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Ectopic hepatocellular carcinoma (HCC) is rare and there has been no report on ectopic HCC arising from both the bile duct and the gallbladder. It is difficult to establish a correct diagnosis for this kind of HCC based on preoperative imaging. All of the preoperative imaging examinations misdiagnosed the HCC as cholangiocarcinoma in our case. However, via retrospective analysis of this case, we found that the patient was positive for hepatitis virus markers and that a tumor marker (α-fetoprotein) was significantly elevated. Therefore, diagnosis of HCC with significantly elevated α-fetoprotein (>200 μg/L) is highly likely, particularly with chronic hepatitis and excluding pregnancy and tumor of genital system.

Objective Anti–α-enolase antibody (Ab) combined with β2 microglobulin (β2-MG) were investigated to predict the incidence of nephritis in systemic lupus erythematosus (SLE) patients. Methods Levels of serum anti–α-enolase Ab and urinary β2-MG were detected in 115 SLE patients, 29 SLE patients with nephritis and 70 healthy controls by ELISA and immunoturbidimetry, respectively. Furthermore, the correlation between anti–α-enolase Ab combined with β2-MG and the incidence of nephritis in SLE patients was evaluated by correlation analysis. Results The optical density value of serum anti–α-enolase Ab in SLE patients with nephritis (0.84) was greatly increased compared with SLE patients (0.76) or healthy controls (0.54). Moreover, the levels of urinary β2-MG in SLE patients with nephritis (6.75 mg/L) were increased compared with SLE patients (3.45 mg/L) or healthy controls (1.48 mg/L). There was a positive correlation between the level of anti–α-enolase Ab and β2-MG ( r = 0.754). Furthermore, anti–α-enolase Ab combined with β2-MG for evaluating the incidence of nephritis in SLE patients had the best assessment of the effectiveness (area under the receiver operating characteristic curve (AUC): 92.7%) compared with only anti–α-enolase Ab (AUC: 80.9%) or β2-MG (AUC: 84.5%). Conclusion These data suggested that anti–α-enolase Ab may be a potential indicator for the prediction of nephritis in SLE patients.

Chronic fluid over-hydration is common in dialysis patients. It is associated with mortality and cardiovascular events. Optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. The purpose of this study was to evaluate the usefulness of ultrasound in quantifying body water. In 35 hemodialysis patients, we performed ultrasound of the chest, pre-tibial skin tissue thickness (TT), heart and inferior vena cava (IVC) before and after dialysis. We compared B-line scores of lungs, IVC diameters and cardiac functions in pre-dialysis and post-dialysis groups. We then estimated the correlations between ultrasound parameters and ultrafiltration volumes. Ultrafiltration parameters were adjusted prospectively for subsequent dialysis. As a result, both extravascular and intravascular water decreased during ultrafiltration. The median numbers of B-line scores (10 [0-42] vs. 4 [0-30]; p0.001); mitral valve blood flow velocities E (0.83 ± 0.23 m/s vs. 0.70 ± 0.20 m/s; p0.001), A (0.93 ± 0.28 vs. 0.89 ± 0.23 m/s; p0.001) and E/e' (12.47 ± 4.92 vs. 10.37 ± 4.0; p0.001); IVC diameters at end-expiration (17.51 ± 3.33 mm vs. 14.26 ± 3.45 mm; p0.001); and right pre-tibial TT (2.86 ± 1.36 mm vs. 2.43 ± 1.24 mm; p0.001) decreased during dialysis. Ultrafiltration volume was most associated with B-line score (adjusting for age and sex) (β = -3.340; p = 0.003). In addition, the B-line score after dialysis was significantly associated with left ventricular ejection fraction (r = -0.393; p = 0.019) and TT (r = -0.447; p = 0.007). Ultrafiltration volume was prospectively increased then if the B-line score was6 in the previous dialysis. All patients tolerated the protocol well without any symptoms. Ultrafiltration volume was most associated with lung water, reflected by variation in B-line score. It was not associated with cardiac function, IVC diameter, IVC collapse rate or TT. Lung ultrasound is a useful imaging tool for dialysis patients.

Purpose To evaluate the diagnostic performance of ultrasonography (US) in the identification and exclusion of biliary atresia with a modified triangular cord thickness metric together with a gallbladder classification scheme, as well as hepatic artery (HA) diameter and liver and spleen size, in a large sample of jaundiced infants. Materials and Methods The ethics committee approved this study, and written informed parental consent was obtained. In 273 infants with conjugated hyperbilirubinemia (total bilirubin level ≥ 31.2 μmol/L, with direct bilirubin levelindirect bilirubin level), detailed abdominal US was performed to exclude biliary atresia. Biliary atresia was found in 129 infants and ruled out in 144. A modified triangular cord thickness was measured at the anterior branch of the right portal vein, and a gallbladder classification scheme was identified that incorporated the appearance of the gallbladder and a gallbladder length-to-width ratio of up to 5.2 when the lumen was visualized, as well as HA diameter and liver and spleen size. Reference standard diagnosis was based on results of one or more of the following: surgery, liver biopsy, cholangiography, and clinical follow-up. Area under the receiver operating characteristic curve (AUC) analysis, binary logistic regression analysis, Fisher exact test, and unpaired t test were performed. Results Triangular cord thickness, HA diameter, ratio of gallbladder length to gallbladder width, liver size, and spleen size exhibited statistically significant differences (all P.05) between the group with biliary atresia and the group without. AUCs of triangular cord thickness, ratio of gallbladder length to width, and HA diameter were 0.952, 0.844, and 0.838, respectively. Logistic regression analysis demonstrated that these three US parameters were significantly associated (all P.05) with biliary atresia. The combination of triangular cord thickness and gallbladder classification could yield comparable AUCs (0.915 vs 0.933, P = .400) and a higher sensitivity (96.9% vs 92.2%), compared with triangular cord thickness alone. Conclusion By using the combination of modified triangular cord thickness and gallbladder classification scheme, most infants with biliary atresia could be identified. (©) RSNA, 2015.

The goal of our study was to evaluate the differences between quantitative parameters of hepatocellular carcinoma (HCC) with or without portal vein tumor thrombosis (PVTT) on contrast-enhanced ultrasound (CEUS). Twenty-four patients with HCC with PVTT and 48 without PVTT underwent CEUS using sulfur hexafluoride microbubbles. Dynamic images were analyzed with quantification software. Time-intensity curves were obtained for HCC and surrounding liver parenchyma, and parameters including the intensity maximum (IMAX), rising time (RT), mean transit time and time to peak (TTP) were compared within and between the PVTT and control groups, respectively. RT and TTP of HCC were significantly faster than those of surrounding liver parenchyma in both the PVTT and control groups. IMAX of HCC was significantly stronger than that of surrounding liver in the control group, but not significantly different from that of liver parenchyma in the PVTT group. RT and TTP of HCC and surrounding liver were significantly faster in the PVTT group compared with the control group, whereas IMAX values of HCC in the PVTT group were lower than those in the control group. HCC with PVTT presents different hemodynamic parameters, with faster RT and TTP and lower IMAX than those for HCC without PVTT. Quantitative perfusion analysis of CEUS may be a potential method for predicting PVTT.

We aimed to compare contrast-enhanced ultrasound (CEUS) with contrast-enhanced computed tomography (CECT) for evaluating the treatment response to transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). Treatment responses of 130 patients who underwent TACE were evaluated by CEUS and CECT. We initially compared the abilities of CEUS and CECT to detect residual tumour, which were confirmed by histology or angiography. Then, we compared the tumour response to TACE assessed by CEUS and CECT, according to Modified Response Evaluation Criteria in Solid Tumours (mRECIST). The sensitivity and accuracy of detecting residual tumour by CEUS vs. CECT were 95.9 % vs. 76.2 % (p

Fungal inflammatory pseudotumor (FIPT) of the liver is a rare disease that may be mistaken for a malignant tumor. It is difficult to diagnose because of its nonspecific clinical and imaging features. We report the case of a 46-year-old Asian man who presented with a mass in the right upper quadrant of the abdomen. The patient had undergone transcatheter arterial chemoembolization therapy at another institution 6 months earlier, but the mass had continued to enlarge. He had no history of chronic hepatitis B, and the serum α-fetoprotein was negative. Contrast-enhanced ultrasonography and computed tomography images were suggestive of hepatocellular carcinoma. However, ultrasound-guided biopsy revealed features of chronic inflammation. The mass was resected and found to be an FIPT. We discuss the details of the case and review related articles.

AIM To evaluate the usefulness of contrast-enhanced ultrasonography (CEUS) in differentiating malignant from benign peripheral pulmonary lesions, and to evaluate the feasibility, accuracy, and utility of CEUS-guided biopsy for peripheral pulmonary lesions. MATERIALS AND METHODS Thirty-three patients with histopathologically confirmed peripheral pulmonary lesions (22 malignant, 11 benign) were enrolled in this retrospective study. Conventional ultrasound (US) was first performed and then CEUS with a contrast-specific mode and sulfur hexafluoride-filled microbubble contrast agent. CEUS indices—time of enhancement (TE), time to peak (TP), extent of peak (EP), mean transit time (MTT), area under curve (AUC), and slope—were recorded and compared between the groups. The ability of CEUS and US to detect necrotic areas within lesions was also compared and the accuracy of CEUS-guided biopsy was calculated. RESULTS On CEUS, TE was significantly shorter in acute pneumonia lesions than in other types of lesions (p=0.03). Other indices were not significantly different between benign and malignant lesions. Detection of necrosis within lesions was significantly higher with CEUS than with US (51.5% versus 27.3%; p=0.04). The accuracy of CEUS-guided biopsy was 96.9% (32/33). CONCLUSION The study findings suggest that CEUS can identify necrotic areas within lesions, and thereby, play a useful role in imaging-guided biopsy. The present pilot study indicates that CEUS may help to identify acute pneumonia lesions from other types of pulmonary lesions. CEUS might be a useful additional technique for the diagnosis of lung lesions.

Background Radiofrequency ablation (RFA) is a widely applied treatment for hepatocellular carcinoma (HCC), but insufficient RFA can promote rapid progression of the residual tumor through the hypoxia inducible factor-1α (HIF-1α)/vascular endothelial growth factor A (VEGFA) pathway. Although sorafenib has been successfully applied to advanced HCC, the use of sorafenib in residual tumor cells after RFA has rarely been tested. Purpose To evaluate the potential role of sorafenib as an adjunct to RFA to reduce the recurrence rate after insufficient RFA. Material and Methods Xenograft tumors of SMMC 7721 were created by subcutaneously inoculating nude mice with hepatoma cells (5× 106 cells per mouse). Fourteen days after inoculation, all mice were divided into three groups (control group [sham puncture], RFA group, and RFA combined with sorafenib treatment group) with six mice in each group. Each group was given a different treatment procedure. After treatment, the volume of the tumors was calculated from the resected specimens. The mRNA and protein expression of HIF-1a and VEGFA was quantified by real-time PCR and immunohistochemistry analysis. The micro-vessel density (MVD) was determined by CD34 immunohistochemistry. Results Real-time PCR and immunohistochemistry analysis showed that, compared to the RFA group, HIF-1α and VEGFA expression were significantly decreased in the group that received RFA combined with sorafenib treatment ( P < 0.05). By comparing the control group with the RFA group, we found that insufficient RFA promoted HIF-1α and VEGFA expression ( P < 0.05). Similar results were obtained for MVD expression. Additionally, the combination of RFA with sorafenib therapy resulted in a synergistic reduction in tumor growth compared to insufficient RFA and sham puncture ( P < 0.05). Conclusion Sorafenib was able to inhibit the expression of HIF-1α and VEGFA, and sorafenib was able to increase time to recurrence when used as an adjunct to RFA.

Percutaneous ablative therapies (PAT) are valuable modalities for posthepatectomy recurrent hepatocellular carcinoma (RHCC), but its impact on long-term outcome and prognosis prediction have not been well documented. The present study aimed to analyze prognostic factors and to propose a prognosis-predicting model for RHCC treated with PAT. A total of 288 patients with posthepatectomy RHCC treated with percutaneous ethanol ablation, radiofrequency ablation, microwave ablation, or ethanol ablation combined with radiofrequency ablation were included. Survival and prognostic factors were analyzed. A prognosis-predicting model was created by quantifying and integrating all prognostic factors. Three-, 5-, and 7-year postablation survival rates were 37.8, 20.7, and 14.2 %, respectively. Multivariate analysis revealed that interval between recurrence and initial hepatectomy, tumor number, largest diameter of tumor, and Barcelona Clinic Liver Cancer stage at hepatectomy were independent prognostic factors for survival. A scoring system for prognostic factors was proposed, and summation of 4 prognostic factors (prognostic score) was ranged from 4 to 10. Prognostic score was classified into three strata, designated as prognostic classes A (score 4 and 5), B (score 6 and 7), and C (≥8). Three-, 5-, and 7-year postablation survival rates were 62.8, 39.4, and 26.9 % in class A, 36.9, 15.5, and 7.2 % in B, and 5.5, 0, and 0 % in class C, respectively (p = 0.00). Three-, 5-, 7-, and 10-year survival rates after initial hepatectomy were 82.4, 66.3, 52.1, and 36.4 % in class A, 51.6, 34.8, 20.7, and 6.6 % in class B, and 11.9, 7.8, 0, and 0 % in class C, respectively (p = 0.00). The prognostic model developed in the study could clearly predict different long-term outcomes for patients with posthepatectomy RHCC and thus help decide appropriate therapeutic strategy.

To retrospectively determine the accuracy of baseline ultrasound (BUS) and of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of pancreatic solid-cystic lesions.Fifty-four pancreatic solid-cystic lesions in 52 patients were examined with BUS and CEUS, two different seniority radiologists read the images independently, Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic value of BUS and CEUS in the diagnosis of benign or malignant pancreatic solid-cystic lesions, the diagnostic consistency between different seniority radiologists was evaluated by Kappa statistics.Among the 54 lesions, there were pancreatic cyst five cases, pancreatic pseudocyst twenty cases, pancreatic cystadenoma eight cases, pancreatic cystadenocarcinoma seven cases, intraductal papillary mucinous neoplasm of pancreas (IPMN) three cases, pancreatic carcinoma combined liquefied six cases, solid-pseudopallary tumor of pancreas (SPTP) three cases, pancreatic myopericytoma one case, pancreatic lymphangioma one case. After ROC analysis, the areas under the ROC curve (Az) were 0.752 by BUS, 0.928 by CEUS to resident radiologist, and 0.896 by BUS, 0.954 by CEUS to staff radiologist. The correct diagnosis rate of specific disease was 42.6% by BUS, 64.8% by CEUS to staff radiologist (P0.05), and 33.3% by BUS, 53.7% by CEUS to resident radiologist (P0.05). The interobserver agreement in CEUS is higher than that in BUS, the Kappa value was 0.889 ± 0.062 and 0.428 ± 0.126 respectively.Compared with BUS, CEUS can significantly enhance the diagnostic rate of pancreatic solid-cystic lesions.

Objective: To investigate the potential usefulness of three-dimensional contrast-enhanced ultrasound (3D-CEUS) in evaluating the treatment response for liver cancer after local therapies. Methods: A total of 107 lesions in 95 consecutive patients with liver cancer underwent local therapies and thereafter received low acoustic power 3D-CEUS examination. The LOGIQ 9 ultrasound scanner and a volume transducer were used and the ultrasound contrast agent was SonoVue. The image quality of 3D-CEUS images was evaluated and the influence of 3D-CEUS to clinical outcome was investigated. Results: The image quality of 3D-CEUS was defined as high in 102 (102/107, 95.3%) lesions and common in 5 (5/107, 4.7%) lesions. 3D-CEUS did not change the diagnosis in any patient compared with 2D-CEUS. However, 3D-CEUS changed the management in 3 (2.8%) of 107 lesions, increased confidence but made no change in diagnosis in 85 (79.5%) lesions, added some information but did not change management or diagnosis in 15 (14.0%), and made no change in 4 (3.7%), respectively, in comparison with 2D-CEUS. Conclusion: 3D-CEUS enhances the diagnostic confidence in the majority of the patients and even changes the management in some patients. 3D-CEUS has potential usefulness in evaluating treatment response for liver cancer after local therapies.

Objective To compare the enhancement pattern of hilar cholangiocarcinoma on contrast-enhanced ultrasound (CEUS) with that on contrast-enhanced computed tomography (CECT). Methods Thirty-two consecutive patients with pathologically proven hilar cholangiocarcinomas were evaluated by both low mechanical index CEUS and CECT. The enhancement feature of the tumor, portal vein infiltration, and lesion conspicuity on them was investigated. Results In the arterial phase, the numbers of the lesions showing hyperenhancement, isoenhancement, and hypoenhancement, were 14 (43.8%), 14 (43.8%), and 4 (12.6%), on CEUS, and 12 (37.5%), 9 (28.1%), and 11 (34.4%), on CECT ( P = 0.162). In portal phase, the numbers of the lesions showing hypoenhancement, isoenhancement, and hyperenhancement were 30 (93.8%), 1 (3.1%), and 1 (3.1%), on CEUS, and 23 (71.9%), 8 (25.0%), and 1 (3.1%), on CECT ( P = 0.046). The detection rates for portal vein infiltration were 84.2% (16/19) for baseline ultrasound, 89.5% (17/19) for CEUS, and 78.9% (15/19) for CECT (all P > 0.05 between every two groups). CEUS significantly improved the lesion conspicuity in comparison with CECT. CEUS and CECT made correct diagnoses in 30 (93.8%) and 25 (78.1%) lesions prior to pathological examination ( P = 0.125). Conclusion The enhancement pattern of hilar cholangiocarcinoma on CEUS was similar with that on CECT in arterial phase, whereas in portal phase hilar cholangiocarcinoma shows hypoenhancement more likely on CEUS. CEUS and CECT lead to similar results in evaluating portal vein infiltration and diagnosis of this entity.

Purpose The objective of this study was to investigate the contrast-enhanced ultrasound (CEUS) imaging features of focal liver lesions (FLLs) in fatty liver. Method One hundred FLLs in 98 patients with fatty liver were evaluated with real-time CEUS. Results All malignant FLLs showed hyperenhancement in arterial phase and contrast washout in portal and late phases. Among the FLLs, 3.3% of hemangiomas, 12.5% of focal nodular hyperplasias (FNHs), and 2.5% of focal fatty sparing lesions showed contrast washout in the late phase. The sensitivity and specificity for the characterization of hepatocellular carcinoma, metastasis, hemangioma, FNH, and focal fatty sparing lesions were 100% and 95.6%, 60% and 100%, 93.3% and 98.6%, 87.5% and 97.8%, and 92.6% and 100%, respectively. Conclusions Correct characterization of FLLs in fatty liver by CEUS is possible based on their typical enhancement patterns.

To investigate whether ethanol ablation by using a multipronged needle delivery system (multipronged ethanol ablation) could eradicate hepatocellular carcinoma (HCC) up to 5.0 cm in diameter with a single-session high-dose strategy.The hospital ethics committee approved the prospective study, and each patient provided written informed consent. One hundred forty-one patients (125 men, 16 women; mean age, 53 years; range, 27-76 years) with 164 primary or recurrent HCC ranging from 1.3 to 5.0 cm in diameter (mean, 2.9 cm +/- 0.9) were treated with high-dose multipronged ethanol ablation. Patients were unsuitable for surgery, declined surgery and radiofrequency ablation, or had tumors located at unfavorable sites. Primary technique effectiveness (PTE) (complete ablation within two sessions), local tumor progression (LTP), and complications after the treatment were observed. Twenty risk factors of local effectiveness and complications were analyzed by means of univariate and multivariate analysis.Mean number of treatment sessions was 1.1. The mean volume of ethanol per tumor was 31 mL (range, 8-68 mL). PTE was achieved in 134 (95%) of 141 patients and was significantly associated with tumor pattern (capsulated vs noncapsulated, P = .018). After a mean follow-up period of 25 months, LTP was observed in 16 (12%) of 134 patients, and in nine (56%) patients, LTP occurred in tumors 3.1-5.0 cm in diameter. Alanine aminotransferase level (P = .023) was the independent risk factor for LTP. Three (2%) of 141 patients had major complications.Multipronged ethanol ablation with a high-dose strategy can be used to treat HCC up to 5.0 cm in diameter effectively and safely, often in a single session.

To investigate the findings of renal cell carcinomas (RCCs) on contrast-enhanced ultrasound (CEUS).CEUS features of 84 RCCs confirmed by pathologic examination in 81 patients were retrospectively analyzed. A contrast-specific mode and a sulfur hexafluoride-filled microbubble contrast agent were used for CEUS. The enhancement pattern, extent, and dynamic change in the cortical, corticomedullary, and late phases were evaluated.On CEUS, the emergence of tumor enhancement was earlier in two nodules (2.4%), simultaneous in 71 (84.5%), and later in 11 (13.1%), in comparison with the adjacent renal cortex. Seventy-four RCC nodules (88.1%) showed hyper-enhancement (n = 2) or iso-enhancement (n = 72) during the cortical phase, and the remaining 10 (11.9%) showed hypo-enhancement. Twenty-three nodules (27.4%) showed homogeneous enhancement and 61 (72.6%) inhomogeneous enhancement. In the corticomedullary phase, the nodules showed hypo-enhancement in 68 (81.0%) and iso-enhancement in 16 (19.0%). In the late phase, all RCCs showed the same enhancement pattern as that shown in the corticomedullary phase. Seventy-two (85.7%) nodules showed a clear perilesional rim-like enhancement in late phase.Hyper- or iso-enhancement during the cortical phase, subsequent washout in late phase, inhomogeneous enhancement, and perilesional rim-like enhancement are clues for RCCs, which might be useful for characterization of RCCs.

We assessed the usefulness of contrast-enhanced ultrasound (CEUS) in the differentiation of intrahepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC).The CEUS enhancement patterns of 50 ICCs were retrospectively analysed and compared with 50 HCCs. Two readers independently reviewed the baseline ultrasound (BUS) and CEUS images and the diagnostic performances were evaluated by receiver operating characteristic (ROC) analysis. Time-intensity curves (TIC) were plotted for quantification analysis.In the arterial phase, peripheral rim-like hyperenhancement, heterogeneous hyperenhancement, homogeneous hyperenhancement and heterogeneous hypoenhancement were found in 25, 10, 3 and 12 of the ICCs versus 2, 29, 19 and 0 of the HCCs (P0.001), respectively. The diagnostic performance of both readers in terms of the area under the ROC curve (0.745 vs. 0.933 for reader 1, and 0.803 vs. 0.911 for reader 2), sensitivity (28% vs. 90%, and 44% vs. 82%) and accuracy (64% vs. 90%, and 71% vs. 90%) improved significantly after CEUS (all P0.05). The interobserver agreement increased from kappa = 0.575 at BUS to kappa = 0.720 after CEUS. TICs demonstrated that the intensities of the peripheral and central portions of the ICCs were lower than those of HCCs (both P0.05).CEUS improves the diagnostic performance significantly in the differentiation between ICC and HCC.

The study was aimed at evaluating the diagnostic performance of contrast-enhanced ultrasound (CEUS) in characterizing complex cystic focal liver lesions (FLLs). Sixty-seven complex cystic FLLs in 65 patients were examined with conventional ultrasound (US) and real-time CEUS. The US and CEUS images were reviewed by a resident radiologist and a staff radiologist independently. Receiver operating characteristic (ROC) analysis was performed to evaluate the diagnostic performance, and the interobserver agreement was analysed. The results showed that complete non-enhancement throughout three phases of CEUS or sustained enhancement in the portal and late phases were exhibited in most benign lesions. Conversely, hypo-enhancement in the late phase was seen in all malignancies. After ROC analysis, the areas (Az) under the ROC curve were 0.774 at US versus 0.922 at CEUS (P = 0.047) by the resident radiologist, and 0.917 versus 0.935 (P = 0.38) by the staff radiologist. A significant difference in Az between the resident and the staff radiologists was found for US (0.774 versus 0.917, P = 0.044), whereas not found for CEUS (0.922 versus 0.935, P = 0.42). Interobserver agreement was improved after CEUS (κ = 0.325 at US versus κ = 0.774 at CEUS). Real-time CEUS improves the capability of discrimination between benign and malignant complex cystic FLLs, especially for the resident radiologist.

Purpose To evaluate the usefulness of contrast-enhanced sonography (CEUS) in the diagnosis of small hepatocellular carcinoma (HCC) measuring ≤2 cm in diameter. Methods We identified 104 focal liver lesions measuring ≤2 cm in 104 consecutive patients who were enrolled for baseline sonography (BUS) and CEUS examination (49 HCCs, 55 non-HCCs). A real-time, contrast-specific mode of contrast pulse sequencing and a sulphur hexafluoride-filled microbubble contrast agent were used for CEUS. The diagnostic performances of BUS and CEUS in differentiating focal liver lesions (HCC or non-HCC) were analyzed and compared. Results On CEUS, 43 (87.8%) of the 49 HCC lesions were hyperenhanced, 5 (10.2%) were isoenhanced, and 1 (2%) was hypoenhanced during the arterial phase when compared with adjacent liver tissue. Thirty-nine (79.6%) HCCs exhibited washout from the portal phase to the late phase. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy before and after contrast agent administration were 28.6% (14/49) versus 79.6% (39/49) (p 0.05), 82.4% (14/17) versus 90.7% (39/43) (p > 0.05), 59.8% (52/87) versus 90.7% (39/43) (p < 0.01), and 63.5% (66/104) versus 86.5% (90/104) (p < 0.001), respectively. No significant difference in diagnostic performance of CEUS was found between lesions measuring ≤1.5 cm and those 1.6–2 cm and between lesions located at a depth of ≤6 cm from the skin and those located deeper. Conclusions CEUS significantly improved the diagnostic performance in characterization of small HCCs ≤2 cm compared with BUS. © 2007 Wiley Periodicals, Inc. J Clin Ultrasound, 2008

The purpose of this series was to preliminarily evaluate the use of contrast-enhanced sonographically guided percutaneous thermal ablation in the evaluation and treatment of solid-organ bleeding by retrospectively analyzing 6 cases observed in clinical practice. Six patients who underwent contrast-enhanced sonographically guided thermal ablation for treatment of solid-organ bleeding (5 in liver and 1 in spleen) from December 2005 to August 2012 were included in this series. Clinical information, contrast-enhanced sonograms before and after ablation, and the ablation method were retrospectively collected and analyzed. In 5 of the 6 patients, the location of the bleeding lesion was clearly seen. Hemostasis was successfully achieved in 4 of these 5 patients: 1 by radiofrequency ablation and 3 by microwave ablation. Ablation failed to achieve hemostasis in 1 patient who had postbiopsy splenic arterial bleeding because the bleeding vessel was a thick branch of the splenic artery. In the sixth remaining patient, who had bleeding after liver biopsy, hemostasis failed because contrast-enhanced sonography did not precisely locate the bleeding lesion; hence, the ablation zone did not cover the whole lesion. Contrast-enhanced sonographically guided ablation can be an alternative choice for treating solid-organ bleeding because of its effectiveness and minimal invasiveness. However, it should be carefully investigated for those in whom the bleeding lesion cannot be located by contrast-enhanced sonography and in those who have bleeding in a large vessel.

We compared the enhancement pattern of 98 hepatocellular carcinoma nodules in 92 patients on contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT). Contrast-enhanced ultrasound was performed with SonoVue and a low mechanical index method. In arterial phase, 98 nodules were hyperenhancing on CEUS and 94 on CECT. In portal phase, 82 nodules were hypoenhancing on CEUS and 83 on CECT. Peripheral thin-rim-like enhancement was exhibited in 30 nodules on CEUS and 31 on CECT. Intratumoral vessels were visualized in 94 nodules on CEUS and 36 on CECT.

OBJECTIVE The purpose of this study was to assess the diagnostic performance of real-time contrast-enhanced sonography in characterization of small focal liver lesions (FLLs; < or = 3.0 cm in diameter). METHODS Two hundred small FLLs in 200 patients were examined by contrast-enhanced sonography using a contrast-specific mode of contrast pulse sequencing and a sulfur hexafluoride-filled microbubble contrast agent. The sonographic images were reviewed by 2 independent readers. A 5-point confidence level was used to discriminate malignant from benign FLLs, and specific diagnoses were recorded. The diagnostic performances were evaluated by receiver operating characteristic (ROC) analysis, and the interobserver agreement was analyzed by weighted kappa statistics. RESULTS After review of contrast-enhanced sonography, ROC analysis revealed significant improvement in differentiating between malignant and benign small FLLs that the areas under the ROC curve were 0.856 at baseline sonography versus 0.954 at contrast-enhanced sonography for reader 1 (P < .001) and 0.857 versus 0.954 for reader 2 (P = .003). The sensitivity, negative predictive value, and accuracy for both readers also improved significantly after contrast agent administration (all P < .001). A better result of specific diagnosis was obtained (38.5% [77/200] at baseline sonography versus 80.5% [161/200] at contrast-enhanced sonography for reader 1 and 34.5% [69/200] versus 80.5% [161/200] for reader 2; both P < .001) after contrast agent administration, and a better interobserver agreement was achieved (kappa = 0.425 at baseline sonography versus 0.716 at contrast-enhanced sonography). CONCLUSIONS Real-time contrast-enhanced sonography improves the diagnostic performance in small FLLs compared with baseline sonography.

Percutaneous microwave ablation and radiofrequency ablation are two commonly used modalities for the treatment of hepatocellular carcinoma; however, comparisons of them have not been documented adequately.Of 102 patients with biopsy-proved hepatocellular carcinoma, 49 (98 nodules) were treated percutaneously with microwave ablation and 53 (72 nodules) with radiofrequency ablation. The local tumor control, complications related to treatment, and long-term results of the two modalities were compared retrospectively.The complete ablation rates were 94.9% (93/98) using microwave ablation vs 93.1% (67/72) using radiofrequency ablation (P = 0.75), and no significant differences were found either in the ablation of tumors of 3.0 cm or less (P = 1.00) or in those of more than 3.0 cm (P = 1.00) between the two modalities. The local recurrence rates were 11.8% (11/93) using microwave ablation vs 20.9% (14/67) using radiofrequency ablation (P = 0.12), and there were no significant differences between the two modalities either in tumors of 3.0 cm or less (P = 0.36) or in those of more than 3.0 cm (P = 0.82). The rates of major complications associated with microwave ablation and radiofrequency ablation were 8.2% (4/49) vs 5.7% (3/53; P = 0.71). The disease-free survival rates in the microwave ablation group were 45.9%, 26.9%, 26.9%, and 13.4% at 1, 2, 3, and 4 years, respectively, and those in the radiofrequency ablation group were 37.2%, 20.7%, and 15.5% at 1, 2 and 3 years, respectively (P = 0.53). The 1-, 2-, 3-, and 4-year cumulative survival rates for patients who underwent microwave ablation were 81.6%, 61.2%, 50.5%, and 36.8%, respectively, and for patients who underwent radiofrequency ablation the rates were 71.7%, 47.2%, 37.6%, and 24.2%, respectively (P = 0.12).Percutaneous microwave ablation and radiofrequency ablation are both effective methods in treating hepatocellular carcinomas. The local tumor control, complications related to treatment, and long-term survivals were equivalent for the two modalities.

Background Tumour ablation using a thermal energy source has shown promising results, and is particularly suitable for recurrent hepatocellular carcinoma (HCC). The present study evaluated long-term outcomes after percutaneous thermal ablation for recurrent HCC following liver resection. Methods Radiofrequency ablation or microwave ablation was used to treat a total of 124 tumour nodules (0·9–7·0 cm in diameter) in 72 patients with recurrent HCC. Results Complete ablation of 119 (96·0 per cent) of 124 tumour nodules was achieved. There was no treatment-related death and the major complication rate was 4 per cent. During a mean(s.d.) follow-up of 27·9(17·8) months, local recurrence developed in 16 (13·6 per cent) of 118 successfully treated tumour nodules. Distant recurrence developed in 60 (85 per cent) of 71 patients, of whom 26 had repeat metachronous distant recurrence. With repeated ablation for both local and distant recurrence, the 1-, 3- and 5-year overall survival rates after initial ablation were 75, 43 and 18 per cent respectively. Patients with a serum α-fetoprotein level greater than 200 ng/ml before treatment had significantly poorer survival than those with a lower level (P = 0·034) and multivariate analysis identified preablation AFP level as an independent prognostic factor (P = 0·054). Conclusion With their advantages of preservation of non-tumorous liver tissue and easy repetition, percutaneous thermal ablative therapies were particularly suitable for recurrent HCC and improved long-term survival.

To evaluate the efficacy and safety of combined radiofrequency ablation (RFA) and ethanol injection with a multipronged needle in the treatment of medium (3.1–5.0 cm) and large (5.1–7.0 cm) hepatocellular carcinoma (HCC). A total of 65 patients with 67 HCC nodules were enrolled in this prospective study. All of them received the treatment of combined RFA and multipronged ethanol injection percutaneously. The average volume of injected ethanol was 14.4 ± 4.1 ml (range, 9–30 ml). The average number of RFA electrode insertions was 1.7 ± 0.8 (range, 1–4). The rate of initial local complete response (CR) was 94.0 % (63/67). After additional treatment, technical success was achieved in all HCC nodules. There were no treatment-related deaths, and major complications were observed in 3 (4.6 %) patients. After a mean follow-up of 20.0 ± 7.6 months, local tumour progression was observed in 10 (10/67, 14.9 %) tumours, whereas distant recurrence developed in 32 (32/65, 49.2 %) patients. The 1-year and 2-year survival rates were 93.1 % and 88.1 %, respectively. The combination of RFA and multipronged ethanol injection in the treatment of medium and large HCC is safe and effective with a high rate of local tumour control. • Combined radiofrequency ablation and multipronged ethanol injection is a new therapeutic strategy • Treatment is safe and effective for medium and large hepatocellular carcinoma (HCC) • A multipronged needle allows for a homogeneous ethanol distribution

To investigate and compare contrast-enhanced ultrasound (CEUS) in the characterisation of histologically proven focal nodular hyperplasia (FNH) with contrast-enhanced computed tomography (CECT). CEUS was performed in 85 patients with 85 histologically proven FNHs. Enhancement, centrifugal filling, spoke-wheel arteries, feeding artery and central scarring were reviewed and correlated with lesion size or liver background. Independent factors for predicting FNH from other focal liver lesions (FLLs) were evaluated. Forty-seven FLLs with CECT were randomly selected for comparison of diagnostic performance with CEUS. Centrifugal filling was more common (P = 0.002) and the significant predictor (P = 0.003) in FNHs ≤3 cm. Lesion size or liver background has no significant influence on the detection rate of the spoke-wheel arteries and feeding artery (P > 0.05). Central scarring was found in 42.6 % of FNHs ≥3 cm (P = 0.000). The area under the ROC curve, sensitivity and specificity showed no significant differences between CEUS and CECT (P > 0.05), except that the sensitivity of CEUS was better for reader 1 (P = 0.041). CEUS is valuable in characterising centrifugal filling signs or spoke wheels in small FNHs and should be employed as the first-line imaging technique for diagnosis of FNH. • The confident diagnosis of focal nodular hyperplasia is important in liver imaging. • The centrifugal filling sign is useful for diagnosis of FNHs ≤3 cm. • Contrast-enhanced ultrasound and contrast-enhanced CT have similar diagnostic performance for FNH. • CEUS should be the first-line imaging technique for the diagnosis of FNH.

To evaluate the feasibility, accuracy, and utility of sonography (US) and CT fusion imaging guidance for radiofrequency ablation (RFA) of malignant liver tumors not visualized on conventional US.Seventy-seven patients with hepatocellular carcinoma and 15 patients with metastatic liver cancer with a total of 136 lesions underwent RFA with US and CT fusion imaging guidance. The mean number of punctures, success rate of a single ablation session, local tumor progression rates, and long-term outcome were evaluated. Treatment efficacy was evaluated by dynamic CT and contrast-enhanced US 1 month after RFA.RFA was technically feasible in all patients, and no major complications occurred. The mean ± SD time needed to synchronize US and CT images was 13.9 ± 11.9 minutes (range, 5-55 minutes). The success rate of a single ablation session was 83.8% (114/136), and tumor residue was present in 7.4% of lesions (10/136). The mean number of treatment sessions was 1.2 ± 0.5 sessions. During follow-up, local tumor progression was observed for 15 (11.9%) lesions. Distant tumor recurrence was found in 51 (55.4%) patients.US and CT fusion-assisted RFA is a safe and efficacious treatment for patients with hepatocellular carcinoma and metastatic liver cancer.

OBJECTIVES To prospectively evaluate the objective differential characteristics between cystic biliary atresia and choledochal cysts on sonography among neonates and young infants. METHODS Twenty-three patients who had sonographic findings of a portal cyst and a final diagnosis were included. Their final diagnoses were cystic biliary atresia in 12 patients and choledochal cysts in 11. All of them underwent detailed sonographic scanning. Data for cystic biliary atresia and choledochal cyst groups were compared by the χ(2) test for categorical variables and an unpaired t test for continuous variables. RESULTS The triangular cord sign was detected in 11 patients in the atresia group but in none in the cyst group (P < .001). Nine of 11 patients in the cyst group had dilatation of intrahepatic bile ducts, whereas none in the atresia group had that feature (P < .001). Sonography also showed sludge deposits in the cysts in 6 of 11 patients in the cyst group, whereas none in the atresia group had sludge deposits (P = .005). The mean width and length of the cysts in the cyst group were significantly larger than those in the atresia group (P< .05 for both). The mean hepatic artery diameter was significantly larger in the atresia group than in the cyst group (P < .001). The difference in gallbladder abnormalities between the atresia (n = 11) and cyst (n = 0) groups was also significant (P < .001). When all specific sonographic features were used, all patients were correctly classified into the atresia and cyst groups. CONCLUSIONS The triangular cord sign, intrahepatic bile duct dilatation, and echoic cysts might be regarded as objective sonographic features for differentiating cystic biliary atresia and choledochal cysts. Other sonographic features might be very supportive.

Percutaneous ultrasound-guided radiofrequency ablation is increasingly being studied in the treatment of renal tumors. Because percutaneous ultrasound-guided radiofrequency ablation is a minimally invasive and nephron-sparing procedure, it is ideally suited for patients with a single kidney, multiple tumors, or contraindications to conventional surgery. We report on a patient with Von Hippel-Lindau (VHL) disease who had multicentric tumors in the single kidney that was successfully treated with percutaneous ultrasound-guided radiofrequncy ablation. The one-year follow-up showed that there was no local recurrence or metastasis. And genetic testing showed the patient had a T to G heterozygotic missense mutation at nucleotide 515 of VHL gene exon 1.

The purpose of this study was to compare the capability of contrast-enhanced ultrasonography (CEUS) and contrast-enhanced computed tomography (CECT) in evaluating the vascularity of liver metastases.Both CEUS and CECT examinations were performed on 70 patients with liver metastases, which were from colon carcinoma in 31, rectal carcinoma in 17, pancreatic carcinoma in 5, and others in 17. In patients with multiple lesions, the most easily observed lesion was selected as the target lesion for evaluation of vascularity.Peak enhancement of the target lesion during the arterial phase was characterized as hyperenhancement, isoenhancement, hypo-enhancement, and nonenhancement in 61 (87.1%), 6 (8.6%), 3 (4.3%), and 0 (0%) patients on CEUS, respectively, and in 52 (74.3%), 8 (11.4%), 8 (11.4%), and 2 (2.9%) on CECT. Contrast-enhanced ultrasonography showed more lesions with hyperenhancement than CECT (P.01). The enhancement pattern during the arterial phase was homogeneous, inhomogeneous, and rimlike in 30 (42.9%), 16 (22.9%), and 24 (34.2%) patients on CEUS and in 13 (18.6%), 8 (11.4%), and 49 (70%) on CECT. Contrast-enhanced ultrasonography revealed more lesions with homogeneous enhancement than CECT (P.01). Contrast-enhanced ultrasonography showed dysmorphic vessels in 33 patients (47.1%) during the arterial phase, whereas CECT showed dysmorphic vessels in 27 (38.6%; P.01). Contrast-enhanced ultrasonography showed hypervascular lesions in 58.6% of patients, whereas CECT showed hypervascular lesions in 12.9% (P.01).Contrast-enhanced ultrasonography was superior to CECT in assessing the vascularity of liver metastases.

OBJECTIVE The purpose of this study was to evaluate the usefulness of contrast-enhanced ultrasonography (CEUS) in differentiating renal cell carcinoma (RCC) from renal angiomyolipoma (RAML). METHODS One hundred nineteen patients with 126 renal lesions (33 RAMLs and 93 RCCs) who had undergone CEUS were retrospectively studied. All of the lesions were histopathologically or clinical proved. Contrast-enhanced ultrasonography was performed using low-acoustic power modes and a sulfur hexafluoride-filled microbubble contrast agent. The baseline sonograms and CEUS images were retrospectively analyzed in consensus by 2 radiologists. The tumor echogenicity, enhancement patterns, and degree of enhancement at different phases were evaluated. The diagnostic efficacy of CEUS in differentiating the two diseases was computed and compared. RESULTS On CEUS, the features of wash-out from hyperenhancement or isoenhancement to hypoenhancement over time (observed in 3.0% of RAMLs and 71.0% of RCCs; P < .001), heterogeneous enhancement (observed in 12.1% of RAMLs and 74.2% of RCCs; P < .001), and an enhanced perilesional rim (observed in 3.0% of RAMLs and 79.6% of RCCs; P < .001) achieved significant difference between RCCs and RAMLs. Early wash-out and heterogeneous enhancement or peritumoral rim enhancement yielded the highest diagnostic capability in differentiating RCC from RAML. The corresponding sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 88.2% (82 of 93), 97.0% (32 of 33), 98.8% (82 of 83), 74.4% (32 of 43), and 90.5% (114 of 126), respectively. CONCLUSIONS The CEUS features of early wash-out, heterogeneous enhancement, and an enhanced peritumoral rim highly suggest RCC, whereas homogeneous enhancement and prolonged enhancement are characteristic manifestations of RAML. Contrast-enhanced ultrasonography is valuable in differentiating RCC from RAML.

The value of contrast-enhanced ultrasound (CEUS) in differential diagnosis between benign and malignant gallbladder diseases was investigated. Thirty-three patients with gallbladder carcinomas and 47 with benign gallbladder diseases underwent CEUS. The lesion enhancement time, enhancement extent, pattern, dynamic change of enhancement and the intactness of gallbladder wall were evaluated. In the early phase at CEUS, hyper-, iso-, hypo-, and non-enhancement were found in 84.8% (28/33), 9.1% (3/33), 6.1% (2/33), and 0% (0/33) of gallbladder carcinomas, and 70.3% (33/47), 17.0% (8/47), 2.1% (1/47), and 10.6% (5/47) of benign diseases (p > 0.05). Hyper-enhancement or iso-enhancement in the early phase and then fading out to hypo-enhancement within 35 s after contrast agent administration was found in 90.9% (30/33) of carcinomas and 17.0% (8/47) of benign lesions (p < 0.001). Destruction of the gallbladder wall intactness was absent in benign diseases, whereas it was present in 28 (84.8%) of the 33 carcinomas (p < 0.001). Destruction of gallbladder wall intactness on CEUS yielded the highest capability in differential diagnosis, with sensitivity, specificity, and Youden’s index of 84.8% (28/33), 100% (47/47), and 0.85, respectively. Conventional US made correct original diagnoses in 55 (68.8%) patients, whereas CEUS in 77 (96.3%). Thus, CEUS is useful in differential diagnosis between malignant and benign gallbladder diseases.

The objective was to evaluate whether the echogenicity of focal liver lesions (FLLs) on baseline gray-scale ultrasound (US) interferes with the diagnostic performance of contrast-enhanced US (CEUS) for small FLLs. Three-hundred and eighty-eight patients were examined by real-time CEUS using a sulfur hexafluoride-filled microbubble contrast agent. The images of 114 hyperechoic lesions, 30 isoechoic lesions and 244 hypoechoic lesions were reviewed by two blinded independent readers. A five-point confidence level was used to discriminate malignant from benign lesions, and specific diagnoses were made. The diagnostic performances were evaluated by receiver-operating characteristic (ROC) analysis. The diagnostic performances of CEUS on hyperechoic lesions in terms of the areas (Az) under the ROC curve were 0.987 (reader 1) and 0.981 (reader 2), and were 0.987 (reader 1) and 0.984 (reader 2) for iso- and hypoechoic lesions, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87.0-95.9%, 93.1-100%, 88.6-100%, 70.0-97.1% and 90.0-95.1%, respectively. The echogenicity of FLLs on baseline gray-scale US does not appear to interfere with the diagnostic ability of CEUS for small FLLs.

Three-dimensional contrast-enhanced ultrasound (3D-CEUS) is a combination of three-dimensional ultrasound (3DUS) and contrast-enhanced ultrasound (CEUS). To evaluate the feasibility of 3D-CEUS in liver imaging, investigate possible influencing factors to its image quality, and evaluate the influence of 3D-CEUS to clinical outcome, low acoustic power (mechanical index, 0.08-0.13) 3D-CEUS was carried out in 102 focal liver lesions in 92 patients by using the LOGIQ 9 ultrasound scanner and a volume transducer (frequency range, 2-5 MHz; focusing ability, 2-25 cm in depth; azimuth aperture 5.9 cm). The lesions were classified into two groups: group 1 (n=51) for characterization and group 2 (n=51) for local treatment response evaluation. The factors that influenced the image quality of 3D-CEUS were analyzed. The image quality and usefulness of 3D-CEUS between the two groups were compared by using the chi(2)-test. The results showed that the lesion diameter, location, and scanning route had no significant influence on the image quality in both groups, whereas interfering factors damaged the image quality in group 1. In group 1, during arterial phase, high image quality was more frequently found in hyperenhanced and hypo- or non-enhanced lesions compared with isoenhanced lesions. In group 2, interfering factor and local treatment response had no obvious influence on the image quality. The visualization rate of high image quality was 94.1% (48/51) in group 2 vs. 72.6% (37/51) in group 1 (P=0.012). The investigators found that 3D-CEUS improved confidence but made no change in diagnosis in 19 (37.3%) of 51 lesions in group 1, whereas 41 (80.4%) of 51 lesions in group 2 (P=0.000). 3D-CEUS tends to obtain better image quality and lead to higher diagnostic confidence in the lesions for local treatment response evaluation, and perhaps is more useful in this aspect in future clinical settings.

Objective The purpose of this study was to investigate the features of infected focal liver lesions on contrast-enhanced ultrasound (CEUS) imaging. Methods Thirty-two hepatic abscesses, 15 infected granulomas, and 6 inflammatory pseudotumors in 53 patients were evaluated with real-time CEUS before awareness of the definitive diagnosis. A 2.4-mL dose of a sulfur hexafluoride-filled microbubble contrast agent was administered by intravenous bolus injection. Results The numbers of abscesses with hyperenhancement, isoenhancement, and hypoenhancement in the arterial phase were 26 (81.3%), 5 (15.6%), and 1 (3.1%), respectively. Thirty (93.8%) lesions were irregularly rim enhanced with nonenhanced areas; enhanced septa were shown in 22 (68.8%) lesions; and transient hyperenhancement of liver parenchyma around the lesion was shown in 20 (62.5%). In 31 abscesses with hyperenhancement or isoenhancement in the arterial phase, 25 (80.6%) showed contrast wash-out and changed in appearance to hypoenhancement in the late phase. As for infected granulomas and inflammatory pseudotumors, 16 (76.2%) lesions showed hyperenhancement or isoenhancement in the arterial phase, and all of them were hypoenhanced in the portal and late phases. Conclusions Most infected focal liver lesions showed more rapid contrast wash-out than the surrounding liver parenchyma, which is similar to malignant lesions. Abscesses typically showed features of rim enhancement, enhanced internal septa, nonenhanced central necrotic areas, and transient hyperenhanced liver parenchyma around the lesions. The CEUS appearance of infected granulomas and inflammatory pseudotumors was variable, and a biopsy was necessary for definitive diagnosis.

Objective This presentation aims to provide an overview of the manifestations of some unusual benign focal liver lesions (FLLs) on low-acoustic power contrast-enhanced sonography (CES) with a sulfur hexafluoride contrast agent. Methods The patients were selected retrospectively from 2209 cases with FLLs who had undergone CES examinations for characterization during the past 3 years. The pathologic examinations proved that they were intrahepatic biliary cystadenoma (n = 1), angiomyolipoma (AML; n = 4), lipoma (n = 1), biliary epithelial dysplasia (n = 1), a fungal inflammatory mass (n = 1), tuberculoma (n = 2), an inflammatory pseudotumor (n = 7), sarcoidosis (n = 1), solitary necrotic nodules (n = 2), peliosis hepatis (n = 2), and focal fibrosis after surgery (n = 4). Results Contrast-enhanced sonography was beneficial in leading to a diagnosis of benignity for some lesions showing hyperenhancement during the arterial phase and sustained enhancement during the portal or late phase, such as liver AML and lipoma. The benign nature of other lesions showing no enhancement during all phases, such as solitary necrotic nodules and focal fibrosis, was also suggestible. On the other hand, for those lesions showing hyperenhancement, isoenhancement, or hypoenhancement during the arterial phase and hypoenhancement during the late phase, including intrahepatic biliary cystadenoma, biliary epithelial dysplasia, infected liver diseases, the inflammatory pseudotumor, sarcoidosis, and peliosis hepatis, the differential diagnosis between benignity and malignancy was difficult, and pathologic tests were mandatory. Conclusions The CES features of unusual benign FLLs may enrich knowledge when performing CES examinations for characterization and may provide clues for a specific diagnosis of an individual lesion such as liver AML.

Purpose. To characterize focal liver lesions (FLLs) using real-time contrast-enhancedsonography (CEUS) with a low mechanical index mode and a sulfur hexafluoride-filled microbubble contrast agent. Methods. CEUS was performed in 190 patients with FLLs, including hepatocellular carcinoma (HCC) (n = 107), liver metastasis (n = 21), intrahepatic cholangiocarcinoma (ICC) (n = 7), liver hemangioma (n = 37), focal nodular hyperplasia (FNH) (n = 11), regenerative nodule (n = 6) and liver lipoma (n = 1). The cadence contrast pulse sequencing technique and the contrast agent SonoVue® were used for CEUS examination. The enhancement patterns during the arterial, portal, and late phases were evaluated. Results. HCC showed hyperenhancement in 100 (93.5%) of 107 nodules during the arterial phase and hypoenhancement in 102 (95.3%) during the late phase. Liver metastases showed homogeneous enhancement in 8 of 21 (38.1%) nodules and a peripheral regular rim-like enhancement in 11 of 21 (52.4%) nodules during the arterial phase and marked hypoenhancement in 16 of 21 (76.2%) nodules during the late phase. ICC exhibited irregular rim-like enhancement in 4 of 7 (57.1%) nodules during the arterial phase and hypo-enhancement in 7 of 7 (100%) nodules during the late phase. Hemangioma showed peripheral nodular hyperenhancement, and progressive centripetal enhancement was seen in 35 of 37 (94.6%) lesions during the arterial phase. All 11 cases of FNH exhibited homogeneous hyperenhancement during the arterial phase and hyperenhancement (n = 1) or isoenhancement (n = 9) during the late phase. The sensitivity, specificity, and positive predictive value, respectively, were 88.8%, 89.2%, and 91.3% for HCC; 81%, 100%, and 100% for liver metastasis; 57.1%, 100%, and 100% for ICC; 94.6%, 100%, and 100% for liver hemangioma; and 90.9%, 97.8%, and 71.4% for FNH. Conclusions. Low–mechanical index CEUS permits real-time, complete assessment of vascularity in FLLs, which in turn facilitates their characterization. © 2006 Wiley Periodicals, Inc. J Clin Ultrasound 34:261–272, 2006

Objective The purpose of this study was to investigate the imaging findings of peripheral cholangiocarcinoma with low-mechanical index (MI) contrast-enhanced sonography. Methods Eighteen nodules of peripheral cholangiocarcinoma proved by pathologic examination in 18 patients were evaluated with contrast-enhanced sonography. A low-MI real-time contrast-enhanced sonographic mode (ie, contrast pulse sequencing) and a sulfur hexafluoride-filled microbubble contrast agent (SonoVue [BR1]; Bracco SpA, Milan, Italy) were used. Results On contrast-enhanced sonographic images, all 18 nodules (100%) of peripheral cholangiocarcinoma showed inhomogeneous enhancement during the arterial phase, and the emergence of nodule enhancement was earlier in 3 nodules (16.7%), simultaneous in 13 (72.2%), and later in 2 (11.1%), respectively, when compared with the adjacent liver tissue. During the arterial phase, 8 nodules (44.4%) showed irregular peripheral rimlike hyperenhancement, 2 (11.1%) showed inhomogeneous hyperenhancement, and 8 (44.4%) showed inhomogeneous hypoenhancement. In portal and late phases, all 18 nodules (100%) showed hypoenhancement. When contrast-enhanced sonography was added for analysis, the confidence levels of the investigators were improved in 15 (83.3%) of 18 nodules, and 17 (94.4%) of 18 peripheral cholangiocarcinomas were correctly characterized. Conclusions The imaging findings of peripheral cholangiocarcinoma had some characteristics on low-MI contrast-enhanced sonography. Knowledge of these characteristics might be beneficial for improving the diagnostic performance of sonography in evaluating this entity.

To evaluate the clinical performance of an innovative contrast-enhanced ultrasound (CEUS) technique in characterization of focal liver lesions (FLL).CEUS was performed in 505 patients with FLLs. A sulfur hexafluoride-filled microbubble ultrasound contrast agent and a continuous real-time imaging technique of contrast pulse sequencing were used. The observation items included initial nodule enhancement time, enhancement level and pattern, and dynamic evolution of enhancement along with the CEUS phases.There were similar findings for both malignant and benign FLLs in initial enhancement time and enhancement level on CEUS. The dynamic evolution of enhancement along with enhancement phase was the most significant parameter for characterization of FLLs. Most malignant lesions showed enhancement at arterial phase and hypo-enhancing at late phase, whereas the benign lesions presented enhancement at arterial phase and persistent hyper- or iso-enhancing until late phase. Using these characteristics as a diagnostic criteria, the sensitivity, specificity, positive predicative value, negative predicative value and accuracy of CEUS in identifying malignant FLLs were 95.7% (313/327), 86.0% (153/178), 92.6% (313/338), 91.6% (153/167) and 92.3% (466/505), respectively.Characterization of FLLs by using the innovative CEUS technique is recommendable due to its safety, facility and high accuracy.

AIM To identify prognostic factors for long-term outcome for patients with hepatocellular carcinoma (HCC) after percutaneous microwave or radiofrequency ablation. MATERIALS AND METHODS In total, 137 consecutive patients with HCC underwent microwave or radiofrequency ablation with curative intent; 16 possible prognostic factors were evaluated for their association with overall survival (OS) and disease-free survival (DFS) using univariate and multivariate analysis. RESULTS The median OS and DFS were 27.0 months and 8.2 months, respectively. OS rates for all patients at 1, 2, 3, 4 and 5 years were 73.9%, 52.1%, 42.8%, 26.2% and 20.1%, respectively. DFS rates at 1, 2, 3 and 4 years were 38.1%, 21.9%, 18.8%, and 14.1%, respectively. Pretreatment serum alpha-fetoprotein (AFP) >200 ng/ml, pretreatment serum albumin ≤35 g/dl, liver function Child's class C and incomplete ablation were found to be significant predictors for OS by univariate analysis. Using multivariate analysis, incomplete ablation was identified to be the most significant independent predictor for OS. Other independent predictors for OS were serum albumin level, serum AFP level and Child-Pugh classification. Recurrence after hepatectomy and prothrombin time >14 s were identified to be significant predictors for DFS by univariate analysis, and the former was the only independent predictor for DFS by multivariate analysis. CONCLUSION Prognosis for patients with HCC after thermal ablation with curative intent was determined by treatment response to ablation, pretreatment serum AFP, and liver function reserve. Tumour response to treatment was the most predictive factor for long-term survival and was related to tumour size, thus careful selection of patients for ablation therapy is recommended.

To evaluate the clinical values of ultrasound-guided percutaneous composite thermal ablation technique in the treatment of medium and large hepatocellular carcinoma (HCC).By the composite technique of multiple-needle insertion and multi-point energy application, ultrasound-guided percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) were employed to treat 68 patients of HCC with tumor noduleor = 3.1 cm in diameter. There was a total number of 73 tumor nodules, with a mean diameter of (4.5 +/- 1.7) cm (3.1-13.0 cm). Sixty-three patients had single tumor nodule, and the remaining 5 had 2 nodules. With a follow-up time of 1.9 - 67.6 months [(16.0 +/- 14.8) months], the local and long-term efficacy was analyzed.Hepatic subcapsular hematoma were found in 1 patient. And skin burning in 1 patient 1. Complete ablation rate was 78.1% (57/73), local tumor progression was presented in 24.6% tumor nodules (14/57) and distant recurrence developed in 56.7% patients (38/67). The 1-, 3-, 5-years survival rate was 62.3%, 29.6% and 21.6%, respectively, with a median survival time of 18.6 months, (95% confidence interval: 10.9 months, 26.3 months). There were no remarkable differences in complete ablation rate, local tumor progression, distant recurrence rate and survival rate between RFA and MWA.By the composite ablation technique, ultrasound-guided percutaneous thermal ablation was effective in treating medium and large unresectable HCC. And the advantage is minimal invasiveness. RFA and MWA had no marked differences in terms of therapeutic efficacy.

AIM: To investigate the therapeutic efficacy of thermal ablation for treatment of hepatocellular carcinoma (HCC) using microwave and radiofrequency (RF) energy application. MATERIALS AND METHODS: A total of 190 nodules in 97 patients (84 male, 13 female; mean age 53.4 years, range 24–74 years) with HCC were treated with microwave or RF ablation in the last 4 years. The applicators were introduced into the tumours under conscious analgesic sedation by intravenous administration of fentanyl citrate and droperidol and local anaesthesia in both thermal ablation procedures. The patients were then followed up with contrast-enhanced computed tomography (CT) to evaluate treatment response. Survival was analysed using the Kaplan–Meier method. RESULTS: Complete ablation was obtained in 92.6% (176/190) nodules. The complete ablation rates were 94.6% (106/112) in microwave ablation and 89.7% (70/78) in RF ablation. The complete ablation rates in tumours≤2.0, 2.1–3.9 and ≥4.0 cm were 93.1, 93.8 and 86.4%, respectively. Local recurrence was found in 9.5% nodules and the rates in tumours≤2.0, 2.1–3.9 and ≥4.0 cm in diameter were 3.4, 9.9 and 31.8%, respectively. In the follow-up period, 7.1% nodules ablated by microwave and 12.8% by RF presented local recurrence. The 1, 2 and 3-year distant recurrence-free survivals were 47.2, 34.9 and 31.0%, respectively. Estimated mean survival was 32 months, and 1, 2 and 3-year cumulative survivals were 75.6, 58.5, and 50.0%, respectively. One and 2 years survivals of Child–Pugh class A, B and C patients were 83.8 and 70.4%, 78.2 and 53.2%, 36.3 and 27.3%, respectively. CONCLUSION: Thermal ablation therapy by means of microwave and RF energy application is an effective and safe therapeutic technique for hepatocellular carcinoma. Large tumours can be completely ablated, but have a significantly higher risk of local recurrence at follow-up.

Objective. To investigate the usefulness of three-dimensional sonography in procedures of ablation for liver cancers. Methods. Two- and three-dimensional sonography were used in guiding 18 chemical ablation procedures (7 with boiling carboplatin ablation and 11 with ethanol ablation) and 21 radio frequency ablation procedures for treatment of liver cancers. The applicator conspicuity depicted by the 2 imaging modalities, the confidence level of the operator in determining the position relationship between the applicator and the tumor using the 2 imaging modalities, and the alteration of ablation procedures were evaluated. Results. Three-dimensional sonography was better than two-dimensional sonography in delineation of multitined, expandable electrode tips in radio frequency ablation procedures, whereas the 2 modalities were equal in depicting percutaneous transhepatic cholangiography needle tips in chemical ablation procedures. Three-dimensional sonography significantly enhanced the confidence level in defining the spatial relationship between applicator and tumor in comparison with two-dimensional sonography (P

The usefulness of a new three-dimensional ultrasound (3DUS) volumetric system developed recently was validated in volume measurement of liver tumor in the present study. The system was used to estimate the volumes of 22 regular phantoms, 25 irregular phantoms and 37 liver tumors from 33 patients. The results showed that the consumed time of measurement with the system ranged from 1 to 15 min, depending on different rotation angles. The measured volumes at different rotation angles all significantly correlated with the true volumes and there were no significant differences among measured volumes at different angles. The measurement error of 3DUS was 0.3% +/- 3.3% in regular phantoms, -0.4% +/- 3.7% in irregular phantoms and 0.9% +/- 11.3% in liver tumors, respectively, as compared with -5.3 +/- 9.4%, 13.6 +/- 28.0% and 15.3 +/- 37.3% for two-dimensional ultrasound, respectively (all p < 0.05). The volume estimation with 3DUS also had significant intraobserver and interobserver reproducibility both in vitro and in vivo. It can be concluded that the new system that we used can greatly reduce the consumed time and manual labor for volume measurement with high accuracy and reproducibility. 3DUS volumetry using the new system is more acceptable and valuable in clinical practice and is expected to be useful for evaluation of the efficacy of tumor therapy in situ in patients with hepatic tumors.

BACKGROUND: Radiofrequency ablation (RFA) and microwave ablation (MWA) were found to be effective in treating hepatocellular carcinoma (HCC) smaller than 3 cm; however, to the authors' knowledge, the usefulness of thermal ablation in treating larger HCC, especially those >5 cm, has not been well documented. The present study evaluated the therapeutic efficacy of percutaneous thermal ablation with curative intention for HCC measuring between 3.0 cm and 7.0 cm. METHODS: Percutaneous RFA or MWA were used to treat 109 HCC patients with at least 1 tumor measuring between 3.0 cm and 7.0 cm. Fifty‒eight patients received thermal ablation as the first treatment, and the remaining 51 were treated for posthepatectomy recurrent HCC. A total of 89 patients had a main tumor measuring 3.0 cm to 5.0 cm, and 20 patients had main tumors measuring 5.0 cm to 7.0 cm. Local therapeutic efficacy, long-term outcome, and prognostic factors were analyzed. RESULTS: There were no treatment-related deaths, and the major complication rate was 9.2%. Complete ablation rate was 92.6%. Local recurrence (LR) occurred in 22% patients, with a median time to LR of 4.6 months. Distant recurrences developed in 53.2% patients. The 1-year, 3-year, and 5-year survival rates were 75.8%, 30.9%, and 15.4%, respectively. Univariate analysis indicated that incomplete tumor ablation, posthepatectomy recurrence, and preablation α-fetoprotein (AFP) ≥200 ng/mL were 3 unfavorable prognostic factors for long-term survival (P = .000, .015, and .008, respectively). Cox regression analysis confirmed that incomplete tumor ablation, recurrent tumors, and preablation AFP ≥200 ng/mL were independent unfavorable prognostic factors, with an exp(B) of 4.158 (P = .001), 1.568 (P = .082), and 1.593 (P = .082), respectively. CONCLUSIONS: Percutaneous thermal ablation was effective and safe in treating HCC between 3 cm and 7 cm, with acceptable local tumor control and long-term outcomes. Completeness of ablation, previous history of treatment, and preablation AFP level were significant prognostic factors. Cancer 2009. © 2009 American Cancer Society.