Diagnosis of small hepatocellular carcinoma--imaging diagnosis and significance of tumor biopsy

BACKGROUND/AIMS: To compare the effectiveness of different imaging modalities and the significance of tumor biopsy for diagnosing small hepatocellular carcinoma. METHODOLOGY: Nodules (n = 352) with diameters of 30 mm or less newly detected by periodic ultrasonography and computed tomography in 234 patients with chronic liver disease were investigated with magnetic resonance imaging and digital subtraction angiography. These findings were compared with histologic findings. Histologic diagnoses were dysplastic nodule (n = 23), well-differentiated hepatocellular carcinoma (n = 163), moderately differentiated hepatocellular carcinoma (n = 159), and poorly differentiated hepatocellular carcinoma (n = 7). We compared three groups based on-diameters of 10, 11-20, and 21-30 mm. Nodules were diagnosed as hepatocellular carcinoma if they had hypervascular staining on digital subtraction angiography, hyperintensity on magnetic resonance T2-weighted images, arterial phase enhancement on enhanced magnetic resonance imaging, or low-high-low density on enhanced computed tomography. RESULTS: Imaging alone was sufficient to diagnose hepatocellular carcinoma in 66.3% of the well-differentiated nodules and 91.6% of the moderately and poorly differentiated nodules (P < 0.001) The size of the nodule influenced the diagnosis of hepatocellular carcinoma by imaging alone in 65.5% (< or = 10 mm), 77.2% (11-20 mm), and 92.3% (21-30 mm) (< or = 10 vs. 21-30: P < 0.0001, 11-20 vs. 21-30: P < 0.0005). It was impossible to determine the degree of differentiation of the hepatocellular carcinoma by imaging alone. CONCLUSIONS: The effectiveness of imaging for the diagnosis of hepatocellular carcinoma improved with decreasing differentiation and increasing diameter of the nodules. Tumor biopsy was required to make a histological accurate diagnosis.     

不同大小的肝细胞癌超声造影特点

目的:分析不同大小肝细胞癌(hepatocellular carcinoma,HCC)的超声造影(contrast-enhanced ultrasound,CEUS)特点,提高超声对HCC的诊断水平.方法:将我院2011-01/2011-09行超声造影检查并经手术及病理证实为HCC的连续性病例75例90个病灶按照病灶最大直径分为小肝癌(≤3cm)和大肝癌(>3cm)2组,回顾性分析不同大小的HCC超声造影特点.结果:75例90个病灶小肝癌组39个,大肝癌组51个.动脉期,小HCC组39个病灶均呈高增强,其中整体均匀增强37个(94.9%),不均匀增强2个(5.1%);大HCC组51个病灶均呈高增强,其中整体均匀增强27个(52.9%),不均匀增强21个(41.2%),不典型增强3个(6%),不同大小HCC动脉期增强形态具有统计学差异(P<0.05).门脉期,小HCC组等增强10个(25.6%),低增强29个(74.4%),大HCC组高增强7个(13.7%),等增强2个(3.9%),低增强42个(82.4%),不同大小的HCC门脉期增强水平具有统计学差异(P<0.05).延迟期,小HCC组所有病灶均呈低增强,大HCC组1个(2.0%)呈等增强,50个(98.0%)呈低增强,不同大小的HCC延迟期增强水平无统计学差异.结论:HCC超声造影表现与肿瘤大小有一定的相关性,小HCC动脉期增强多为整体均匀增强,大HCC不均匀增强比例较多,门脉期和延迟期大HCC造影剂廓清可能早于小HCC.     

Well-to moderately-differentiated HCC manifesting hyperattenuation on both CT during arteriography and arterial portography

We present a rare case of well- to moderatelydifferentiated hepatocellular carcinoma （HCC） in a 71-year-old woman with hepatitis C virus-related cirrhosis and unusual radiologic features. A 20-mm hypoechoic nodule disclosed by ultrasound in segment two showed hyperattenuation on both computed tomography hepatic arteriography and computed tomography during arterial portography. Contrast-enhanced ultrasound revealed hypervascularity in the early vascular phase and defect in the post-vascular phase, with the same pattern detected by the two imaging techniques. SPIO-MRI revealed a hyperintense nodule. These findings were compatible with those of moderately-differentiated HCC. An ultrasound-guided biopsy showed histological features of well- to moderately-differentiated HCC characterized by more than two-fold the cellularity of the non-tumorous area, fatty change, clear cell change and mild cell atypia with a thin to mid-trabecular pattern. Further studies may provide insights into the correlation between tumor neovascularity in multistep hepatocarcinogenesis and dual hemodynamics, including the artery and the portal vein.     

Well-differentiated HCC manifesting hyperattenuation on CT during arterial portography

A rare case of well-differentiated minute hepatocellular carcinoma (HCC) with hepatitis C virus-related cirrhosis, with unusual radiologic features, is presented. A 10-mm hypoechoic nodule disclosed by ultrasound in segment six showed hypoattenuation on computed tomography hepatic arteriography and hyperattenuation on computed tomography during arterial portography, indicating that the portal vein may have been the dominant vascularity of the nodule. Contrast-enhanced ultrasound revealed hypovascularity in the early arterial phase, isovascularity in the late vascular phase, and the same perfusion as that surrounding the liver parenchyma in the post-vascular phase, with the same pattern observed on the two imaging techniques. These findings were considered not compatible with those of well-differentiated HCC. Ultrasound-guided biopsy showed histological features of well-differentiated HCC with over two-fold the cellularity of the non-tumorous area with a high nuclear/cytoplasmic ratio, increased cytoplasmic eosinophilia, slight atypia and fatty change with an irregular thin trabecular pattern. Further studies may provide insights into the correlation between tumor neovascularity in multistep hepatocarcinogenesis and dual hemodynamics, including the artery and the portal vein.     

New classification of dynamic computed tomography images predictive of malignant characteristics of hepatocellular carcinoma

Aim: The aim of this study was to elucidate whether the histopathological characteristics of hepatocellular carcinoma (HCC) can be predicted from baseline dynamic computed tomography (CT) images. Methods: This retrospective study included 86 consecutive patients with HCC who underwent surgical resection between January 2000 and September 2008. The arterial‐ and portal‐phase dynamic CT images obtained preoperatively were classified into four enhancement patterns: Type‐1 and Type‐2 are homogeneous enhancement patterns without or with increased arterial blood flow, respectively; Type‐3, heterogeneous enhancement pattern with septum‐like structure; and Type‐4, heterogeneous enhancement pattern with irregular ring‐like structures. We also evaluated the predictive factors for poorly‐differentiated HCC, specific macroscopic type of HCC (simple nodular type with extranodular growth [SNEG] and confluent multinodular [CMN]) by univariate and multivariate analyses. Results: The percentages of poorly‐differentiated HCC according to the enhancement pattern were three of 51 nodules (6%) of Type‐1 and ‐2, three of 24 (13%) of Type‐3, and eight of 11 (73%) of Type‐4. The percentages of SNEG/CMN according to the enhancement pattern were 12 of 51 nodules (24%) of Type‐1 and ‐2, 13 of 24 (54%) of Type‐3, and five of 11 (45%) of Type‐4. Multivariate analysis identified Type‐4 pattern as a significant and independent predictor of poorly‐differentiated HCC (P < 0.001) while Type‐3 pattern was a significant predictor of SNEG/CMN (P = 0.017). Conclusion: Heterogeneity of dynamic CT images correlates with malignant characteristics of HCC and can be potentially used to predict the malignant potential of HCC before treatment.     

Accuracy of preoperative prediction of microinvasion of portal vein in hepatocellular carcinoma using superparamagnetic iron oxide-enhanced magnetic resonance imaging and computed tomography during hepatic angiography

Background Our aim was to diagnose microinvasion of the portal vein in hepatocellular carcinoma from preoperative radiological findings and to construct a scoring system. Methods Forty-seven patients (38 men and 9 women; median age, 66.8 years) who underwent hepatic resections for hepatocellular carcinoma were selected retrospectively. Microscopically, 22 had portal vein invasion (PVI) and 25 had no PVI. All patients were examined preoperatively with superparamagnetic iron oxide-enhanced magnetic resonance imaging and computed tomography during hepatic angiography (CTHA). Perilesional enhancement on T1-weighted imaging, tumorous arterioportal (AP) shunt, and corona enhancement (contrast enhancement of the adjacent liver appearing in the late phase of CTHA) were assessed. Relative risk for PVI in terms of clinical and tumor characteristics was also assessed. The relative contribution to PVI was determined by the coefficient of a stepwise logistic regression. Each variable was given a score relative to the coefficient. Results On univariate analysis, distortion of corona, tumorous AP shunt, and tumor size indicated a higher prevalence of PVI. The PVI predictive score was calculated as: total score = (maximum size in cm) + (T1 ring; + = 1, − = 0) + (tumorous AP shunt; + = 3, − = 0) + (distortion of corona; + = 10, − = 0). The PVI (+) group score was four times that of the PVI (−) group (16 vs 4). At a cutoff score of 10, the sensitivity, specificity, and accuracy were 82%, 84%, and 86%. Conclusions Distortion of corona, tumorous AP shunt, and tumor size are good predictors of the risk of PVI. This scoring system is simple and worth using clinically.     

Computed tomography findings of sorafenib-treated hepatic tumors in patients with advanced hepatocellular carcinoma

Background and Aim: The purpose of this study was to describe the computed tomography (CT) findings of sorafenib‐treated hepatic tumors in patients with advanced hepatocellular carcinoma and to correlate the findings to the overall survival (OS). Methods: Twenty‐eight sorafenib‐treated patients who had advanced hepatocellular carcinoma (HCC) with viable hepatic tumors between August 2007 and February 2008 were enrolled in the study. Dynamic CT findings were analyzed with regard to the response of the tumor, based on the response evaluation criteria in solid tumor, version 1.1, and the attenuation values of the tumors during the late arterial and portal venous phases. Survival analyses according to early changes in the tumors were also performed. Results: In all patients, the tumor responses were stable disease or progressive disease on follow‐up CT scans. Prior to the treatment, the mean attenuation values of the tumors were 93.0 ± 20.0 Hounsfield unit (HU) at the late arterial phase, and 107.9 ± 23.0 HU at the portal venous phase. On the first follow‐up CT scans, the mean attenuation values of the late arterial and portal venous phases were 76.9 ± 26.5 HU and 94.2 ± 29.1 HU, respectively (P < 0.01). The median OS was better for the patients with the response of stable disease than the patients with progressive disease (P = 0.013). Conclusions: In patients with advanced HCC who were treated by sorafenib, the size of the hepatic tumors was not significantly reduced. However, the median survival was better for the patients with the response of stable disease. The attenuation values of the tumors became lower after treatment, as compared to the baseline CT scans.     

Usefulness of contrast-enhanced ultrasonography with dynamic flow imaging to evaluate therapeutic effects for hepatocellular carcinoma

BACKGROUND/AIMS: To examine the usefulness of dynamic flow imaging in identifying the therapeutic effects for hepatocellular carcinoma, we performed contrast-enhanced ultrasonography with Levovist. METHODOLOGY: Tumor vascularity of 48 hepatocellular carcinoma nodules in 27 patients infected with hepatitis C virus was assessed before and after radiofrequency ablation therapy by dynamic flow imaging with a wide-band power Doppler technology. RESULTS: All patients showed hypervascular enhancement of hepatocellular carcinoma on contrast-enhanced ultrasonography and/or dynamic computed tomography. The dynamic flow was obtained as vascular and perfusion images of hepatic tumors. The diameters of tumors were 1.1-2.0 cm in 12 nodules, 2.1-3.0 cm in 28, and 3.1-5.0 cm in 8, respectively. We were able to assess the tumor vascularities in 45 of 48 nodules before radiofrequency ablation by the dynamic flow. Three nodules showed insufficient dynamic flow which was located approximately 9 cm in depth from the body surface. The dynamic flow study for the therapeutic efficacy indicated that the tumor vessels disappeared in 43 of the 45 visible nodules. The tumor vascularities were noted in the remaining 2 nodules, and they were successfully retreated by radiofrequency ablation. The frequencies detecting positive enhancement in pretreatment and post-treatment were almost equivalent between vascular phase of dynamic flow on ultrasonography and early phase on helical dynamic computed tomography, although 5 nodules gave different findings; 2 were positive only on ultrasonography, and 3 were positive only on computed tomography. A major complication of radiofrequency ablation procedure was noted in only one case associated with intestinal edema, but it was cured by medical treatment. CONCLUSIONS: The results indicated that contrast-enhanced dynamic flow imaging on ultrasonography is a reliable tool to evaluate intratumoral vascularity both before and after radiofrequency ablation treatment in patients with hepatocellular carcinoma.     

早期肝癌螺旋CT多期增强扫描的影像学特征分析

目的分析早期肝癌的各期增强图像的特点,以期提高临床早期肝癌的检出率。方法以本院手术病理或临床随访证实的直径3cm以下的115例肝占位患者为研究对象,回顾性分析早期肝癌患者64排螺旋CT多期增强扫描各期图像的特点,其中肝细胞癌42例,肝转移癌37例,肝血管瘤36例。结果三组病例在性别构成、年龄分布方面均无显著差异(P均0.05)。肝细胞癌在动脉期多表现为高密度强化,比例显著高于肝转移癌(P0.001);而在门静脉期和平衡期多表现为低密度无强化,比例亦显著高于肝转移癌和肝血管瘤(P0.001)。结论 64排螺旋CT多期增强扫描是诊断早期肝癌行之有效的方法。     

Ultrasound‐guided treatments under low acoustic power contrast harmonic imaging for hepatocellular carcinomas undetected by B‐mode ultrasonography

Background/Aims: The aim was to examine the efficacy of contrast‐enhanced ultrasound (US) with Sonazoid^? to demonstrate ultrasonically unrecognizable hypervascular hepatocellular carcinoma (HCC) and apply percutaneous US‐guided treatments. Methods: The subjects of this prospective study were 44 cirrhotic patients with 55 hypervascular lesions (12.7±4.5 mm) found by contrast‐enhanced computed tomography but unrecognized by non‐contrast US. Contrast‐enhanced US was performed to demonstrate these hepatic lesions after an intravenous injection of Sonazoid^? (0.0075 ml/kg). The sonograms in both the early phase (for 1 min after injection) and the late phase (5–10 min after) were taken in the harmonic imaging mode under a low mechanical index (0.24–0.3). Results: Fifty‐three lesions were demonstrated by contrast‐enhanced US, 52 with positive enhancement in the early phase and 44 with negative enhancement in the late phase. Percutaneous US‐guided treatments were successfully performed for 42 lesions (ethanol injection in 20 and radiofrequency ablation in 22) in 32 patients with reference to contrast‐enhanced US findings. Six patients were treated by transarterial chemoembolization alone because they had more than three lesions in the liver. In the remaining seven lesions in six patients, six were diagnosed as non‐HCC lesions: five with vascular abnormalities such as arterioportal or arteriovenous communication and the other one with benign lesion in alcoholic liver disease. These six lesions and one HCC lesion with severe liver damage were followed up without any treatment. Conclusions: As the detectability of ultrasonically unrecognizable hypervascular HCC improved by contrast‐enhanced US with Sonazoid^?, a wider application of percutaneous US‐guided treatments may be possible.     

Scirrhous hepatocellular carcinoma displaying atypical findings on imaging studies

We describe a 15-mm scirrhous hepatocellular carcinoma （HCC） in a 60-year-old man with B-type cirrhosis. Ultrasound disclosed a 15-mm hypoechoic nodule in segment 7. Contrast-enhanced US revealed heterogeneous, not diffuse, hypervascularity in the early phase and a defect in the Kupffer phase.Contrast-enhanced computed tomography （CT） revealed a heterogeneous hypervascular nodule in the early phase and a low-density area in the late phase.Magnetic resonance imaging （MRI） revealed iso- to hypointensity at T1 and high intensity at T2-weighted sequences. Contrast-enhanced MRI also revealed a heterogeneous hypervascular nodule in the early phase and washout in the late phase. Super-paramagnetic iron oxide-MRI revealed a hvoerintense nodule. CT during hepatic arteriography and CT during arterial portography revealed heterogeneous hyperattenuation and a perfusion defect, respectively. Based on these imaging findings the nodule was diagnosed as a mixed well-differentiated and moderately-differentiated HCC.Histologically, the nodule was moderately-differentiated HCC characterized by typical cytological and structural atypia with dense fibrosis. Immunohistochemically,the nodule was positive for heterochromatin protein 1 and alpha-smooth muscle actin, and negative for cytokeratin 19. From the above findings, the nodule was diagnosed as scirrhous HCC. Clinicians engaged in hepatology should exercise caution with suspected scirrhous HCC when imaging studies reveal atypical findings, as shown in our case on the basis of chronic liver disease.     

Proposal of objective morphological classification system for hepatocellular carcinoma using preoperative multiphase computed tomography

Background

To establish a preoperative morphological classification system for hepatocellular carcinoma using multiphase computed tomography.

Methods

All consecutive patients who were diagnosed with hepatocellular carcinoma between 2004 and 2009 were enrolled, for a total of 232 patients. The concavity and convexity of each outer contour of hepatocellular carcinoma acquired from multiphase computed tomography were analyzed, and the area and depth of each indentation were quantified. The indentation area to tumor area ratio (s:S) and the s:S ratio multiplied by the indentation depth to indentation base ratio (s:S × d:t) were used as feature values reflecting the individual shapes.

Results

Using a hierarchical cluster analysis, the shapes were classified into three groups: Type I (smooth: n = 158), Type II (jagged: n = 63), and Type III (rough: n = 11). The 5-year survival rates for Types I, II, and III were 64, 53, and 0 %, respectively (I vs. II, P = 0.038; I vs. III, P = 0.001; II vs. III, P = 0.002). The 5-year disease-free survival rates for Types I, II, and III were 27, 23, and 0 %, respectively (I vs. III, P = 0.0003 and II vs. III, P = 0.008). Microscopic portal venous invasion was significantly more likely with Type III than with Type I or II (P < 0.001 and P = 0.001, respectively).

Conclusions

The newly developed semiautomatic computed tomography-based morphological classification system appears to provide a promising additional criterion for the prognostic categorization of patients with hepatocellular carcinoma.     

A histopathological study on combined hepatocellular and cholangiocarcinoma: cholangiocarcinoma component is originated from hepatocellular carcinoma

BACKGROUND/AIMS: Combined hepatocellular and cholangiocarcinoma of the liver is relatively infrequent, and its pathogenesis remains obscure. The aim of this study is to investigate its clinical and pathological features and proliferative activity. METHODOLOGY: In this study, we investigated the histopathological features, Ki-67 labeling index, and p53 immunohistochemistry of 18 surgically resected cases of combined hepatocellular and cholangiocarcinoma among 1102 consecutive cases of surgically resected primary liver cancers. All tumors were compatible with the WHO definition of this tumor. Microscopically, we classified the cases into the following three categories according to the arrangement of the hepatocellular carcinoma and cholangiocarcinoma components; (1) Type I in which hepatocellular carcinoma and cholangiocarcinoma formed nodules that could easily be distinguished from each other, (2) Type II in which the both components were finely mixed, so that the two components were almost indistinguishable, and (3) Type III in which the tumors had lobular structures with hepatocellular carcinomas existing centrally and cholangiocarcinomas existing peripherally. RESULTS: Microscopically, the tumors were classified into type I 7 tumors, type II 5 tumors, and type III 6 tumors. In one case of type I, well differentiated hepatocellular carcinoma demonstrated cholangiocarcinoma in "nodules-in-nodules" fashion. The average of Ki-67 labeling index of hepatocellular carcinoma component of combined hepatocellular and cholangiocarcinoma was 4.4 +/- 3.4% and the index of cholangiocarcinoma component was 11.0 +/- 8.5%, which is significantly higher than that of the hepatocellular carcinoma component. On p53 immunohistochemistry, 5 of 18 cases (29.4%) were positive. In one case, the cholangiocarcinoma component was positive for p53, but the hepatocellular carcinoma component was negative. In the other 4 cases, both the hepatocellular carcinoma and cholangiocarcinoma components were positive. CONCLUSIONS: Microscopically, type III seems to be a feature of metaplasia or proliferation of bipotential progenitor cells. Metaplasia of hepatocellular carcinoma to intrahepatic cholangiocarcinoma is assumed to be one of the pathogenic pathways of combined hepatocellular and cholangiocarcinoma.     

Liver cell adenoma showing sequential alteration of radiological findings suggestive of well-differentiated hepatocellular carcinoma

A liver tumor 35 mm in diameter was found incidentally in a 40-year-old woman who had no history of liver diseases or the use of oral contraceptives. Radiological diagnostics showed the typical findings of liver cell adenoma (LCA). Dynamic computed tomography revealed that the tumor showed a homogenous enhancement in the arterial phase and almost the same enhancement as the surrounding liver parenchyma in the delayed phase. The tumor was found to contain fat on magnetic resonance imaging. A benign fat containing liver tumor was suggested. However, radiological findings altered, which caused us to suspect that a welldifferentiated hepatocellular carcinoma (HCC) containing fat was becoming dedifferentiated. Partial hepatectomy was performed and the pathological findings showed the typical findings of LCA. This case was an extremely rare LCA, which had no background of risk for LCA and developed the sequential alteration of the radiological findings to suspect well-differentiated HCC.     

Prospective study of differential diagnosis of hepatic tumors by pattern-based classification of contrast-enhanced sonography

INTRODUCTION Contrast-enhanced harmonic gray-scale sonography is a useful tool for evaluating the vascularity of liver tumors[1-11], because it allows visualization of the blood perfusion of liver tumors without motion artifacts[12] and it is simple, easy, and sufficiently non-invasive to be performed on an out-patient basis. In addition, it can be used in renal failure patients and patients who are allergic to iodine contrast agents. Several investigators have reported that contrast- enha…     

Hepatocellular carcinoma in patients undergoing orthotopic liver transplantation: radiological findings with anatomopathological correlation in Brazil

BACKGROUND: Hepatocellular carcinoma is one of the most common malignant tumors worldwide. Imaging techniques, specially computed tomography and ultrasound, are among the most useful diagnostic tools, although the accuracy of these methods may have a significant variability. AIMS: To determine the prevalence of hepatocellular carcinoma in cirrhotic patients undergoing orthotopic liver transplantation at "Santa Casa de Misericórdia" of Porto Alegre, RS, Brazil; to estimate the sensitivity of computed tomography and ultrasound in pretransplantation detection of hepatocellular carcinoma in this population; to correlate the radiological characteristics with anatomopathological findings. MATERIALS AND METHODS: Retrospective prevalence study. Population: adult, cirrhotic patients undergoing orthotopic liver transplantation from January 1990 to July 2003. Among the 292 transplanted patients, 31 cases of hepatocellular carcinoma were diagnosed, of which 29 were included in the study. Tumor characteristics in both ultrasound and computed tomography were compared to those observed in anatomopathological examination. RESULTS: Prevalence of hepatitis C virus infection among patients with diagnosis of hepatocellular carcinoma was 93.5%, and the prevalence of hepatocellular carcinoma among transplanted patients was 10.6%. The overall sensitivity of the imaging techniques was 70.3% for computed tomography and 72% for ultrasound. CONCLUSION: The prevalence of hepatocellular carcinoma at our institution, as well as the sensitivity of both ultrasound and computed tomography to detect such tumors at pretransplantation screening were similar to those found by other authors, while the prevalence of hepatitis C virus infection, the most common etiological agent for liver disease in our patients, is one of the highest ever reported in literature. Factors influencing hepatocellular carcinoma detection rates were: time from examination to liver transplantation; acquisition of computed tomography images during arterial phase; lesion size. Arterial phase proved to be the most useful part of computed tomography examination in this study.     

Malignant progression of a small HCC nodule: Hypovascular ‘early HCC’ converted to hypervascular ‘small HCC’ within six months

We report a case of hepatocellular carcinoma superimposed on chronic hepatitis C virus (HCV) hepatitis in which final diagnosis of hepatocellular carcinoma was delayed because there was no consensus on hypervascularity with two diagnostic methods at the time of presentation. A 3 cm lesion was initially observed as hypovascular at multidetector-row computed tomography. Conversely, two months later the lesion appeared hypervascular at contrast-ultrasonography and gadolinium-enhanced dynamic magnetic resonance, and hyperintense after superparamagnetic iron oxide-enhanced T2W studies. Only in the late follow-up it was definitively confirmed as hypervascular in the arterial phase of multidetector-row computed tomography. This case clearly highlights some pitfalls in the European Association for the study of the liver guidelines for hepatocellular carcinoma management, which were readdressed in the last American Association for the Study of Liver Diseases (AASLD) and in the forthcoming international proposals, leading to more pragmatic suggestions for clinical practice.     

How to characterize non-hypervascular hepatic nodules on contrast-enhanced computed tomography in chronic liver disease: feasibility of contrast-enhanced ultrasound with a microbubble contrast agent

Background and Aim: Although hypervascular appearance is characteristic in hepatocellular carcinoma (HCC), hepatic nodules without hypervascular appearance are sometimes found in patients with chronic liver disease (CLD). The aim of the present study was to clarify the efficacy of contrast‐enhanced ultrasound (CEUS) with Levovist to characterize small, non‐hypervascular hepatic nodules on contrast‐enhanced computed tomography (CECT) in patients with CLD. Methods: The subject was 41 hepatic nodules (<30 mm, 18.5 ± 5.6 mm) which showed non‐hypervascular appearance on CECT in 35 patients with CLD; their histological results were 31 HCC (15 well, 14 moderate, and two poor) and 10 regenerative nodules (RN). CEUS with Levovist was performed under intermittent scanning (1‐s interval) using APLIO at the early phase and the liver‐specific phase, and the contrast enhancement of the nodule was assessed in comparison to that of the surrounding liver parenchyma. The contrast‐enhanced findings with the time‐intensity analysis were compared with the histological results. Results: Twelve nodules with weak enhancement in the liver‐specific phase were HCC, regardless of their early‐phase appearances. The other 29 nodules with equivalent or weak enhancement in the early phase and equivalent enhancement in the liver‐specific phase were 19 HCC and 10 RN. Among them, the maximum‐intensity ratio of tumor to non‐tumor in the early phase was significantly higher in HCC than in RN (P < 0.01, n = 16), and the receiver‐operating characteristic analysis showed a sensitivity of 1.0 and a specificity of 0.83 for their characterization. Conclusion: CEUS with Levovist may be an alternative to biopsy to characterize small, non‐hypervascular hepatic nodules on CECT in patients with CLD.     

Assessment of tumor hemodynamics in small hepatocellular carcinoma: comparison of Doppler ultrasonography, angiography-assisted computed tomography, and pathological findings.

AIM: We evaluated the usefulness of Doppler ultrasonography (DUS) for the analysis of tumor hemodynamics in small hepatocellular carcinoma (HCC). METHODS: We compared Doppler ultrasound (DUS) findings with angiography-assisted computed tomography (Angio-CT) such as CT during arterial portography and during hepatic arteriography in the evaluation of the intratumoral hemodynamics, and with pathologic findings in 45 small HCC nodules (< or =3.0 cm in diameter) of 43 patients. DUS flow pattern of each nodule was categorized into three types: afferent continuous flow (Type 1), afferent pulsatile flow with afferent continuous flow (Type 2), and afferent pulsatile flow without afferent continuous flow (Type 3). Intratumoral blood supply was determined by Angio-CT, and pathologic findings were evaluated on resected or biopsied specimen. RESULTS: Based on Angio-CT findings, Type 1 nodules showed decreased arterial blood supply (ABS) without decreased portal blood supply (PBS). Type 2 nodules showed unchanged ABS but decreased PBS. Type 3 nodules showed both increased ABS and decreased PBS. DUS findings well represented blood supply of HCC evaluated by Angio-CT. In addition, all Type 1 and 2 nodules were well-differentiated HCC, and all Type 3 nodules were moderately or poorly differentiated HCC; DUS findings well reflected differentiation of HCC. CONCLUSIONS: DUS is a non-invasive imaging method and can be used for the evaluation of the stage of malignancy of small HCC.     

Value of transesophageal 3D echocardiography as an adjunct to conventional 2D imaging in preoperative evaluation of cardiac masses

Background: This study sought to compare three-dimensional (3D) and two-dimensional (2D) transesophageal echocardiography (TEE) to assess intracardiac masses. It was hypothesized that 3D TEE would reveal incremental information for surgical and nonsurgical management. Methods: In 41 patients presenting with intracardiac masses (17 thrombi, 15 myxomas, 2 lymphomas, 2 caseous calcifications of the mitral valve and one each of hypernephroma, hepatocellular carcinoma, rhabdomyosarcoma, lipoma, and fibroelastoma), 2D and 3D TEE were performed, aiming to assess the surface characteristics of the lesions, their relationship to surrounding structures, and attachments. Diagnoses were made by histopathology (n = 28), by computed tomography (n = 8), or by magnetic resonance imaging (n = 5). Benefit was categorized as follows: (A) New information obtained through 3D TEE; (B) helpful unique views but no additional findings compared to 2D TEE; (C) results equivalent to 2D TEE; (D) 3D TEE missed 2D findings. Results: In 15 subjects (37%), 3D TEE revealed one or more items of additional information (category A) regarding type and site of attachment (n = 9, 22%), surface features (n = 6, 15%), and spatial relationship to surrounding structures (n = 8, 20%). In at least 18% of all intracardiac masses, 3D TEE can be expected to deliver supplementary information. In six patients, additional findings led to decisions deviating from those made on the basis of 2D TEE. In 11 subjects (27%), 3D echocardiographic findings were categorized as "B." Conclusions: Information revealed by 3D imaging facilitates therapeutic decision making and especially the choice of an optimal surgical access prior to removal of intracardiac masses.