Real-time blood-pool images of contrast enhanced ultrasound with Definity in the detection of tumour nodules in the liver

Utilizing Contrast-Enhanced Ultrasonography with Phosphatidylserine Microbubbles to Detect Placental Inflammation in Rhesus Macaques

The ability to comprehensively monitor physiological and detect pathophysiologic processes early during pregnancy can reduce maternal and fetal morbidity and mortality. Contrast-enhanced ultrasound (CEUS) is a non-invasive imaging technology that utilizes the acoustic detection of microbubbles to examine vascular spaces. Furthermore, microbubbles conjugated to specific compounds can focus studies on precise physiological pathways. We hypothesized that CEUS with phosphatidylserine microbubbles (MB-PS) could be employed to monitor placental inflammation. We tested this hypothesis in rhesus macaques (Macaca mulatta), a translational and relevant animal model of human placental health. As placental inflammation impacts many at-risk pregnancies, we performed CEUS with MB-PS in pregnant macaques fed a high-fat diet (e.g., a western-style diet, WSD) in the presence or absence of testosterone (T) to mimic the increased risk of polycystic ovary syndrome and subfertility. We have previously demonstrated a placental inflammation phenotype in this model, and, thus, we related the MB-PS CEUS signal intensity to placental inflammation markers: selectin p and angiopoietins. Testosterone exposure increased the MB-PS signal in the placental microcirculation on the maternal side compared to control animals. We found that T increased placental weight and decreased angiopoietin 2 (ANGPT2) immunoreactivity. Furthermore, a significant inverse correlation was found between MB-PS signal and ANGPT2. This indicated that CEUS with MB-PS can be used to monitor placental parameters. We propose that CEUS with MB-PS could aid in the identification of pregnancies at risk of placental vascular compromise.

Microbubble Formulations: Synthesis, Stability, Modeling and Biomedical Applications

Microbubbles are increasingly being used in biomedical applications such as ultrasonic imaging and targeted drug delivery. Microbubbles typically range from 0.1 to 10 µm in size and consist of a protective shell made of lipids or proteins. The shell encapsulates a gaseous core containing gases such as oxygen, sulfur hexafluoride or perfluorocarbons. This review is a consolidated account of information available in the literature on research related to microbubbles. Efforts have been made to present an overview of microbubble synthesis techniques; microbubble stability; microbubbles as contrast agents in ultrasonic imaging and drug delivery vehicles; and side effects related to microbubble administration in humans. Developments related to the modeling of microbubble dissolution and stability are also discussed.

Unenhanced magnetic resonance imaging immediately after radiofrequency ablation of liver malignancy: preliminary results

PURPOSE

To assess the accuracy of unenhanced magnetic resonance imaging (MRI) immediately after the percutaneous ultrasound-guided radiofrequency ablation (RFA) of liver malignancy in predicting treatment efficacy at CT follow-up.

MATERIALS AND METHODS

Percutaneous ablation was prospectively performed in 23 liver malignancies (20 hepatocarcinomas and 3 metastases). After the procedure in the same day all patients were studied with unenhanced MRI. The best sequence to detect the coagulative necrosis was visually established. Pre-RFA CT and post-RFA MRI were registered with non-rigid transformation algorithm. Manual segmentation of lesions and ablated areas in pre-RFA CT, post-RFA MRI, and follow-up CT were obtained. Sensitivity, specificity, positive predictive value (PPV), negative predicitve value (NPV), and accuracy of MRI in predicting the correct centering and the complete treatment of the lesion were calculated in respect to the 1-month follow-up CT.

RESULTS

Fat-saturated T1-weighted (fs T1-w) was the sequence in which the best conspicuity of the ablated area was depicted. Coagulative necrosis was hyperintense in fs T1-w sequence in 17/23 (74%). In respect to follow-up CT, MRI predicted the correct centering of the lesions in 19/20 lesions with sensitivity, specificity, PPV, NPV, and accuracy of 100%, 75%, 95%, 100%, and 100%, respectively. MRI predicted the complete treatment of the lesions in 17/17 lesions with sensitivity, specificity, PPV, NPV, and accuracy of 100%.

CONCLUSION

MRI with the single fs T1-w sequence was highly accurate in predicting the treatment efficacy of percutaneous ablation of liver malignancies in comparison to follow-up CT control. Unnecessary CT in case of incomplete treatment can be therefore easily avoided.

Evolution of contrast agents for ultrasound imaging and ultrasound-mediated drug delivery

Ultrasound (US) is one of the most frequently used diagnostic methods. It is a non-invasive, comparably inexpensive imaging method with a broad spectrum of applications, which can be increased even more by using bubbles as contrast agents (CAs). There are various different types of bubbles: filled with different gases, composed of soft- or hard-shell materials, and ranging in size from nano- to micrometers. These intravascular CAs enable functional analyses, e.g., to acquire organ perfusion in real-time. Molecular analyses are achieved by coupling specific ligands to the bubbles' shell, which bind to marker molecules in the area of interest. Bubbles can also be loaded with or attached to drugs, peptides or genes and can be destroyed by US pulses to locally release the entrapped agent. Recent studies show that US CAs are also valuable tools in hyperthermia-induced ablation therapy of tumors, or can increase cellular uptake of locally released drugs by enhancing membrane permeability. This review summarizes important steps in the development of US CAs and introduces the current clinical applications of contrast-enhanced US. Additionally, an overview of the recent developments in US probe design for functional and molecular diagnosis as well as for drug delivery is given.

Prospective study of ultrasound with perflutrene contrast compared to magnetic resonance imaging in the diagnosis of hepatic hemangiomas

CONTEXT

The incidence of hepatic hemangiomas ranges from 0.4% to 20% in the general population. Conventional ultrasound is usually the first diagnostic method to identify these hemangiomas, typically as an incidental finding. Ultrasonography with second generation contrast materials is being used in various areas of hepatology, yielding similar results to those obtained with computerized tomography and magnetic resonance imaging in the diagnosis of hepatic hemangiomas.

OBJECTIVE

To evaluate the agreement between ultrasound with perflutrene contrast and magnetic resonance imaging in the diagnosis of hepatic hemangiomas.

METHODS

A total of 37 patients were prospectively examined between January 2006 and August 2008. A total of 57 hepatic nodules were documented in this group as incidental findings on routine ultrasound exams. The 37 patients were administered perflutrene contrast without adverse reactions, and were all submitted to magnetic resonance exams.

RESULTS

Conventional ultrasound identified 15 patients with nodules typical of hemangiomas and 22 patients with other nodules. In 35 patients, the contrast characteristics were consistent with hepatic hemangiomas.

CONCLUSION

Agreement between the data obtained from ultrasound with contrast and magnetic resonance was 94.5%. In discordant cases, the magnetic resonance diagnosis prevailed. In the case which presented indeterminate findings on contrast ultrasonography, magnetic resonance was repeated after 3 months, confirming the diagnosis of a hepatic hemangioma. A biopsy was performed on the suspected malignant nodule which also confirmed the presence of a hepatic hemangioma. Ultrasonography with contrast has the advantages of being more accessible to the public at large and lower cost than magnetic resonance. The results of our study highlight the need for a new protocol in hepatic nodules incidentally identified on conventional ultrasonography. In the case of typical hemangiomas, conventional ultrasound is sufficient for diagnosis. However, for poorly defined nodules, ultrasonography with contrast is indicated. After confirming the presence of a hepatic hemangioma on contrast ultrasonography, no further exams are needed to finalize the diagnosis.

Current trends in liposome research

Among the several drug delivery systems, liposomes--phospholipid nanosized vesicles with a bilayered membrane structure--have drawn a lot of interest as advanced and versatile pharmaceutical carriers for both low and high molecular weight pharmaceuticals. At present, liposomal formulations span multiple areas, from clinical application of the liposomal drugs to the development of various multifunctional liposomal systems to be used in therapy and diagnostics. This chapter provides a brief overview of various liposomal products currently under development at experimental and preclinical level.

Assessment of hepatic VX2 tumors with combined percutaneous transhepatic lymphosonography and contrast-enhanced ultrasonographic imaging

AIM: To evaluate the feasibility and efficacy of percutaneous transhepatic lymphosonography (PTL) as a novel method for the detection of tumor lymphangiogenesis in hepatic VX₂ of rabbits and to evaluate combined PTL and routine contrast-enhanced ultrasonographic imaging for the diagnosis of liver cancer.

METHODS: Ten rabbits with VX₂ tumor were included in this study. SonoVue (0.1 mL/kg) was injected into each rabbit via an ear vein for contrast-enhanced ultrasonographic imaging, and 0.5 mL SonoVue was injected into the normal liver parenchyma near the VX₂ tumor for PTL. Images and/or movie clips were stored for further analysis.

RESULTS: Ultrasonographic imaging showed VX₂ tumors ranging 5-19 mm in the liver of rabbits. The VX₂ tumor was hyperechoic and hypoechoic to liver parenchyma at the early and later phase, respectively. The hepatic lymph vessels were visualized immediately after injection of contrast medium and continuously visualized with SonoVue^® during PTL. The boundaries of VX₂ tumors were hyperechoic to liver parenchyma and the tumors. There was a significant difference in the values for the boundaries of VX₂ tumors after injection compared with the liver normal parenchyma and the tumor parenchyma during PTL.

CONCLUSION: PTL is a novel method for the detection of tumor lymphangiogenesis in hepatic VX₂ of rabbits. Combined PTL and contrast-enhanced ultrasonographic imaging can improve the diagnosis of liver cancer.

Mechanism of hepatic parenchyma-specific contrast of microbubble-based contrast agent for ultrasonography: microscopic studies in rat liver

OBJECTIVE

The objective of this study was to elucidate the mechanism of hepatic parenchyma-specific contrast of Sonazoid (microbubble contrast agent) using microscopic techniques.

MATERIALS AND METHODS

Sonazoid was intravenously injected into rats to investigate the microbubble dynamics and distribution within hepatic microcirculation in exteriorized liver using intravital microscopy and to observe dose dependency of ultrasound hepatic contrast effect. In vitro and in vivo uptake of microbubbles by Kupffer cells was examined using confocal laser scanning microscopy.

RESULTS

Intravital observation demonstrated freely flowing microbubbles in the sinusoid and some microbubbles co-localized with Kupffer cells. The microbubbles internalized in Kupffer cells were identified with reflected light by confocal laser scanning microscopy. The percentage of Kupffer cells taking up microbubbles was about 1% at clinical dose at which the homogeneous hepatic contrast was observed.

CONCLUSIONS

The hepatic parenchyma-specific contrast by Sonazoid is due to distribution of the microbubbles in Kupffer cells.

Application of percutaneous ultrasound-guided treatment for ultrasonically invisible hypervascular hepatocellular carcinoma using microbubble contrast agent

AIM

To evaluate the efficacy of contrast-enhanced ultrasound for the localization of ultrasonically invisible hypervascular lesions in the liver to facilitate percutaneous ultrasound-guided treatment.

MATERIALS AND METHODS

Forty patients with 47 ultrasonically invisible hypervascular lesions (5-20mm) diagnosed on contrast-enhanced computed tomography were enrolled in the retrospective study. Contrast-enhanced ultrasound (CEUS) with Levovist was performed to localize the lesions both in the early phase and liver-specific phase. Diagnosis of was confirmed by percutaneous needle biopsy where feasible, and on the basis of on treatment outcomes or changes in computed tomography findings in those not amenable to biopsy.

RESULTS

Thirty-two lesions were diagnosed as hepatocellular carcinoma (HCC). Contrast-enhanced ultrasound localized hepatocellular carcinoma in 24/32 (75%) lesions, the mean diameter (15.1+/-4.9mm), as measured using computed tomography, being significantly larger than that of the remaining eight lesions (10.5+/-2.1mm). Ultrasound-guided treatment was performed in 19 of the 24 lesions, and transarterial chemoembolization (TACE) was applied for the other five lesions because of difficult percutaneous access. Five of the eight non-visualised lesions were treated by transarterial chemoembolization, and the other three by surgical resection. The beneficial effect of CEUS was significantly greater when the reason for poor initial visualisation was the coarse liver architecture (17/17) than when it was due to adverse location (seven of 15, p<0.005). Fifteen of the CT-detected hypervascular lesions were considered to represent false positives for HCC, based on their behaviour during follow-up.

CONCLUSION

Contrast-enhanced ultrasound with Levovist facilitates the application of percutaneous ultrasound-guided treatment by improving localization of ultrasonically invisible hypervascular hepatocellular carcinomas in the liver.

The role of contrast-enhanced ultrasound in planning treatment protocols for hepatocellular carcinoma before radiofrequency ablation

AIM

To evaluate the clinical value of contrast-enhanced ultrasound (CEUS) for patients with hepatocellular carcinoma (HCC) in identifying the tumour number, ablation range and feeding vessels before ultrasound-guided radiofrequency ablation (RFA), and to compare the efficacy of RFA after CEUS with the efficacy of RFA after non-enhanced ultrasonography (US) without contrast medium administration.

MATERIALS AND METHODS

From 2002 to 2005, 81 patients with 110 HCCs underwent CEUS with SonoVue before RFA treatment (group A). Eighty six patients with 112 HCCs who underwent US without contrast enhancement before RFA served as the control group (group B). The average diameters of the lesions in group A and group B were 3.6+/-1.1cm and 3.5+/-1.1cm, respectively. There were no significant differences in clinical data between the two groups. Regular follow-up after treatment was performed using contrast-enhanced computed tomography (CECT). After treatment, complete necrosis was defined as the absence of viable tissue in treated tumours at the 1-year follow-up CECT.

RESULTS

Using CEUS an additional seven small lesions (< or =2.0 cm) were found compared with those found using CECT and conventional US. CEUS showed that 56.4% of lesions (62/110 tumours) were larger in size and 49.1% (54/110 tumours) became more irregular in shape during the arterial phase than on conventional US. Feeding vessels were detected using CEUS in 52 (91.2%) of 57 lesions that were larger than 3.5 cm. The follow-up period was at least 1 year for each case. The complete tumour necrosis rate in group A was significantly higher than that in group B (92.2% versus 83.0%; p=0.036).

CONCLUSION

CEUS can be used to more accurately define the size and contour of lesions, and to detect additional small or satellite lesions and the feeding vessel of HCC tumours. CEUS provided important information for designing the ablation protocol, and might improve the efficacy of RFA.

Recent applications of ultrasound: diagnosis and treatment of hepatocellular carcinoma

Ultrasound (US) has the advantages of real-time observation, simple technique, and a noninvasive procedure compared to other imaging modalities. The recent development of digital technologies has enabled the observation of sonograms with improved signal-to-noise ratio, penetration, and spatial and contrast resolutions. Furthermore, microbubble contrast agents have increased the diagnostic ability of US examination, and the use of three-dimensional sonograms is now not unusual. These advances have furthered the usefulness of US for liver tumors in clinical practice. This article reviews the recent applications of US in the diagnosis and treatment of hepatocellular carcinoma.

Microbubble disappearance-time is the appropriate timing for liver-specific imaging after injection of Levovist

Contrast enhancement in the portal vein was repeatedly observed at 1 min intervals with wide-band Doppler ultrasonography in 152 consecutive patients (132 with liver cirrhosis and HCC, 20 controls), 5 min after the injection of Levovist. The duration time of contrast enhancement in the portal vein (microbubble disappearance-time; MD-T) was measured in all patients and contrast-enhanced appearances were compared between the 5 min phase and MD-T phase in 68 HCC nodules. MD-T in patients with liver cirrhosis (572.4 +/- 117.9 s) was significantly longer than in controls (481.6 +/- 89.3 s, p < 0.05). MD-T was prolonged in patients with Child B and C compared with Child A (p < 0.05). The contrast-enhanced appearances between the two phases were different in 30 of 68 HCC nodules (44.1%), showing positive enhancement in the 5 min phase and negative enhancement in the MD-T phase. The proposed MD-T may become an essential factor for the evaluation of liver-specific sonograms.