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Purpose: To investigate the clinical effectiveness and safety of ultrasound (US)-guided percutaneous microwave ablation (MWA) for colorectal liver metastasis (CRLM) and evaluate the influencing factors of local efficacy. Methods: From January 2013 to January 2017, 137 CRLM patients accepting US-guided percutaneous MWA were included. The 2450-MHz microwave ablation system and a cooled-shaft antenna were used. All patients were regularly followed up for at least 6 months. Technical success, complete ablation, local tumor progression (LTP), complications and side effects were assessed. Logistic regression analysis was used to identify the independent prognostic factors for LTP. Results: In total, 411 lesions (mean diameter 15.4 ± 7.2 mm, range 5–67 mm) were treated. Complete ablation was achieved in 99.27% (408/411) of lesions and 97.81% (134/137) of patients. LTP occurred in 5.35% (22/411) of lesions and 16.06% (22/137) of patients. LTP was more likely to occur in lesions larger than 3 cm in diameter (OR: 14.71; p

To assess influencing factors for quantitative analysis of contrast-enhanced ultrasound (CEUS) in Crohn's disease (CD), dynamic CEUS examinations from 77 consecutive CD patients were recorded. Peak intensity (PI) values were calculated using the pre-installed quantification software of the ultrasound scanner. The influence of depth, pressure from the ultrasound probe and intraluminal gas was analyzed. The PI value of the anterior wall was lower than that of the posterior wall when the depth was ≤3.4 cm (17.9 dB vs. 21.3 dB; p 0.05) or evident pressure was exerted (19.1 dB vs. 22.5 dB; p 0.01). In the presence of intraluminal gas, the PI of the anterior wall was higher than that of the posterior wall (20.7 dB vs. 18.8 dB; p 0.05). Nevertheless, no significant difference was found between the PI value of anterior and posterior walls when the depth was3.4 cm (19.8 dB vs. 20.3 dB), moderate pressure was exerted (20.5 dB vs. 21.1 dB) or luminal gas was excluded between the two bowel walls (18.9 dB vs. 21.2 dB; p ≥ 0.05). The factors of depth, pressure from the ultrasound probe and intraluminal gas can affect the quantification results of CEUS. It is preferable to place the region of interest in the posterior wall when luminal gas is absent and in the anterior wall when luminal gas is present. In the latter case, more attention should be paid to reducing pressure by the ultrasound probe.

To prospectively investigate the usefulness of acoustic structure quantification (ASQ) for noninvasive assessment of liver fibrosis in patients with chronic hepatitis B (CHB). Consecutive patients with CHB scheduled for liver biopsy or partial liver resection underwent standardized ASQ examinations. The ASQ parameter, named focal disturbance (FD) ratio, were compared with METAVIR scores. The analysis was based on receiver operating characteristic (ROC) curves and multiple regression analysis. A total of 114 patients were enrolled in the final analysis. The area under the ROC curve for the FD ratio was 0.84 for significant fibrosis (≥ F2), 0.86 for severe fibrosis (≥ F3), and 0.83 for cirrhosis (= F4). The optimal cutoff values for the FD ratio were 0.25, 0.30 and 0.50 for fibrosis stages ≥ F2, ≥ F3 and = F4, respectively. The prevalence of a difference of at least two stages between the FD ratio and the histological stage was 12.3 % (14 of 114). The fibrosis stage (P

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.

The aim of this study was to summarize the imaging features of chronic radiation proctitis (CRP) on endorectal ultrasound (ERUS) and investigate the value of ERUS in the evaluation of disease activity. 40 CRP patients and 30 control patients were investigated by ERUS. Rectal wall thickness and layers, ulcers and rectovaginal fistulas were evaluated by B-mode ultrasound. Power Doppler imaging was used to evaluate the vascularity of the rectal wall using a semiquantitative score. Disease activity was calculated according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 (CTCAE 4.0). Imaging findings for patients with mild and severe CRP were compared. For 30 patients in the control group, the average maximum thickness of the rectal wall was 3.07 ± 0.73 mm, with all exhibiting typical wall stratification and level 0 vascularity. For the 40 CRP patients, there was marked thickening of the rectal wall (average thickness = 9.42 ± 1.94 mm), which was significantly thicker than in the control group (p 0.05). The rectal walls of the mild group were significantly thinner than those of the severe group (8.71 ± 1.67 mm vs. 10.00 ± 2.00 mm, p 0.05). Among the 22 severe cases, 19 cases (19/22, 86.4%) exhibited hyper-vascularity (level IV) or blurred wall stratification (including hypo-echoic submucosa, ulcer and fistula); 12 of the 18 mild cases (166.7%) exhibited a vascularity of level III and typical wall stratification. A significant association (p 0.05) was observed between stratification and vascularity of the rectal wall and CRP activity. When ERUS findings of blurred rectal wall stratification or increasing vascularity (level IV) were used to evaluate CRP activity, the sensitivity was 86.4% (95% confidence interval: 64.0-96.4) and the specificity was 66.7% (95% confidence interval: 41.2-85.6). Thickening of the rectal wall, blurred wall stratification and increased vascularity are characteristic ERUS findings of CRP. ERUS is helpful in the comprehensive evaluation of disease activity and may provide objective evidence during treatment planning and follow-up.

To compare the performance of contrast-enhanced ultrasound (CEUS) using high-frequency linear and convex probes in the detection of small colorectal liver metastases (CRLMs). A total of 85 patients with 143 small CRLMs were evaluated. High-frequency ultrasound (US) and CEUS detected significantly more superficial lesions within 60 mm below the skin than a convex probe (p

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.

To evaluate the diagnostic performance of quantitative analysis as an adjunctive diagnostic tool to contrast-enhanced ultrasound (US) for the differentiation of atypical benign focal liver lesions (FLLs) from malignancies in fatty liver. Twenty-seven benign FLLs and fifty-six malignant FLLs that appeared hyper-enhanced during the arterial phase with washout in the portal or late phase in fatty liver were analyzed. Chi-square tests and logistic regression were applied to identify the specific features. Three sets of criteria were assigned: 1) all FLLs subjected to routine contrast-enhanced US; 2) all FLLs subjected to quantification analysis and contrast-enhanced US; and 3) parts of FLLs that could not be diagnosed using contrast-enhanced US (n = 66, 75.9%) but instead were diagnosed using parametric features. The sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC) of the three sets of criteria were analyzed. The AUCs of the criterion set 2 were significantly higher than those of criterion set 1 (0.904 versus 0.792, P = 0.008). Criterion set 3 showed a relatively high sensitivity (90.2%) with a relatively high AUC (0.845). The quantification analysis offers improved diagnostic performance for the differential identification of atypical benign FLLs from malignancies in fatty liver.

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.

To prospectively compare microwave (MW) ablation using a modified internal cooled-shaft antenna with radiofrequency (RF) ablation in in vivo porcine liver and in patients with small hepatocellular carcinoma (sHCC).In an animal study, MW and RF ablations using a cooled-shaft antenna or internally cooled electrode were performed in in vivo porcine liver. Coagulation diameters of both ablations were compared. For clinical study, 42 patients with sHCC were treated with MW or RF ablation. Complete ablation (CA) and local tumour progression (LTP) were compared.MW ablation produced significantly larger ablation zones than RF ablation in both porcine liver and sHCC with an ablated volume of 33.3 ± 15.6 cm(3) vs. 18.9 ± 9.1 cm(3) and 109.3 ± 58.3 cm(3) vs. 48.7 ± 30.5 cm(3), respectively. The CA rate was 95.5 % (21/22) for MW ablation and 95.0 % (19/20) for RF ablation. In a 5.1-month follow-up, the LTP rate was 18.2 % (4/22) in the MW ablation group and 15.0 % (3/20) in the RF ablation group.MW ablation using a modified cooled-shaft antenna produces a larger ablation zone than RF ablation, with an efficacy similar to RF ablation in local tumour control. MW ablation is a safe and promising treatment of sHCC.

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.

Heat shock proteins (HSPs) induced by thermal ablation therapy may help presenting tumor antigen to the host immune system and be a valuable adjuvant in the ablation therapy of liver cancer. This paper described our preliminary study on the expression of HSP70 in rabbit liver after contrast-enhanced ultrasound (CEUS) and radiofrequency (RF) ablation. Twenty-five male New Zealand white rabbits were divided into five groups as: control group (n=5), ultrasound group (n=5), CEUS group (n=5), RF group (n=5) and CEUS+ RF group (n=5). Clinical ultrasound and RF ablation equipment were used in the present experiment. Sonazoid was used as the contrast agent. All the animals were sacrificed 24 h after the procedure, and HSP70 was detected by immunohistochemistry staining and Western blot analysis. In the groups without RF ablation, there was no evidence of HSP70 expression in the liver tissue of the control group and ultrasound group, whereas positive HSP70 expression was detected in the liver tissue of the CEUS group, with a mean optical density of 0.33. In the RF and CEUS+ RF groups, there were cells showing HSP70 expression in the normal liver tissue far from the ablation region. The mean densities of HSP70 expression were 0.31 in the RF group and 0.35 in the CEUS+ RF group, respectively. With regard to the distribution of HSP70 expression of the RF and CEUS+ RF groups, the marginal areas were stronger than liver tissue 1 cm away from the margin, and the ablated tissues showed no evidence of HSP70 expression. The mean density of HSP70 expression in the marginal areas were 0.47 in the RF group and 0.42 in the CEUS+ RF group, respectively. CEUS using Sonazoid may produce HSP70 expression in the normal liver parenchyma after CEUS examination and RF ablation. (E-mail: moriyasu@tokyo-med.ac.jp).

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.

Purpose To investigate the behavior of perflubutane microbubbles outside and inside Kupffer cells during diagnostic ultrasound (US) examination, and to determine the thresholds of the acoustic pressure of different kinds of behavior. Methods Acoustic behavior of perflubutane microbubbles inside and outside Kupffer cells in an acoustic field induced by a clinical US transducer and equipment was optically observed in vitro. The acoustic pressure was measured simultaneously by a calibrated hydrophone and an oscilloscope. Results The acoustic behavior of microbubbles was optically categorized as stabilization, oscillation, transposition, shrinkage, and destruction. The mechanical index (MI) displayed on the US equipment correlated well with the acoustic pressure at the level of microbubbles measured hydrophonically. At a frame rate of 15 Hz with a frequency of 3.5 MHz and pulse repetition frequency of 3 KHz, the thresholds in term of MI for free microbubbles to begin oscillation, reach best oscillation, transposition, shrinkage, and destruction were 0.21, 0.44, 0.53, 0.75, and 1.03, respectively. Although adherent and phagocytosed microbubbles showed more stability enduring insonation compared with free microbubbles, the thresholds of shrinkage and destruction were MI 1.03 and 1.18 for adherent microbubbles, and 1.18 and 1.37 for phagocytosed microbubbles, respectively. Neither oscillation nor transposition of microbubbles inside Kupffer cells was observed microscopically. No cell damage because of microbubbles destruction was found in the present study. Conclusion Perflubutane microbubbles outside and inside Kupffer cells respond to external US insonation with same parameters of a clinical contrast-enhanced US study according to the acoustic pressure. Free microbubbles behave as stabilization, oscillation, transposition, shrinkage, and destruction under insonation. The adherent and phagocytosed microbubbles are more stable under insonation than free microbubbles, but still respond showing shrinkage and destruction when MI is over 1.03.

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

To evaluate diagnostic performance of contrast-enhanced (CE) ultrasonography (US) and microflow (MF) imaging in differentiation of atypical hepatocellular carcinoma (HCC) from focal nodular hyperplasia (FNH).Institutional review board approval was obtained, and informed consent was waived. A total of 103 patients (mean age, 43.9 years; age range, 17-75 years) were included; 38 patients with HCC and 65 with FNH underwent CE US, and vascular architecture pattern (VAP) and arrival time parametric (ATP) images were analyzed. Resident and staff radiologists independently and retrospectively reviewed CE US, VAP, and ATP images. χ(2) test and logistic regression analysis were applied to identify specific features of FNH or HCC on CE US and MF images. To compare diagnostic performance of CE US with or without MF imaging, four sets of criteria were assigned: (a) routine CE US alone, (b) VAP and CE US, (c) ATP imaging and CE US, and (d) all three methods in combination. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) of resident and staff radiologists were analyzed. Cohen κ statistic was used to assess agreement of CE US and MF imaging features between staff and resident radiologists.MF imaging offered significant improvements over most detection rates achieved with routine CE US signs in both groups. For staff radiologists, AUCs from criteria sets 3 (AUC = 0.873, P.05) and 4 (AUC = 0.887, P.05) were significantly higher than AUC from criteria set 1 (AUC = 0.835). For resident radiologists, specificity (71% and 69% vs 25%, P.01) and accuracy (78% and 79% vs 50%, P.01) of criteria sets 3 and 4 were significantly higher than those of criteria set 1. Moreover, AUCs for criteria sets 2 (AUC = 0.728, P.05), 3 (AUC = 0.823, P.01), and 4 (AUC = 0.857, P.01) were significantly higher than those for criteria set 1 (AUC = 0.667).When compared with routine CE US, MF imaging can more effectively depict specific features and offers improved diagnostic performance in the differentiation of atypical HCC from FNH, especially when used by resident radiologists. Online supplemental material is available for this article.

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.

Cavernous hemangiomas of the adrenal gland are rare in clinical practice. Recently some cases have come to clinical attention as incidental findings on sonography, computed tomography (CT), or magnetic resonance imaging (MRI). 1-3 With many reports regarding its CT or MRI manifestation, sonographic features of this entity have seldom been delineated. 1-5 We report the case of a patient with a huge nonfunctioning cavernous hemangioma of the adrenal gland and describe the imaging findings of the lesion.

Objective. To compare three-dimensional sonography with two-dimensional sonography for diagnosis of gallbladder diseases. Methods. Sixty-three patients with gallbladder diseases were examined with two- and three-dimensional sonography. The morphologic features presented on both modalities were analyzed, and the diagnostic accuracies of both modalities were evaluated and compared. Results. Both two- and three-dimensional sonography facilitated correct diagnosis in all patients with gallstones. Three-dimensional sonography had no influence on the diagnosis of gallstones compared with two-dimensional sonography. Three-dimensional sonography showed the granular surfaces in 18 (81.8%) of 22 cases of polypoid lesions and the pedunculated fundus in 19 (86.4%) of 22, whereas two-dimensional sonography displayed them in 10 (45.5%) and 3 (13.6%) of 22, respectively (P

The aims of the present study are to assess the impact factors on acoustic structure quantification (ASQ) ultrasound and find the optimal parameter for the assessment of liver fibrosis. Twenty healthy volunteers underwent ASQ examinations to evaluate impact factors in ASQ image acquisition and analysis. An additional 113 patients with liver diseases underwent standardized ASQ examinations, and the results were compared with histologic staging of liver fibrosis. We found that the right liver displayed lower values of ASQ parameters than the left (p = 0.000–0.021). Receive gain experienced no significant impact except gain 70 (p = 0.193–1.000). With regard to different diameter of involved vessels in regions of interest, the group ≤2.0 mm differed significantly with the group 2.1–5.0 mm (p = 0.000–0.033) and the group >5.0 mm (p = 0.000–0.062). However, the region of interest size (p = 0.438–1.000) and depth (p = 0.072–0.764) had no statistical impact. Good intra- and inter-operator reproducibilities were found in both image acquisitions and offline image analyses. In the liver fibrosis study, the focal disturbance ratio had the highest correlation with histologic fibrosis stage (r = 0.67, p < 0.001). In conclusion, the testing position, receive gain and involved vessels were the main factors in ASQ examinations and focal disturbance ratio was the optimal parameter in the assessment of liver fibrosis.

To determine the accuracy of two-dimensional shear wave elastography (2D-SWE) for noninvasive staging of hepatic fibrosis in chronic hepatitis B (CHB). Patients with CHB infection who underwent liver biopsy were consecutively included. Receiver-operating characteristic (ROC) curves were constructed to assess the overall accuracy and identify optimal cutoff values. Three hundred three patients were analysed. The diagnostic performance characteristics were determined for the first 202 patients (the index cohort) and were validated on the next 101 patients (validation cohort). The areas under the ROC curves for significant fibrosis, severe fibrosis and cirrhosis were all greater than 0.90 and did not differ significantly between the index and validation cohorts. Using the cutoff values generated from the index cohort, the validation cohort 2D-SWE had negative predictive values of 82.6 % (95 % confidence interval [CI]: 68.4 % − 92.3 %) for significant fibrosis, 95.1 % (95 % CI: 86.3 % − 99.0 %) for severe fibrosis and 97.4 % (95 % CI: 90.8 % − 99.7 %) for cirrhosis. The positive predictive values were 83.6 % (95 % CI: 71.2 % − 92.2 %), 65.0 % (95 % CI: 48.1 − 79.5 %) and 60.0 % (95 % CI: 38.7 % − 78.9 %), respectively. The 2D-SWE showed good diagnostic accuracy in staging liver fibrosis in patients with CHB infection and assisted in excluding liver fibrosis and cirrhosis. • Two-dimensional shear wave elastography showed good diagnostic accuracy in assessing liver fibrosis. • Diagnostic performance did not differ significantly between the index and validation cohorts. • Two-dimensional shear wave elastography assisted in excluding liver fibrosis and cirrhosis.

The purpose of this study was to distinguish passive retention of microbubbles in liver sinusoids from active intracellular retaining, and to provide further evidence of post vascular liver specific phase of perflubutane microbubble contrast-enhanced ultrasound for potential use in the detection of focal liver lesions. Fifty-four rats were divided into three groups: saline group (G1, as a control, n=6), sulphur hexafluoride microbubble group (G2, n=24) and perflubutane microbubble group (G3, n=24). The livers were perfused at 2, 5, 10 and 20 min after injection of perflubutane or sulphur hexafluoride gas-filled microbubbles or normal saline. Changes in contrast-enhanced images within the liver were quantified. After perfusion, the echogenicity of the liver in the saline group increased from -49.44 ± 0.08 dB to - 44.37 ± 1.02 dB (p< 0.05). In G2, the enhancement decreased significantly after perfusion at 2 and 5 min, and increased at 10 and 20 min (all p< 0.05). In G3, the enhancement decreased from -18.05 ± 2.28 dB to - 26.76 ± 1.69 dB only at 2 min after perfusion (p < 0.05). Perflubutane microbubbles provided a post vascular liver specific phase on contrast-enhanced ultrasound, which could begin as early as 5 min after administration of the contrast agent in rats. This study suggests that perflubutane microbubbles could result in a liver specific phase and provide valuable information for diagnosis and detection of focal liver lesions which may improve the efficiency of contrast-enhanced ultrasound in clinical diagnoses of liver diseases.

Objectives To identify the vascular architecture of focal liver lesions using micro flow imaging and compare it with characteristics on contrast harmonic imaging during the arterial phase. Methods Micro flow imaging and contrast harmonic imaging were performed in 118 patients with various focal liver lesions: hepatocellular carcinoma (n = 70), metastasis(n = 19), intrahepatic cholangiocarcinoma (n = 3), lymphoma (n = 1), hemangioma (n = 17), and focal nodular hyperplasia (n = 8). The vascular architecture of the lesions on micro flow imaging was evaluated by 2 investigators independently to reveal 6 patterns (types IVI). Enhancement characteristics on contrast harmonic imaging were also evaluated. Results Inter-reader agreement for delineating the vascular architecture was higher on contrast harmonic imaging (κ= 0.856) than micro flow imaging (κ= 0.613). On micro flow imaging, the vascular patterns of hepatocellular carcinomas were types I (28.6%), II (65.7%), and III (5.7%). On contrast harmonic imaging, 44 of 70 (62.9%) hepatocellular carcinomas showed chaotic vessels, of which 40 were type II and 4 were type II. The vascular patterns of metastases were types IV (78.9%), I (10.5%), and II (10.5%). Typical rim enhancement was identified in 57.9% of metastases on contrast harmonic imaging, and all were type IV. The vascular patterns of focal nodular hyperplasia were types VI (87.5%) and I (12.5%). Typical spoked wheel arteries were identified on contrast harmonic imaging in 2 focal nodular hyperplasia cases. The vascular patterns of hemangiomas were types V (94.1%) and II (5.9%). Typical peripheral nodular enhancement was identified in 88.2% of hemangiomas on contrast harmonic imaging, and all were type V. The χ2 test revealed that differences in vascular architecture between the lesions were significant on micro flow imaging (P < .001). Conclusions Micro flow imaging permitted detailed delineation of the vascular architecture of focal liver lesions. Hepatocellular carcinoma, metastasis, focal nodular hyperplasia, and hemangioma showed characteristic vascular architecture.

The purpose of this report is to inform medical professionals of a case in which brachiocephalic vein thrombosis caused a transient ischemic attack (TIA). A brain computerized tomography (CT) scan, magnetic resonance imaging, digital subtraction angiography, head and lung CT angiography, jugular venography, cardiac color Doppler ultrasound scan, color Doppler ultrasound scan of the neck and lower vascular extremities and 24-hour, continuous electrocardiogram monitoring were performed. A 50-year-old male experienced a total of 31 onsets of weakness in the right side of his body, speech impairment and numbness in the right side of his body during a period of 20 days. Imaging results did not reveal evidence of a cerebral infarction. The potential of a TIA with an arterial origin and other causes were ruled out, and a left brachiocephalic vein thrombosis and left jugular vein congestion were discovered. Thus, the brachiocephalic vein thrombosis was considered to be the cause of the TIA. The patient received anticoagulant and antiplatelet aggregation treatment. On the following day after the termination of the TIA, a color Doppler ultrasound scan detected the opening of the jugular venous arch, but the blood flow that returned to the superior vena cava via the left brachiocephalic vein did not significantly increase. A brachiocephalic vein thrombosis can be the cause of a TIA. In addition to the anticoagulant and antiplatelet aggregation treatment, the opening of the collateral of veins, including that of the jugular venous arch, may play an important role in reducing venous congestion and in terminating TIAs.

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.

Due to the hidden hemorrhage and a lack of specificity in its manifestations, perirenal hemorrhage as a complication of interventional radiology procedures is not always diagnosed in a timely manner; furthermore, the cause of hemorrhage is often misidentified or uncertain. In this report, two cases of elderly male patients who each had a perirenal hemorrhage on the same side after an interventional radiology operation against head and neck vessels by the same operator on the same day are described. This study demonstrated that the perirenal hemorrhages in both patients were related to the interventional radiology operations, providing a reminder that operating gently and always keeping the guide wire in sight during the insertion are critical for reducing the incidence rate of perirenal hemorrhage.

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.

To verify whether arterial-phase contrast-enhanced ultrasonography (CEUS) of tumor parenchymal tissue is useful for evaluation of anti-angiogenesis agents.Rabbits with liver tumor were subjected to CEUS, and images of the nodular maximal diameter in vascular phase were recorded. Image analysis was performed to plot the time intensity curve (TIC) at the tumor parenchyma, which set the diameter of the region of interest of intensity measurement. The TIC was calculated to obtain the time to peak intensity (TPI) and the magnitude of PI. Rabbits were randomly assigned to a treatment group with sorafenib and a control group. Two weeks later, the same ultrasound examination was repeated followed by pathological testing to assess the effect of sorafenib on the liver tumor.In four rabbits in the treatment group, the rate of change of tumor size was decreased compared with that of the control (the rate 2.3 vs 7.9, P = 0.02). The TPI of the treatment group elongated significantly (the rate 3.1 vs 1.1, P = 0.07 for SonoVue, 2.0 vs 0.88, P = 0.09 for Sonazoid). The magnitude of PI showed no significant changes. In pathological examination, capillary diameters in the treatment group were significantly smaller than those in the control group (26.4 vs 42.8 μm, P = 0.013).Analysis of the TIC in the arterial phase of tumor tissue could evaluate the efficacy of anti-angiogenesis drug treatment in liver tumor.

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.

To describe the survival state and to investigate the risk factors of death on patients with subarachnoid hemorrhage (SAH).Age, past history, number of encephalic region suffering SAH, laboratory examination indexes, therapeutic measures, complications and prognosis of 174 patients with SAH were followed-up and investigated. The survival states and risk factors of death of the patients with SAH were identified by both Kaplan-Meier survival analysis and Cox proportional risk model.There were 10 patients (5.75%) losing follow-up investigation and 164 patients with SAH completed the follow-up investigation. 66 patients died and the longest follow-up investigation time was 5.64 years. The survival rates of 28 days, 1 year and 3-5 years were 70.60%, 63.40% and 57.20% respectively. The treatment of nimotop, aneurysm occlusion treatment and aneurysm embolotherapy could decrease the death of SAH. At the same time, advanced age, the long time smoking, hyponatremia, the rising of leucocyte in acute stage, repeated hemorrhage and cerebral angio spasm were the independent risk factors to the death of patients.Prognosis of patients with advanced age, the rising of leucocyte in acute stage, gastrointestinal blooding, hyponatremia, repeated hemorrhage and cerebral angio spasm were unfavorable. When giving patients with aneurysm, the aneurysm occlusion and embolotherapy and nimotop treatment, the death risk could be reduced.

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.

Objective. The purpose of this study was to evaluate micro flow imaging (MFI) in depicting the vascular architecture of hepatocellular carcinoma (HCC) and the correlation between pathologic differentiation and the intratumoral vascular architecture pattern. Methods. Micro flow imaging and contrast harmonic imaging (CHI) were performed in 37 patients with HCC. A sulfur hexafluoride-filled microbubble contrast agent was used. The enhancement level and intratumoral vessels were evaluated on CHI. The vascular architecture of each tumor was evaluated on MFI. Pathologic differentiation of the tumors was classified according to the Edmondson grading system. Results. All 37 HCCs showed hyperenhancement in the arterial phase and hypoenhancement in the portal and late phases on CHI. Intratumoral vessels in the arterial phase were visualized in 20 (54.1%) HCCs. On MFI, the vascular architecture in all lesions was clearly delineated and categorized into 3 patterns: cotton, shrubbery, and deadwood, identified in 12 (32.4%), 22 (59.5%), and 3 (8.1%) of the tumors evaluated, respectively. A χ 2 test showed that pathologic differentiation significantly correlated to the vascular pattern (P = .006). Three (75%) of 4 Edmondson grade I HCCs showed the cotton pattern; 18 (75.0%) of 24 Edmondson grade II HCCs showed the shrubbery pattern; and the deadwood pattern was shown only in Edmondson grade III and IV HCCs. Conclusions. The MFI technique is more effective in depicting the intratumoral vascular architecture. The vascular architecture pattern correlates with pathologic differentiation of HCC. Key words: contrast-enhanced ultrasonography; contrast harmonic imaging; hepatocellular carcinoma; micro flow imaging; vascular architecture.

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

To compare the clinical results of surgical resection (SR) and percutaneous thermal ablation (PTA) for early-stage hepatocellular carcinoma (HCC) (single tumor noduleor= 5 cm in diameter, oror= 3 nodules withor= 3 cm in diameter).One hundred and five patients with 114 HCC nodules were randomly allocated to SR (n = 54) and ultrasound-guided PTA with microwave or radiofrequency energy (n = 51).The complete tumor elimination rates in SR and PTA groups were similar (100% vs 94.7%) and the local recurrence rates were both 0. There were no significant differences in distance recurrence rate (16.7% vs 27.5%, P = 0.182) and time to the first recurrence (4.9 month vs 9.6 month, P = 0.130) between the SR and PTA groups. One, 2-, and 3-year disease-free survival rates were 82.4%, 82.4% and 82.4%, respectively, in SR group, whereas they were 78.5%, 61.5% and 51.3% in PTA group, respectively. The difference between these two groups was statistically not significant (P = 0.128). The overall survival rates in SR group were 91.3%, 86.4% and 86.4% at 1, 2, and 3 years, respectively, and those in PTA group were 93.5%, 87.1% and 87.1%, respectively. There was no significant difference between these two groups (P = 0.808). Compared with SR, PTA required less treatment time (27 min vs 145 min, P0.005), less necessity for blood transfusion (0 patient vs 7 patients, P = 0.013) and less hospital-stay (5.2 d vs 19.1, P0.005). There was no significant difference in the rate of treatment-related complication between the two groups (11.1% for SR vs 7.8% for PTA, P = 0.742). At day 7 and day 30 after treatment, the numbers of patient with physical status (WHO Performance Status grades) of grade 0 - 1 were 32 and 44 in PTA group, respectively, significantly more than 16 and 33 in SR group (P = 0.001 and P = 0.004, respectively).Besides minimal invasiveness, easy to access and cost saving, PTA achieved equivalent local therapeutical effectiveness and 3-year survival outcomes as SR did, and may be considered as a one of the first-choice treatment modality for treatment of early-stage HCC.

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.