Duplex pulsed Doppler sonography of portal vein thrombosis in hepatocellular carcinoma

The AFSUMB Consensus Statements and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound using Sonazoid

The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The 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 nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

The AFSUMB Consensus Statements and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound using Sonazoid

The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The 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 nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients

AIM: To clarify which method has accuracy: 2nd generation contrast-enhanced ultrasound or biopsy of portal vein thrombus in the differential diagnosis of portal vein thrombosis.

METHODS: One hundred and eighty-six patients with hepatocellular carcinoma and portal vein thrombosis underwent in blinded fashion a 2nd generation contrast-enhanced ultrasound and biopsy of portal vein thrombus; both results were examined on the basis of the follow-up of patients compared to reference-standard.

RESULTS: One hundred and eight patients completed the study. Benign thrombosis on 2nd generation contrast-enhanced ultrasound was characterised by progressive hypoenhancing of the thrombus; in malignant portal vein thrombosis there was a precocious homogeneous enhancement of the thrombus. On follow-up there were 50 of 108 patients with benign thrombosis: all were correctly diagnosed by both methods. There were 58 of 108 patients with malignant thrombosis: amongst these, 52 were correctly diagnosed by both methods, the remainder did not present malignant cells on portal vein thrombus biopsy and showed on 2nd generation contrast-enhanced ultrasound an inhomogeneous enhancement pattern. A new biopsy during the follow-up, guided to the area of thrombus that showed up on 2nd generation contrast-enhanced ultrasound, demonstrated an enhancing pattern indicating malignant cells.

CONCLUSION: In patients with hepatocellular carcinoma complicated by portal vein thrombosis, 2nd generation contrast-enhanced ultrasound of portal vein thrombus is very useful in assessing the benign or malignant nature of the thrombus. Puncture biopsy of thrombus is usually accurate but presents some sampling errors, so, when pathological results are required, 2nd generation contrast-enhanced ultrasound could guide the sampling needle to the correct area of the thrombus.

Characterization of portal vein thrombus with the use of contrast-enhanced sonography

OBJECTIVES

To select an appropriate treatment regimen, it is essential to accurately characterize the nature of a thrombus. This study prospectively assessed the ability of contrast-enhanced sonography to differentiate between benign and malignant portal vein thrombosis in a population of high-risk patients.

METHODS

Fifty-five patients (43 men and 12 women; mean age, 66 years; range, 55-83 years) with thrombi of the portal venous system were examined by power Doppler sonography and contrast-enhanced sonography with the intravenous contrast agent SH U 508A (Levovist; Schering AG, Berlin, Germany). Of the thrombi, 40 were characterized as malignant and 15 as benign. Pulsatile flow in the thrombus on power Doppler sonography and positive enhancement of the thrombus on contrast-enhanced sonography were judged as indications of a malignant thrombus. The sensitivity and specificity of both methods in differentiating the nature of the thrombus were evaluated.

RESULTS

The detection of pulsatile flow in a portal vein thrombus as the criterion for diagnosing malignant portal vein thrombus yielded overall sensitivity of 82.5% and specificity of 100%, whereas positive enhancement of the portal vein thrombus itself as a criterion for diagnosing malignancy yielded overall sensitivity and specificity of 100% for each.

CONCLUSIONS

Contrast-enhanced sonography can be helpful in discriminating between benign and malignant portal vein thrombi.

Portal venous thrombosis: percutaneous therapy and outcome

PURPOSE

To study the efficacy of percutaneous treatment for portal vein thrombosis (PVT).

MATERIALS AND METHODS

Of 20 patients who were evaluated for symptomatic portal occlusion, 14 were successfully treated with use of percutaneous techniques. In patients with noncavernomatous PVT (n = 15), the initial treatment was to increase portal output by creating a transjugular intrahepatic portosystemic shunt (TIPS), which was successful in 12 cases. Methods to decrease arterial input to the portal system (hepatosplenic arterial embolization) were used as primary therapy in two patients and in an additional two patients with continued symptoms, despite a functioning TIPS.

RESULTS

All TIPS survivors had patent shunts, although patients with complete PVT required more frequent revisions compared to patients with nonocclusive PVT. Hepatosplenic arterial embolization controlled symptoms in the four patients who were treated, but both patients with patent TIPS died of liver failure after embolization. Of the 14 patients treated, eight died at a mean of 6.2 months (six from hepatoma).

CONCLUSION

TIPS is effective in patients with noncavernomatous PVT, although patients with complete thrombosis experience recurrent shunt occlusions and also may develop hepatoma. If TIPS fails, or if symptoms recur, hepatosplenic arterial embolization may be an option.

Change in hepatic arterial hemodynamics induced by hepatocellular carcinoma detected with Doppler sonography

PURPOSE

To understand the hemodynamic differences between the hepatic arterial branches that supply hepatocellular carcinomas (HCCs) and those that do not, we compared the velocity waveforms of both types of arteries.

METHODS

Using duplex color Doppler sonography, we examined 38 patients with HCC localized within a single lobe of the liver and 34 patients with chronic liver disease but without HCC (controls). We measured angle-corrected peak systolic velocity and the pulsatility index (PI) of color-coded hepatic arteries along the right anterior segmental portal branch and the vertical segment of the left portal vein.

RESULTS

There was no significant difference in peak systolic velocity and PI between the arterial branches tested in the controls. In contrast, we found a significantly lower PI and a higher peak systolic velocity in the arterial branches supplying the tumor than in those not supplying the tumor in patients with an HCC 3 cm or larger in diameter (p < 0.05). The degree of these hemodynamic changes correlated with the tumor size and the presence or absence of tumor thrombus in the major portal branches.

CONCLUSIONS

These results indicate that the hepatic arterial branch supplying an HCC has a lower impedance than the branch not supplying the tumor.

Sonographic diagnosis of hepatic vascular disorders

Perhaps the most valuable application of duplex sonography in the abdomen is in the diagnosis of vascular disorders of the liver. Duplex sonography provides an accurate assessment of the portal and hepatic venous systems that is both noninvasive and convenient, because the examination can be conducted at the bedside. In this article, the normal features of portal and hepatic venous flow are considered as well as the sonographic manifestations of pathological conditions, including: (1) portal hypertension; (2) portosystemic collaterals; (3) portal vein thrombosis; and (4) hepatic vein thrombosis (Budd-Chiari syndrome).