Analysis of neuroendocrine tumour metastases in the liver using contrast enhanced ultrasonography

Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Prevalence of benign focal liver lesions and non-hepatocellular carcinoma malignant lesions in liver cirrhosis

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.

This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses.

Diagnostic Value of CEUS Prompting Liver Biopsy: Histopathological Correlation of Hepatic Lesions with Ambiguous Imaging Characteristics

Background: Contrast-enhanced ultrasound (CEUS) allows for dynamic analysis of vascularization patterns of unclear hepatic lesions. Our study aimed to evaluate the diagnostic performance of CEUS for further characterizing suspicious liver lesions by comparing findings from CEUS examinations with corresponding histopathology. Methods: Between 2005 and 2016, 160 patients with unclear liver lesions underwent CEUS followed by liver biopsy. All examinations were performed by an experienced consultant radiologist (EFSUMB Level 3) and included native B-mode ultrasound, Color Doppler, and CEUS. A second-generation blood pool contrast agent was applied for CEUS. Results: CEUS was successfully performed in all patients without occurrence of any adverse side effects. CEUS showed a sensitivity of 94.5%, a specificity of 70.6%, a true positive rate of 87.3%, and a true negative rate of 85.7% compared to histopathological results as the reference standard. Conclusions: CEUS represents a safe imaging modality with a high diagnostic accuracy in assessing both—benign and malignant—liver lesions compared to corresponding histopathological results.

Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver - Update 2020 - WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Do we need contrast agents for EUS?

We recently introduced a series of articles that dealt with controversies in EUS. In Part I, the authors discussed which clinical information is necessary prior to EUS and whether other imaging modalities are required before embarking on EUS examinations. Part II focuses on technical details and controversies about the use of EUS in special situations. In this article, important practical issues regarding the application of contrast-enhanced EUS in various clinical settings are raised and controversially discussed from different points of view.

Surgical Approaches to the Management of Neuroendocrine Liver Metastases

Surgical approaches to hepatic metastases occupy an important role in the management of patients with neuroendocrine neoplasms and may have curative or palliative intentions. Resection of hepatic disease with curative intent is the only modality offering potential cure for patients with liver metastases; however, only a minority of patients are eligible. Regardless of resection margin, disease recurrence almost invariably occurs and novel adjuvant/neoadjuvant therapies are mandated to be included within multimodal treatment concepts. Liver transplantation in meticulously selected patients may be associated with excellent outcomes, but unfortunately demands on donated organs limit the wider utilization of this approach.

Role of contrast-enhanced ultrasound to define prognosis and predict response to biotherapy in pancreatic neuroendocrine tumors

PURPOSE

The incidence of neuroendocrine tumors (NETs) is progressively increasing. Most cases arise from the digestive system, where ileum, rectum and pancreas represent the commonest site of origin. Liver metastases are frequently detected at diagnosis or during the follow-up. Contrast-enhanced ultrasound (CEUS) is used in patients with pancreatic NETs (P-NETs) and liver metastases from P-NET but its role has not been standardized. The aim of this retrospective study was to investigate CEUS in patients with P-NETs and liver metastases from P-NET both as prognostic factor and predictor of response to therapy with somatostatin analogues (SSAs).

METHODS

CEUS was performed at the diagnosis of NET and 3, 6 and 12 months after the beginning of SSAs. CEUS pattern was compared with contrast-enhanced computed tomography (CT) pattern.

RESULTS

There was a significant association between CEUS and CT pattern (X ² = 79.0; p < 0.0001). A significant association was found between CEUS pattern and Ki-67 index (X ² = 24.6; p < 0.0001). The hypervascular homogeneous CEUS typical pattern was associated with low tumor grading (G1 or G2) (X ² = 24.0; p < 0.0001). CEUS pattern changed from hypervascular homogeneous in baseline to hypovascular/hypervascular inhomogeneous after SSA therapy, with a significant association between tumor response at CT scan and appearance of hypervascular inhomogeneous pattern at CEUS evaluation (6 months: X ² = 57.0; p < 0.0001; 12 months: X ² = 49.8; p < 0.0001).

CONCLUSIONS

In patients with P-NET, CEUS pattern correlates with tumor grading, being homogeneous in G1-G2 but not in G3 tumors. After therapy with SSAs, CEUS is predictive of response to SSAs. These findings seem to support a role of CEUS as prognostic and predictive factor of response.

Contrast enhanced ultrasound features of hepatic cystadenoma and hepatic cystadenocarcinoma

OBJECTIVE

Hepatic (biliary) cystic tumor (HBCT) is a rare focal cystic liver lesion, which has been rarely described in the literature. In our current multicenter, retrospective study, we aimed to analyze contrast enhanced ultrasound (CEUS) features and its diagnostic performance in histologically proved HBCT.

MATERIAL AND METHODS

Twenty-three patients with single HBCT were retrospectively analyzed. Histologically, 17 (73.9%) were benign hepatic (biliary) cystadenoma (HBCA), 6 (26.1%) were hepatic (biliary) cystadenocarcinoma (HBCAC). All CEUS examinations were assessed by two independent radiologists in consensus. Criteria of CEUS imaging evaluation included the contrast enhancement pattern of lesion (hypoenhancing, hyperenhancing, isoenhancing in comparison to the surrounding liver parenchyma) during the arterial, portal venous and late phases.

RESULTS

After injection of ultrasound contrast agents, most of the HBCTs (78.3%, 18/23) had typical honeycomb enhancement pattern of the cystic wall, septa or mural nodules. Comparing between HBCA and HBCAC, hyperenhancement of the honeycomb septa during the arterial phase was more common in HBCA (p = .047). However, hypoenhancement during the portal venous and late phases was the characteristic of HBCAC (p = .041).

CONCLUSIONS

The EFSUMB algorithm for CEUS for characterization of solid focal liver lesions is also applicable to HBCT. CEUS evaluation can avoid further diagnostic investigations or invasive biopsy procedure.

Evaluation of Liver Metastases Using Contrast-Enhanced Ultrasound: Enhancement Patterns and Influencing Factors

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.

Differential diagnosis of small solid pancreatic lesions

BACKGROUND AND AIMS

Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at a late stage. Little is known about the incidental finding of early-stage PDAC. The aim of the current study was to determine the etiology of small solid pancreatic lesions (≤15 mm) to optimize clinical management.

METHODS

Inclusion criterion for the retrospective study analysis was the incidental finding of primarily undetermined small solid pancreatic lesions ≤15 mm in 394 asymptomatic patients. Final diagnoses were based on histology or cytology obtained by imaging-guided biopsy (and at least 12-month follow-up) and/or surgery. Contrast-enhanced US or contrast-enhanced EUS was performed in 219 patients.

RESULTS

The final diagnoses of 394 patients were as follows: 146 PDACs, 156 neuroendocrine tumors, 28 metastases into the pancreas from other primary sites, and 64 various other etiologies. Contrast-enhanced US allowed differential diagnosis of PDAC and non-PDAC in 189 of 219 patients (86%).

CONCLUSIONS

Approximately 40% of patients with small solid pancreatic lesions had very early stage PDAC. Approximately 60% of small solid pancreatic lesions ≤15 mm are not PDAC and, therefore, do not require radical surgery. Without preoperative diagnosis, an unacceptably large proportion of patients would be exposed to radical surgery with significant morbidity and mortality.

Relative Elastic Modulus Imaging Using Sector Ultrasound Data for Abdominal Applications: An Evaluation of Strategies and Feasibility

We reconstruct the elastic modulus distribution for one tissue mimicking (TM) phantom and two in vivo biopsy-confirmed liver tumors using curvilinear ultrasound echo data. Spatial distribution of the relative elastic modulus values is determined by solving an inverse problem within a region of interest (ROI). This inverse problem solution requires knowledge of the ultrasonically measured displacement field in a uniform rectilinear grid to ensure that the resolution on the resultant relative elastic modulus elastogram will be uniform over the entire ROI. Taking advantage of a new speckle tracking algorithm, two different displacement tracking strategies are investigated: 1) sector-shaped ultrasound data were converted to ultrasound data on a rectilinear grid prior to speckle tracking and 2) axial and lateral displacements directly obtained from sector-shaped data were converted to vertical and horizontal displacements on a rectilinear grid after speckle tracking. Compared with strain elastography (SE), TM phantom results show that relative elastic modulus imaging (REMI) using Strategy 2 provided higher contrast-to-noise ratios (>300% and 25% increases compared with SE and REMI using Strategy 1, respectively). Furthermore, in phantoms, REMI using Strategy 2 more accurately (a 1.3% difference to shear wave elastography measurements) estimated the elastic contrast ratio between the target and the background, compared with both SE (20%-25%) and REMI using Strategy 1 (4.1%). It was also observed that relative modulus elastograms were more consistent with anatomical structures visualized on corresponding B-mode images for the two in vivo liver cases. Overall, we conclude that applying REMI is feasible for abdominal organs such as the liver. Strategy 2 offered improved and consistent results for the data investigated.

Primary hepatic neuroendocrine tumors: clinical characteristics and imaging features on contrast-enhanced ultrasound and computed tomography

OBJECTIVE

Primary hepatic neuroendocrine tumor (PHNET) is an extremely rare liver neoplasm, and its clinical characteristics and imaging features are not well understood. The aim of this study was to analyze the clinical profiles and imaging features of PHNETs on contrast-enhanced ultrasound (CEUS) and computed tomography (CT) METHODS: Patients with PHNET between January 2008 and December 2015 were retrospectively identified, and their demographics, laboratory data, and imaging characteristics on CEUS and CT analyzed.

RESULTS

Ten consecutive patients with PHNETs were included (including one G1, seven G2, and two G3 of tumor grades).The median age of patient was 45 years (range: 27-72 years), and 60.0% of patients were male. The most common symptom was abdominal pain (60.0%), and cirrhosis was found in 40.0% of patients. Tumors were confined within the liver in 60.0% of patients, while the remaining patients had extra-hepatic metastasis. The tumors revealed hyperechoic in 60% of patients and mixed echoic in 30% of patients on conventional US, displaying intense arterial enhancement followed by washout in the portal and/or the late phases in 80.0% of patients on CEUS and 60% at CT.

CONCLUSIONS

Although PHNET is a very rare liver tumor, it should be considered as a possible differential diagnosis in the management of hepatic tumors. Most PHNETs were hyperechoic or mixed echoic on conventional US, showing similar enhancement patterns to that of hepatocellular carcinoma on CEUS.

Fortuitously discovered liver lesions

The fortuitously discovered liver lesion is a common problem. Consensus might be expected in terms of its work-up, and yet there is none. This stems in part from the fact that there is no preventive campaign involving the early detection of liver tumors other than for patients with known liver cirrhosis and oncological patients. The work-up (detection and differential diagnosis) of liver tumors comprises theoretical considerations, history, physical examination, laboratory tests, standard ultrasound, Doppler ultrasound techniques, contrast-enhanced ultrasound (CEUS), computed tomography and magnetic resonance imaging, as well as image-guided biopsy. CEUS techniques have proved to be the most pertinent method; these techniques became part of the clinical routine about 10 years ago in Europe and Asia and are used for a variety of indications in daily clinical practice. CEUS is in many cases the first and also decisive technical intervention for detecting and characterizing liver tumors. This development is reflected in many CEUS guidelines, e.g., in the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines 2004, 2008 and 2012 as well as the recently published World Federation for Ultrasound in Medicine and Biology-EFSUMB guidelines 2012. This article sets out considerations for making a structured work-up of incidental liver tumors feasible.

Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver - update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

Contrast-enhanced endoscopic ultrasound

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) introduced guidelines on the use of contrast-enhanced ultrasound (CEUS) in 2004. This EFSUMB-document focused mainly on liver applications. However, new applications extending beyond the liver were developed thereafter. Increased interest in recent years in CEUS technique and in the application of CEUS in novel fields like endoscopic ultrasound (EUS) has revolutionized indications and applications. As a result, the EFSUMB initiated a new update of the guidelines in 2011 to include this additional knowledge. Some of the contrast-enhanced EUS (CE-EUS) indications are established, whereas others are preliminary; these latter indications are categorized as emergent CEUS applications since the available evidence is insufficient for general recommendation. This article focuses on the use of CE-EUS in various clinical settings. The reader will get an overview of current indications and possible applications of CE-EUS. This involves the introduction of different contrast studies including color Doppler techniques (known as contrast-enhanced high mechanical index endosonography or CEHMI-EUS) as well as more modern high-resolution contrast-enhanced techniques (known as contrast-enhanced low mechanical index endosonography or CELMI EUS).

Management of neuroendocrine tumors in children, adolescents, and young adults

Neuroendocrine tumors, often referred to as carcinoid tumors, are relatively rare within the pediatric and young adult populations. However, when they do occur, the more aggressive tumors can be associated with significant morbidity and even mortality in this younger age group. This article reviews the history of pediatric neuroendocrine tumors, typical clinical presentation, appropriate diagnostic studies, staging, and treatment of this unusual cancer.

Impact of CT-based diagnostic imaging on management and outcome of nonfunctioning pancreatic tumors

BACKGROUND

Sporadic malignant non-functioning pancreatic endocrine tumors (NF-PETs) are an important subset of pancreatic neoplasms. The aim of this study was to assess the impact of improved imaging on these features in a tertiary referral centre within a 20-year follow-up.

PATIENTS AND METHODS

From 1988 to 2009, 51 patients were treated for sporadic malignant NF-PETs. Forty-one patients who underwent tumor resection were retrospectively attributed according to the date of the initial diagnosis, group 1: 1988-1999 vs. group 2: 2000-2009.

RESULTS

Cross-sectional imaging led to positive prediction of NF-PETs in all patients. Curative resection was achieved in 76%. Synchronous metastases were present in 56% with a positive prediction of 43%. In group 1, the mean reported CT-determined tumor size was 56 vs. 54 mm in group 2 (p = 0.89). Synchronous metastases were present in 61% in group 1 vs. 57% (p = 0.99) in group 2. Metachronous metastases were recorded in 39% in group 1 vs. 43% (p = 0.84) in group 2. The mean interval from initial resection to diagnosis of metastatic disease was significantly shorter (p = 0.01) in patients from group 1 (14 vs. 61 months). Cumulative 5- and 10-year survival rates were 77% and 72% in group 1 vs. a 5-year survival rate of 66% in group 2.

CONCLUSION

So far, improved CT-based imaging has no impact on earlier detection of initial synchronous metastases in sporadic malignant NF-PETs, while metachronous metastases are detected earlier.

Contrast harmonic ultrasonographic appearance of focal space-occupying renal lesions

To describe the contrast-enhanced ultrasonographic appearance of various focal, space-occupying renal lesions and determine its value in their detection and characterization. Following baseline B-mode sonography of 15 dogs and one cat with renal space-occupying lesion(s), contrast-enhanced sonography was performed. The resulting images were evaluated qualitatively using conspicuity and number of lesions, and enhancement patterns were assessed during early arterial and late corticomedullary phases. Renal lesions were malignant in the cat (renal cell carcinoma) and 10 dogs (four renal cell carcinoma, two histiocytic sarcoma, one B-cell lymphoma, two hemangiosarcoma metastasis, one ch emodectoma metastasis) and benign in five dogs (two abscesses, one traumatic hematoma, one idiopathic hematoma, one hemorrhagic/necrotic nodule). Substantial overlap was present regarding the baseline sonographic features of benign vs. malignant lesions. With contrast-enhanced sonography, all renal cell carcinomas were characterized by large tortuous arteries, sometimes enhancing slightly earlier than vessels in the surrounding normal kidney. During the late corticomedullary phase, renal cell carcinomas had intense homo- or heterogeneous, iso- or slightly hypoechoic enhancement, which decreased progressively. Compared with renal cell carcinoma, histiocytic sarcoma and lymphoma had smaller and less obvious arteries, and an earlier loss of enhancement during the late phase. All hemangiosarcoma metastases appeared as nonenhancing nodules during the early arterial and late corticomedullary phases of enhancement, and additional lesions were detected. Histiocytic sarcoma and benign lesions had increased conspicuity with baseline sonography. The descriptions provided herein will be valuable as more work is done to establish the role of contrast-enhanced sonography in the assessment of renal lesions.

Contrast-enhanced ultrasonography in evaluating hepatic metastases from neuroendocrine tumours

OBJECTIVES

At presentation, gastroenteropancreatic neuroendocrine tumours (GEP NETs) frequently show prognostically negative hepatic involvement. The aim of this study was to characterise hepatic metastases of GEP NETs as revealed by contrast-enhanced ultrasonography (CEUS), which allows the fine definition of the microvascular system, and to correlate these findings to the biological behaviour of the tumour.

METHODS

Eighteen out of 62 GEP NET patients examined between January 2007 and September 2008 had histologically proven hepatic metastases from primary ileal (#6), gastric (#1) or rectal (#1) carcinoids, pancreatic tumours (#7), or primary duodenal (#2) or occult gastrinomas (#1), and all underwent low mechanical index real-time CEUS with SonoVue injection.

RESULTS

Strong early enhancement in the arterial phase was observed in 15 cases (83%), and a rapid wash-out in the portal venous phase in 14 (78%). In the late venous phase, the lesions were hypoechoic in 12 cases (67%), isoechoic in five (28%), and hyperechoic in one (0.05%). The time of arterial enhancement correlated with the Ki-67 proliferative index (r(s)=0.516; p=0.028).

CONCLUSIONS

Most of the neuroendocrine liver metastases showed increased arterial enhancement at CEUS, a behaviour that is similar to that of hepatocellular carcinomas and the opposite of that of other metastases. CEUS can be a useful diagnostic means of characterising such metastases.

Nordic Guidelines 2010 for diagnosis and treatment of gastroenteropancreatic neuroendocrine tumours

The diagnostic work-up and treatment of patients with neuroendocrine tumours has undergone a major change during the last decade. New diagnostic possibilities and treatment options have been developed. These Nordic guidelines, written by a group with a major interest in the subject, summarises our current view on how to diagnose and treat these patients. The guidelines are meant to be useful in the daily practice for clinicians handling patients with neuroendocrine tumours.

Contrast-enhanced ultrasound with SonoVue: differentiation between benign and malignant focal liver lesions in 317 patients

PURPOSE

The aim of the study was to investigate the ability of contrast-enhanced sonography (CEUS) with the contrast agent SonoVue to differentiate between benign and malignant focal liver lesions.

METHODS

In a prospective study, we examined 317 patients (204 males, 113 females, aged 59 +/- 12 years) with focal liver lesions detected by B-mode gray-scale sonography. After intravenous injection of 1.2 mL SonoVue, the liver was examined continuously for 3 minutes using low-MI sonography with contrast-specific software. Final diagnosis was established by histopathology, CT, MRI, or HIDA-scintigraphy.

RESULTS

Two hundred nine patients had malignant focal lesions, including 107 hepatocellular carcinomas, 70 metastases, 26 cholangiocellular carcinomas, and 6 other types of malignancy. One hundred eight patients had benign focal lesions, including 30 regenerative nodules, 30 hemangiomas, 13 cases of focal nodular hyperplasia, 12 abscesses, 8 cases of necrosis, 7 cases of focal steatosis areas, and 8 other benign lesions. Hypoenhancement or no enhancement in the late phase was found in 91% of the malignant lesions but in only 37% of the benign lesions (p < 0.001, sensitivity = 64%, specificity = 93%). Hyperenhancement in the late phase was found in 20% of the benign lesions but in none of the malignant lesions (p < 0.001, sensitivity = 21%, specificity = 100%). Hyperenhancement in the early phase with diffuse complete enhancement was found in 30% of the patients with malignant lesions but in only 2% of the patients with benign lesions (p < 0.001, sensitivity = 30%, specificity = 98%). CEUS had a sensitivity of 90%, a specificity of 99%, and an accuracy of 89% in the diagnosis of malignant liver lesions.

CONCLUSION

CEUS is helpful in the differentiation between benign and malignant focal liver lesions.

Detection of hepatic metastases from carcinoid tumor: prospective evaluation of contrast-enhanced ultrasonography

The purpose of our study was to prospectively compare unenhanced ultrasonography (US) to contrast-enhanced US (CEUS) in the detection of hepatic metastases from carcinoid tumor. Thirty patients with carcinoid tumor prospectively underwent US, CEUS, and magnetic resonance imaging (MRI). Differences in sensitivity at US and CEUS were compared using a combination of the results of MR imaging, fine-needle biopsy, and follow-up imaging. Lesion conspicuity was assessed subjectively for US and CEUS. Seventeen patients had a total of 69 hepatic metastases. The addition of CEUS improved the detection of individual metastases from 47 (Se 68%; 95% CI: 57.0, 79.0) to 68 (Se 99%; 99% CI: 96.7, 100.0). Contrast enhancement improved the subjective conspicuity of metastases in 85% of patients. CEUS showed one more metastasis than did MRI in one patient, and MRI showed one more than did CEUS in one patient. CEUS is more sensitive than US in the detection of carcinoid liver metastases.

[Contrast medium sonography of neuroendocrine tumors of the gastroenteropancreatic system]

Ultrasonography is at present the primary diagnostic imaging method in patients with abdominal complaints. The innovations in echo enhancers in the last decade in connection with improved software and hardware have substantially extended the diagnostic spectrum of ultrasonography. Thus contrast-enhanced sonography with pulse inversion technology at low mechanical index allows a continuous evaluation of the perfusion of organs and tumors. Neuroendocrine tumors represent a heterogeneous group of endodermal/epithelial tumors, which are often hypervascularized. The morphology and the perfusion behavior of neuroendocrine tumors should be known because the therapeutic options differ substantially from those of other tumors. Contrast-enhanced sonography has already proven to be a valuable alternative in the diagnosis of neuroendocrine neoplasms and their metastases in relation to the established radiological procedures.

Synchronous gastric neuroendocrine carcinoma and hepatocellular carcinoma: a case report

Gastric neuroendocrine carcinomas (NECs) are rare tumours that are divided into four subtypes depending on tumour characteristics. Patients with NECs are known to have an increased risk of synchronous and metachronous cancers mainly located in the gastrointestinal tract. A case of synchronous gastric NEC and hepatocellular carcinoma in a patient with several other precancerous lesions is presented. The patient had anaemia, and a gastric tumour and two duodenal polyps were identified on upper endoscopy. A CT scan of the abdomen revealed several lesions in the liver. The lesions were invisible on B-mode sonography and real-time sonography fused with CT was used to identify and biopsy one of the lesions. Histology showed hepatocellular carcinoma. A literature search showed that only one case of a hepatocellular carcinoma synchronous with a gastric NEC has been reported previously.

TRIAL REGISTRATION NUMBER

NCT00781924.