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CEUS in the portal venous and late phase after injection of SonoVue® considerably improves the characterization of liver tumors compared with conventional B mode ultrasound, leading to possible preoperative differentiation of malignant liver lesions from benign ones. In this chapter, we discussed contrast enhanced ultrasound features of some common malignant focal liver lesions, including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, liver metastasis, as well as dysplasia nodulars in liver cirrhosis.

On contrast enhanced ultrasound (CEUS), key features to differentiate benign focal liver lesions from malignant ones is sustained enhancement. Dynamic real-time CEUS performed with purely intravascular microbubble contrast ultrasound agents is very powerful imaging method for noninvasive diagnosis of benign liver tumors in both normal and cirrhotic livers. While comparing to CT or MRI scans, CEUS has the unique advantage such as real-time dynamic imaging, convenience, no radiation, it is extremely useful to visualize very early or late CEUS enhancement pattern of tumors. In this chapter, we discussed CEUS features of hepatic hemangioma, focal nodular hyperplasia, hepatocellular adenomas, as well as focal fatty infiltration.

Objectives To explore the enhancement features of early hepatocellular carcinoma (HCC, including well-differentiated HCC and high-grade dysplastic nodules with a focus of HCC) and high-grade dysplastic nodules (HGDNs) on contrast-enhanced ultrasound (CEUS), correlated with the histopathologic findings. Methods This retrospective study enrolled 81 patients with 85 pathologically confirmed hepatic lesions (69 early HCCs and 16 HGDNs). All of the hepatic lesions were examined by CEUS with SonoVue (Bracco SpA, Milan, Italy) before surgery or biopsy. The enhancement features of early HCCs and HGDNs were evaluated and compared with histopathologic findings. Results Thirty-eight (55.1%) early HCCs showed arterial-phase hyperenhancement (APHE). The major enhancement pattern of early HCCs was APHE without portal venous/late-phase wash-out (20 of 69 [29.0%]). Eight (11.6%) early HCCs manifested APHE. Wash-out was observed in 30 (43.5%) early HCCs. Sixteen (23.2%) early HCCs showed very-late wash-out (>120 seconds). Wash-out was not observed in all HGDNs. Of the 16 HGDNs, arterial-phase isoenhancement without portal venous/late-phase wash-out was the major enhancement pattern (n = 7 [43.8%]). The degree of CD34 expression of sinusoidal endothelial cells was more diffuse in early HCCs than in HGDNs (56.5% versus 12.5%; P = .001). Arterial-phase enhancement patterns of early HCCs on CEUS were correlated with the degree of CD34 expression (P = .039). Conclusions Enhancement patterns were significantly different between early HCCs and HGDNs on CEUS. Diffuse CD34 expression of sinusoidal endothelial cells in early HCC was correlated with APHE on CEUS.

To compare the diagnostic values of retraction phenomenon in the coronal planes and descriptors in the Breast Imaging Reporting and Data System-Ultrasound (BI-RADS-US) lexicon in differentiating benign and malignant breast masses using an automated breast volume scanner (ABVS).Two hundred and eight female patients with 237 pathologically proven breast masses (120 benign and 117 malignant) were included in this study. ABVS was performed for each mass after preoperative localization by conventional ultrasonography (US). Multivariate logistic regression analysis was performed to assess independent variables for malignancy prediction. Diagnostic performance was evaluated through the receiver operating characteristic (ROC) curve analysis.Retraction phenomenon (odds ratio [OR]: 76.70; 95% confidence interval [CI]: 12.55, 468.70; P0.001) was the strongest independent predictor for malignant masses, followed by microlobulated margins (OR: 55.87; 95% CI: 12.56, 248.44; P0.001), angular margins (OR: 36.44; 95% CI: 4.55, 292.06; P=0.001), calcifications (OR: 5.53; 95% CI: 1.34, 22.88; P=0.018,) and patient age (OR: 1.10; 95% CI: 1.03, 1.17; P=0.004). Mass shape, orientation, echo pattern, indistinct margins, spiculated margins, and mass size were not significantly associated with breast malignancy. Area under the ROC curve (Az) for microlobulated margins and retraction phenomenon was higher than that for other significant independent predictors. Az, sensitivity, and specificity were 0.877 (95% CI: 0.829, 0.926) and 0.838 (95% CI: 0.783, 0.892), 82.9% and 70.1%, and 92.5% and 98.3%, respectively, for microlobulated margins and retraction phenomenon.Retraction phenomenon and microlobulated margins have high diagnostic values in the differentiation of benign and malignant breast masses using an ABVS.

AIM To analyse the correlation between imaging features using multiple techniques and extracellular mucus content in pure mucinous breast carcinoma (PMBC). MATERIALS AND METHODS A retrospective review of available images from 25 patients with 25 PMBC tumours was conducted, with ultrasonography (US), ultrasonic elastography (USE), mammography, and breast-specific gamma imaging (BSGI) available for 25, 15, 11, and eight patients, respectively. Microscopic slides from each tumour were evaluated for extracellular mucus content. The correlation between imaging features and mucus content was analysed using linear-by-linear association chi-square tests or Spearman's rank correlation analyses. RESULTS On US images, a significant correlation was found between mucus content and echo pattern (p=0.042) and colour Doppler blood flow (p=0.032), with a trend that the lower mucus content present in tumours, the more likely they were detected with isoechoic echo and high blood flow. On USE images, a moderate negative correlation (r=–0.60, p=0.029) was observed between mucus content and tumour stiffness. On BSGI images, a strong negative correlation (r=–0.92, p=0.001) was shown between mucus content and lesion to non-lesion ratio (L/N) values of radioactivity counts. No significant correlation was found between mucus content and mammography imaging features (all p>0.05). CONCLUSION Imaging features at US, USE, and BSGI correlated with extracellular mucus content in PMBC tumours, among which the L/N value using BSGI imaging is the most relevant feature.

Objectives The purpose of this study was to evaluate the sonographic and pathologic features of littoral cell angioma of the spleen in 7 patients. Methods The sonographic appearance in 7 cases of littoral cell angioma confirmed by surgical pathologic examination was retrospectively reviewed. All underwent color Doppler imaging. Two underwent contrast-enhanced sonography. The sonographic appearance was compared with pathologic findings. Results Splenic lesions were solitary in 5 cases and multiple in 2 cases. The masses ranged from 10 to 64 mm in maximum diameter. Five hypoechoic and 2 hyperechoic lesions on grayscale sonography corresponded to few and multiple blood-filled spaces on pathologic examination, respectively. Four hypovascular lesions, 1 hypervascular lesion, and the other 2 hypervascular lesions full of color flow signals on color Doppler imaging corresponded to few, several, and multiple arteries on pathologic examination. On contrast-enhanced sonography, 1 hypervascular lesion full of color flow signals showed homogeneous hyperenhancement for 8 minutes during the arterial and parenchymal phases. One hypovascular lesion showed inhomogeneous isoenhancement transiently during the arterial phase and became hypoechoic later. Conclusions Littoral cell angioma is a primary vascular splenic neoplasm with variable features on grayscale sonography and color Doppler imaging as well as contrast-enhanced sonography. The sonographic appearance of littoral cell angioma mainly depends on the type and number of tumor vessels.

To investigate the correlation between the imaging features obtained by an automated breast volume scanner (ABVS) and molecular subtypes of breast cancer.We examined 303 malignant breast tumours by ABVS for specific imaging features and by immunohistochemical analysis to determine the molecular subtype. ABVS imaging features, including retraction phenomenon, shape, margins, echogenicity, post-acoustic features, echogenic halo, and calcifications were analysed by univariate and multivariate logistic regression analyses to determine the significant predictive factors of the molecular subtypes.By univariate logistic regression analysis, the predictive factors of the Luminal-A subtype (n=128) were retraction phenomenon (odds ratio [OR]=10.188), post-acoustic shadowing (OR=5.112), and echogenic halo (OR=3.263, P0.001). The predictive factors of the Human-epidermal-growth-factor-receptor-2-amplified subtype (n=39) were calcifications (OR=6.210), absence of retraction phenomenon (OR=4.375), non-mass lesions (OR=4.286, P0.001), absence of echogenic halo (OR=3.851, P=0.035), and post-acoustic enhancement (OR=3.641, P=0.008). The predictors for the Triple-Negative subtype (n=47) were absence of retraction phenomenon (OR=5.884), post-acoustic enhancement (OR=5.255, P0.001), absence of echogenic halo (OR=4.138, P=0.002), and absence of calcifications (OR=3.363, P=0.001). Predictors for the Luminal-B subtype (n=89) had a relatively lower association (OR≤2.328). By multivariate logistic regression analysis, retraction phenomenon was the strongest independent predictor for the Luminal-A subtype (OR=9.063, P0.001) when present and for the Triple-Negative subtype (OR=4.875, P0.001) when absent.ABVS imaging features, especially retraction phenomenon, have a strong correlation with the molecular subtypes, expanding the scope of ultrasound in identifying breast cancer subtypes with confidence.

To identify features which determine the papillary nature of breast lesions by contrast-enhanced ultrasound (CEUS) based on morphological and pathological correlations, and predict which papillomas are malignant. A retrospective review of 47 papillary lesions and 51 hypervascular benign abnormalities was performed. Enhancement patterns and diagnostic performance of CEUS were assessed. The most frequent finding in papillary lesions was perilesional linear ductal enhancement (87.2 %) followed by heterogeneous enhancement (80.9 %), and the presence of perfusion defects (66 %). Among all CEUS morphological descriptors, a perilesional linear ductal enhancement pattern was the most effective feature to discriminate between papillary and hypervascular benign lesions. Using this criterion, the positive and negative predictive value for papilloma were 100 % and 89.5 %, respectively. A perilesional linear ductal pattern correlated with a ductal origin. The distinctive features associated with atypical or malignant papillomas were non-confluent enhancement, late overall wash-out, the presence of regional perfusion defect, clumped vascular pattern, and the presence of peripheral radial or penetrating vessels. The sensitivity, specificity, and positive and negative predictive values for predicting malignancy were 91.7 %, 82.6 %, 84.6 % and 90.5 %, respectively. CEUS provided characteristic enhancement patterns which could be helpful for identifying papillary lesions and for predicting potentially malignant papillomas. • Papillary breast lesions display a characteristic appearance on CEUS. • Adding CEUS to conventional US helps identify the papillary nature of papillomas. • CEUS may be helpful for predicting potential malignancies among papillomas.