide variety of surgical operations,such as hepatobiliary, pancreatic, endocrine, cardiovascular,and neurologic surgery. Our overview of IOUS, including instrumentation,techniques, indications, advantages, disadvantages,and future perspective, is described in this article. Being safe, quick, accurate, and versatile intraoperatively, IOUS is a valuable technique that surgeons are recommended to master to improve intraoperative decision making and surgical procedures.

Preoperative evaluation of hepatic lesions for the staging of hepatocellular and metastatic liver carcinoma using endoscopic ultrasonography

BACKGROUND

Noninvasive imaging techniques, such as dynamic computed tomography (CT), magnetic resonance imaging and transabdominal ultrasonography are limited in their ability to detect hepatic lesions less than one cm. Intraoperative ultrasonography (IOUS) is currently the most sensitive modality for the detection of small hepatic lesions. However, IOUS is invasive requiring laparoscopy or formal laparotomy. We sought to evaluate the feasibility of using endoscopic ultrasonograhpy (EUS) for the detection and diagnosis of hepatic masses in patients with hepatocellular cancer (HCCA) and metastatic lesions (ML). We hypothesized that EUS could detect small (<1.0 cm) hepatic lesions undetectable by CT scan and could be used for biopsy of deep-seated hepatic lesions.

METHODS

Consecutive patients referred for EUS with suspected liver lesions were evaluated between July 2000 and October 2001. All patients underwent EUS using an Olympus (EM30) radial echoendoscope. If liver lesions were confirmed and fine needle aspiration (FNA) was deemed necessary, a linear array scope was used and an FNA performed with a 22-gauge needle. Two passes were made for each lesion.

RESULTS

14 patients underwent evaluation with dynamic CT scans and EUS. In all 14 patients, EUS successfully identified hepatic lesions ranging in size from 0.3 cm to 14 cm (right lobe: n = 3, left lobe: n = 1, bilobar: n = 8). Moreover, EUS identified new or additional lesions in 28% (4 of 14) of the patients, all less than 0.5 cm in size (HCCA: n = 2, ML: n = 2), influencing the clinical management. In 2 of 14 patients EUS identified liver lesions, previously described as suspicious by CT scan, to be hemangiomas. Nine patients underwent EUS-guided FNA of hepatic lesions (deep seated: n = 3, superficial: n = 6). All FNA passes yielded adequate specimens (malignant: n = 8, benign: n = 1).

CONCLUSIONS

Our preliminary experience suggests that EUS is a feasible preoperative staging tool for liver masses suspected to be HCCA or metastatic lesions. EUS can detect small hepatic lesions previously undetected by dynamic CT scans. Furthermore, EUS-guided FNA can confirm additional HCCA liver lesions or liver metastases, in deep-seated locations, upstaging patients and changing clinical management.