J Liver Cancer.  2019 Sep;19(2):91-96. 10.17998/jlc.19.2.91.

Contrast-enhanced Ultrasonography: The Third Modality for Differentiation of Liver Mass

• Kang MK
• Kim MY
• Kang SH
• Baik SK

• KMID: 2463609
• DOI: http://doi.org/10.17998/jlc.19.2.91

Abstract

Contrast-enhanced ultrasonography (CEUS) using microbubble ultrasonography contrast agent can show the vascular structure and unique contrast enhancement patterns of focal liver lesions, including hepatocellular carcinoma (HCC). CEUS shows three phases, similar to a vascular pattern on computer tomography (CT), and typical arterial enhancement and portal or late phase washout in HCC. CEUS can show real-time images without nephrotoxicity or radiation hazard and can be used as guidance for loco-regional treatment and estimation of treatment response of HCC. In addition, some data recently revealed the usefulness of CEUS in the early estimation of response to anti-cancer pharmacological (i.e., sorafenib) therapy in advanced HCC. Although CEUS has limitations in clinical practice and more investigation is needed for its validation, it is recommended as a main diagnostic modality in a few major clinical practice guidelines for HCC. Thus, greater understanding of CEUS is necessary to extend its application in real practice for diagnosis and management of diseases.

Keyword

Contrast-enhanced ultrasonography; Ultrasonography contrast agent; Hepatocellular carcinoma

MeSH Terms

Carcinoma, Hepatocellular
Diagnosis
Liver*
Microbubbles
Ultrasonography*

Figure

• 

  Figure 1. Example of enhancement pattern of hemangioma using SonoVue® (A), Hepatocellular carcinoma (HCC) using SonoVue® (B), and HCC using Sonazoid® (C) in contrast-enhanced ultrasonography (CEUS). Grey scale ultrasonography image of HCC (a). In general, compared with surrounding parenchyma, HCC shows hyperenhancement in the arterial phase (b) and washout in the portal (c) or late phase (d). In particular, Sonazoid® CEUS presents HCC as dark defects in the Kupffer phase (C, e).

Reference

1. Piscaglia F, Venturi A, Mancini M, Giangregorio F, Vidili G, Magnolfi F, et al. Diagnostic features of real-time contrast-enhanced ultrasound in focal nodular hyperplasia of the liver. Ultraschall Med. 2010; 31:276–282.

2. Nicolau C, Ripollés T. Contrast-enhanced ultrasound in abdominal imaging. Abdom Imaging. 2012; 37:1–19.

3. Bolondi L, Correas JM, Lencioni R, Weskott HP, Piscaglia F. New perspectives for the use of contrast-enhanced liver ultrasound in clinical practice. Dig Liver Dis. 2007; 39:187–195.

4. Lencioni R, Cioni D, Bartolozzi C. Tissue harmonic and contrast-specific imaging: back to gray scale in ultrasound. Eur Radiol. 2002; 12:151–165.

5. Claudon M, Dietrich CF, Choi BI, Cosgrove DO, Kudo M, Nolsøe CP, et al. 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. Ultrasound Med Biol. 2013; 39:187–210.

6. Wilson SR, Burns PN. Microbubble-enhanced US in body imaging: what role? Radiology. 2010; 257:24–39.

7. Moriyasu F, Itoh K. Efficacy of perflubutane microbubble-enhanced ultrasound in the characterization and detection of focal liver lesions: phase 3 multicenter clinical trial. AJR Am J Roentgenol. 2009; 193:86–95.

8. Rettenbacher T. Focal liver lesions: role of contrast-enhanced ultrasound. Eur J Radiol. 2007; 64:173–182.

9. Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004; 363:345–351.

10. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007; 357:2277–2284.

11. Braun B. Focal liver processes: "better is the enemy of good": CEUS in the fast lane. Ultraschall Med. 2009; 30:329–332.

12. Piskunowicz M, Kosiak W, Irga N. Primum non nocere? Why can't we use second generation ultrasound contrast agents for the examination of children? Ultraschall Med. 2011; 32:83–6.

13. Claudon M, Cosgrove D, Albrecht T, Bolondi L, Bosio M, Calliada F, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) - update 2008. Ultraschall Med. 2008; 29:28–44.

14. Strobel D, Seitz K, Blank W, Schuler A, Dietrich C, von Herbay A, et al. Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice (DEGUM multicenter trial). Ultraschall Med. 2008; 29:499–505.

15. Leoni S, Piscaglia F, Granito A, Borghi A, Galassi M, Marinelli S, et al. Characterization of primary and recurrent nodules in liver cirrhosis using contrast-enhanced ultrasound: which vascular criteria should be adopted? Ultraschall Med. 2013; 34:280–287.

16. Furlan A, Marin D, Cabassa P, Taibbi A, Brunelli E, Agnello F, et al. Enhancement pattern of small hepatocellular carcinoma (HCC) at contrast-enhanced US (CEUS), MDCT, and MRI: intermodality agreement and comparison of diagnostic sensitivity between 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines. Eur J Radiol. 2012; 81:2099–2105.

17. Forner A, Vilana R, Ayuso C, Bianchi L, Solé M, Ayuso JR, et al. Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma. Hepatology. 2008; 47:97–104.

18. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of hepatocellular carcinoma. J Hepatol. 2018; 69:182–236.

19. Korean Liver Cancer Association-National Cancer Center. 2018 KLCA-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma [Internet]. Seoul (KR): Korean Liver Cancer Association-National Cancer Center;[cited 2018 Jun 15]. Available from: http://livercancer.or.kr/file/2018_guidelines_20190315_v4.pdf.

20. Omata M, Cheng AL, Kokudo N, Kudo M, Lee JM, Jia J, et al. Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int. 2017; 11:317–370.

21. American College of Radiology (ACR). Liver Imaging Reporting and Data System version 2018 [Internet]. Philadelphia (US): American College of Radiology;[cited 2019 Sep 23]. Available from: https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS.