Hepatic focal nodular hyperplasia: findings with color Doppler sonography

Color Doppler sonographic images of five patients with a total of six lesions of FNH were reviewed. All cases were confirmed pathologically. All six lesions showed increased intralesional flow in comparison to surrounding liver parenchyma on color Doppler sonography. Four of the six lesions showed significant peripheral flow; two of the six lesions showed central flow radiating peripherally from a central vessel. We conclude that increased color Doppler flow may be a characteristic feature of FNH. Increased internal flow has also been reported in HCC and hepatic metastatic disease. Considerable overlap is seen in color Doppler flow patterns. However, in patients clinically at low risk for malignancy, detection of a liver mass with increased color Doppler flow should suggest the diagnosis of FNH.     

Cirrhosis: Diagnosis by liver surface analysis with high-frequency ultrasound

To determine the sensitivity, specificity, and predictive values of the sonographic analysis of liver surface irregularities for the diagnosis of cirrhosis, the authors conducted a prospective and blinded study in 70 subjects with abnormal liver function tests. All patients included underwent liver biopsy within 15 days of the sonographic study. Twenty-three subjects with no signs or symptoms of liver disease were examined to assess the sonographic appearance of normal liver surface. Studies were performed with a small-parts probe, high-frequency transducer (7.5 MHz). Three basic patterns of liver surface were found: type I, normal; type II, focal abnormality; and type III, diffuse irregularity. Considering diffuse surface irregularity as an objective sonographic sign of cirrhosis, the study's sensitivity was 87.5%, specificity 81.5%, and positive and negative predictive values were 80% and 88.5%, respectively. Disease prevalence for cirrhosis was 45%. We conclude that sonographic analysis of the liver surface is a useful noninvasive test for the diagnosis of cirrhosis in the appropriate clinical setting.     

Sonographic features of liver involvement by lymphoma.

OBJECTIVE: The liver is one of the most frequent extranodal locations of non-Hodgkin lymphoma and Hodgkin disease. Nevertheless, lymphoma constitutes only 6% to 8% of focal lesions of the liver. Few studies have evaluated the sonographic patterns of lymphoma with liver involvement. The purpose of this study was to describe the sonographic features and to evaluate the accuracy of sonography for the diagnosis of lymphoma with liver infiltration. METHODS: The abdominal sonographic findings of 23 consecutive patients with histologically proven diagnosis of lymphoma with liver involvement were reviewed. RESULTS: The most prevalent sonographic features were hepatomegaly and splenomegaly. Abdominal lymphoadenopathies were identified in 34.8% of cases. Liver nodules were seen in half of patients, and the most frequent sonographic appearance was as multiple small focal lesions. Differences in sonographic patterns between high- and low-grade non-Hodgkin lymphoma were not seen. None of the patients with Hodgkin disease had liver nodules. Concordance between sonography and computed tomography for the diagnosis of focal liver lesions was observed. CONCLUSIONS: Sonography may contribute to the diagnosis of liver infiltration by lymphoma. The presence of multiple focal liver lesions associated with splenomegaly and lymphoadenopathies should make us consider the diagnosis of lymphoma with liver involvement. Nevertheless, the low specificity of these findings requires histologic confirmation of lymphomatous infiltration of the liver.     

反向脉冲谐波超声造影显像评价肝恶性肿瘤介入治疗疗效

目的探讨反向脉冲谐波超声造影显像评价肝恶性肿瘤介入治疗疗效的临床应用价值.方法对10例接受介入治疗后的肝恶性肿瘤病灶进行反向脉冲谐波超声造影显像,观察病灶的血流灌注,并与造影前后病灶的彩色多普勒显像进行对照,超声检查后随访14～16个月.结果应用反向脉冲谐波超声造影显像,本组的10例介入治疗后肝肿瘤灶血流显示率(60%)较造影前(10%)提高,且高于彩色多普勒超声造影显像方式(40%).随访发现复发的4例中,反向脉冲谐波超声造影显像均可见血流信号(100%),彩色多普勒超声造影显像在2例中(50%)观察到血流信号,而造影前仅在1例中(25%)观察到血流信号.结论反向脉冲谐波超声造影显像对于评估肝恶性肿瘤介入治疗疗效较传统超声显像方法更可靠,并有望成为经皮介入治疗的有效辅助工具.     

Focal hepatic fatty infiltration as a cause of pseudotumors: ultrasonographic patterns and clinical differentiation

Focal hepatic fatty infiltration may be mistaken for hepatic neoplasm on ultrasonography. A sonographic feature mimicking "space occupying lesions" was identified in 41 cases with focal fatty liver, which led to the recognition of four sonographic patterns: (1) Ten patients in whom the livers were characterized by irregular configurations of hyperechoic and hypoechoic areas. Although confusing to inexperienced sonographers, all of them were properly interpreted by experienced sonographers. (2) One patient in whom the hepatic sonography revealed a hyperechoic nodule, but which was correctly diagnosed by computed tomography (CT) scan. (3) Six patients in whom the livers were characterized by multiple confluent hyperechoic lesions, which were all misinterpreted by sonographers and misinterpreted following CT scans in 4 cases and angiography in 3 cases. (4) Twenty-four patients in whom the livers revealed focal spared areas, which was misdiagnosed by sonographers in 14 cases, but correctly diagnosed by CT scan in all 24 cases.     

肝脏淋巴瘤的超声影像分析

目的探讨肝脏淋巴瘤超声及超声造影图像特征。方法对18例手术及穿刺活检病理证实为肝脏淋巴瘤患者的超声及超声造影图像特征进行回顾性分析。结果18例肝脏淋巴瘤患者常规超声及超声造影表现：（1）结节型病变6例,常规超声显示肝内单发或多发低回声病灶,边界清晰（2例病灶内出现纤维条索样高回声）,2例病灶内可见条状血流信号,4例未见血流信号;3例（5个病灶）超声造影表现为动脉期不同程度快速增强,门脉期快速廓清,延迟期呈低回声;术前超声及超声造影诊断恶性或可疑恶性病变5例;无定性诊断1例,病理均诊断为非霍奇金淋巴瘤。（2）弥漫型病变11例,常规超声显示肝脏弥漫性增大,其中8例回声均匀,3例回声欠均匀;8例肝内血流走行及分布未见异常,3例出现静脉变细或栓塞;术前超声诊断恶性或可疑恶性7例,无定性诊断4例;病理诊断霍奇金淋巴瘤1例,非霍奇金淋巴瘤10例。（3）混合型病变1例,常规超声显示肝脏增大,回声不均,其内见多个片状低回声区,边界模糊,肝内血流走行及分布未见异常,术前超声诊断为恶性或可疑恶性病变,病理诊断为非霍奇金淋巴瘤。（4）肝脾及淋巴结肿大：常规超声显示18例患者中11例肝脾肿大、腹腔及腹膜后淋巴结肿大。结论肝脏淋巴瘤超声声像图有一定特征,结合超声造影表现,可为肝脏淋巴瘤的诊断及鉴别诊断提供重要信息。     

Blunt hepatic trauma: evaluation with contrast-enhanced sonography: sonographic findings and clinical application.

OBJECTIVE: The purpose of this study was to report our initial experience in the assessment of liver trauma with real-time contrast-enhanced sonography (CES). METHODS: From January 2000 to December 2003, there were 431 hemodynamically stable patients evaluated with sonography for blunt abdominal trauma. Among these patients, 87 were selected to undergo second-level imaging, consisting of CES and computed tomographic (CT) evaluation. Indications for further assessment were baseline sonographic findings positive for liver injury, baseline sonographic findings positive for injury to other abdominal parenchyma, baseline sonographic findings positive for free fluid only, baseline sonographic findings indeterminate, and baseline sonographic findings negative with persistent clinical or laboratory suspicion. RESULTS: There were 23 hepatic lesions shown by CT in 21 patients. Peritoneal or retroperitoneal fluid was identified in 19 of 21 positive cases by all 3 imaging modalities. Liver injury was found in 15 patients on sonography and in 19 on CES. Contrast-enhanced sonography compared better than unenhanced sonography with the criterion standard for related injury conspicuity, injury size, completeness of injury extension, and involvement of the liver capsule. Both CES and CT showed intrahepatic contrast material pooling in 2 cases. All patients with false-negative sonographic or CES findings recovered uneventfully. CONCLUSIONS: Contrast-enhanced sonography is an effective tool in the evaluation of blunt hepatic trauma, being more sensitive than baseline sonography and correlating better than baseline sonography with CT findings. In institutions where sonography is regarded as the initial procedure to screen patients with trauma, this technique may increase its effectiveness. In addition, CES may be valuable in the follow-up of patients with conservatively treated liver trauma.     

Sonographic evaluation of the anterior liver surface in chronic liver diseases using a 7.5-MHz annular-array transducer: correlation with laparoscopic and histopathologic findings

PURPOSE: We studied the sonographic appearance of the anterior liver surface using an ultrasound scanner equipped with a 7.5-MHz annular-array transducer to determine the accuracy of this imaging modality in monitoring the course of chronic liver diseases. METHODS: We prospectively evaluated patterns of the liver surface in the sonograms of 77 consecutive patients with chronic liver diseases who had undergone sonographic examination with a 7.5-MHz annular-array transducer and a 3.75-MHz convex-array transducer over a 2-year period and compared these findings with those of laparoscopy (using previously described categories) and histopathology. RESULTS: Histopathologically confirmed disease prevalences for inactive chronic hepatitis, active chronic hepatitis, liver cirrhosis, and others were 10% (8/77), 56% (43/77), 29% (22/77), and 5% (4/77), respectively. The sonographic appearance of the liver surface with the 3.75-MHz transducer was classified as either a regular or an irregular pattern. The regular pattern corresponded to 69% (34/50) of the cases in laparoscopic category 200 or 300 and the irregular pattern with 85% (23/27) of the cases in category 400 or 500. The sonographic appearance of the liver surface with the 7.5-MHz transducer was classified as regular, unevenly irregular, diffusely irregular, or nodular. These 4 patterns detected 75% (24/32), 78% (14/18), 52% (12/23), and 75% (3/4) of the cases of laparoscopic categories 200, 300, 400, and 500, respectively. In a comparison of the sonographic patterns of the liver surface with the differential histopathologic findings, the regular sonographic pattern corresponded to 88% (7/8) of the cases of inactive chronic hepatitis, the unevenly irregular pattern with 35% (15/43) of the cases of active chronic hepatitis, and the diffusely irregular and nodular patterns (considered as 1 group) with 68% (15/22) of the cases of liver cirrhosis. CONCLUSIONS: Our results suggest that sonographic evaluation of the liver surface with a 7.5-MHz annular-array transducer using this classification provides detailed information on the evolution of chronic liver diseases that correlates with the laparoscopic and histopathologic findings and thus is a useful noninvasive method for monitoring the disease course to cirrhosis.     

Is sonography superior to enzyme diagnosis in the detection of hepatic steatosis?

In order to evaluate the diagnostic value of sonography in steatosis of the liver, liver biopsies were performed in 52 patients with sonographically diagnosed steatosis of the liver. 27 of 28 patients with normal serum enzymes showed an estimated steatosis of 10 to 40% on histological examination. In the other 24 patients with increased serum enzyme levels histological steatosis was found in 20 patients. 8 further patients with presumed systemic disorders had both normal sonographic findings and normal serum enzyme levels and when subjected to liver biopsy showed an estimated steatosis in the range of 5 to 10%. Reliable sonographic diagnosis of steatosis of the liver can be made only if the degree of steatosis exceeds 10% at least. Normal serum enzyme levels do not exclude steatosis of the liver.     

Classification of the thyroid nodules based on characteristic sonographic textural feature and correlated histopathology using hierarchical support vector machines

In this study, the ultrasound images of thyroid nodules were classified to facilitate clinical diagnosis and management. The hierarchical support vector machines (SVM) classification system was used to select the characteristic sonographic textural feature that represents the major histopathologic components of the thyroid nodules. Two ultrasound systems (LA39 and i12L mentioned in the Materials and Methods section) were used for comparison. Seventy-six thyroid nodular lesions and 157 regions-of-interest thyroid ultrasound image from each system were recruited in the study. The parameters affecting image acquisition were kept in the same condition for all lesions. Commonly used texture analysis methods were applied to characterize thyroid ultrasound images. Image features were classified according to the corresponding pathologic findings. To estimate their relevance and performance to classification, SVMs were used as a feature selector and a classifier. The thyroid nodules are first categorized as two main types, i.e., follicle base and fibrosis base nodule, by sum average. The follicle base nodules can be further and completely classified into follicles with few cells, follicles with follicular cells and follicles with papillary cancer cells by run length nonuniformity (RLNU). The fibrosis base nodules are further classified by sum square into fibrosis with few cells and fibrosis with dominant cells. The fibrosis base neoplasm with dominant cells can be separated into fibrosis with follicular cells and fibrosis with papillary cancer cells by entropy. The hierarchical SVM classification system achieves a diagnostic accuracy between 96.34% and 100%. Besides, the best sonographic textural feature can be selected by the system for the differentiation between the follicle and fibrosis base thyroid nodules or the cell types mixed in them. In follicle base thyroid nodules, papillary cancers show higher sonographic textural RLNU but less than follicular cells. In fibrosis base thyroid nodules, papillary cancers show increased sonographic textural variance and entropy.     

Observer error in the characterization of hepatic lesions in patients with neoplastic liver disease

Sixteen patients with known neoplastic liver disease underwent 20 ultrasound examinations by two separate teams to determine the level of agreement in the measurement of lesion size and sonographic characteristics. The intraclass correlation coefficient for the observations on lesion size was r = 0.97 (95% lower confidence limit r = 0.96). We conclude that sonographic estimation of the size of neoplastic liver lesions in highly reproducible and that the measurements obtained may be safely incorporated into the criteria of response for cancer clinical trials.     

Contrast-enhanced three-dimensional fusion sonography of small liver metastases with pathologic correlation

PURPOSE: To demonstrate that liver metastases with a diameter of < or =40 mm show characteristic features on three-dimensional (3D) fusion sonographic images and that these sonographic findings can be correlated with histopathologic features of surgical specimens. METHODS: Liver metastases measuring < or =40 mm were examined via contrast-enhanced 3D fusion sonography. The characteristic sonographic findings of 17 tumor nodules in 11 patients with a histopathologically confirmed diagnosis of liver metastases were investigated, and their correspondence to the pathologic features were examined in 12 resected nodules. RESULTS: On sonograms, central vessels were visualized in all 17 tumor nodules and peripheral vessels were visualized in 12 nodules. On histopathologic examination, the portal triad vessels corresponded to the central vessels and were located at the center of the tumors. A thin layer of peritumoral hepatocytes showing various changes was also observed, and a group of tiny vessels were seen running along this layer of cells. CONCLUSIONS: Liver metastases measuring 40 mm or less in diameter were characterized by the presence of both central and peripheral vessels on contrast-enhanced 3D fusion sonography. There was good correlation between sonographic and histopathologic findings.     

Sonographic findings of the hepatobiliary-pancreatic system in adult patients with cystic fibrosis.

OBJECTIVE: Sonography of the liver, biliary system, and pancreas in adult patients with cystic fibrosis is by far less systematically documented than in pediatric patients with cystic fibrosis. In this prospective study, duplex sonographic findings of the liver, biliary system, and pancreas in adult patients with cystic fibrosis were compared with those of healthy control subjects. METHODS: Seventy-two consecutive patients with cystic fibrosis and 60 healthy control subjects were examined by high-resolution sonography. The incidence of perihepatic lymphadenopathy, the hepatic echo pattern, the detection rate of liver tumors, the flow patterns in the hepatic and portal veins, and pathologic gallbladder and pancreas findings were recorded. Additionally, cholestasis-indicating enzyme levels (gamma-glutamyl transpeptidase and alkaline phosphatase), liver function test results (alanine aminotransferase and aspartate aminotransferase levels), and amylase and lipase levels were recorded as well. RESULTS: Patients with cystic fibrosis, when compared with healthy subjects on sonographic examination, had a higher incidence of microgallbladder (25% versus 0%) and cystic lesions of the pancreas (18% versus 0%). The number of abnormal echo patterns of the liver was increased (46% versus 15%), with a higher incidence of a nontriphasic flow pattern in the right hepatic vein. The differences proved to be statistically significant (P < .05). CONCLUSIONS: Typical sonographic findings in adult patients with cystic fibrosis are a microgallbladder and small cystic lesions of the pancreas. Pathologic findings of the liver can be shown by B-mode and duplex sonography, but the resulting patterns are less characteristic.     

Hepatic sonography in the evaluation of potential multi-organ donors

PurposeThe aim of the present study was to evaluate the usefulness and the limits of pre-explant ultrasonography of the liver in the workup of multi-organ donor patients.Methods and materialsBetween January 2001 and March 2004, 52 sonographic examinations of the liver were performed on potential multi-organ donors aged 2–72 years (mean: 45.3). In all cases, the cause of death was cerebral hemorrhage/ischemia (spontaneous or traumatic). The examinations included evaluation of the echo-texture of the liver, the presence or the absence of focal lesions or diffuse disease, vascularity, and the biliary tract.ResultsIn one patient, three hepatic cysts were found, three presented solid hyperechoic lesions that were later confirmed to be hemangiomas by pre-implant histologic examination, and 18 patients were found to have diffuse chronic liver disease. In four of these cases, the sonographic diagnosis was not concordant with the results of the biopsy examination.ConclusionUltrasonography can be considered a reliable method for detecting focal liver lesions in potential organ donors. Distinguishing between benign and malignant lesions on the basis of sonographic findings is not required since this can be accomplished during the routine biopsy examination. It is also reliable for the evaluation of vascularity and the biliary tract, but it was of limited use in defining the nature and severity of chronic diffuse liver disease.     

Primary small cell carcinoma of the pancreas with an unusual sonographic appearance

We present a case of primary pancreatic small cell carcinoma with an unusual sonographic feature. A 75-year-old woman presented with poor appetite and weight loss. Abdominal sonographic examination revealed a diffusely enlarged pancreas with relative increased echogenicity and smooth contour. CT also confirmed the diffuse infiltrative pattern of the tumor. The diagnosis was confirmed via sonographically guided biopsy. The tumor was composed of small cells with hyperchromatic nuclei and scanty cytoplasm infiltrating the pancreatic tissue, consistent with small cell carcinoma of the pancreas. Primary pancreatic small cell carcinoma rarely presents as the diffuse infiltrating type. These unusual sonographic features must be differentiated from other pancreatic tumors presenting as diffuse pancreatic enlargement.     

Posterior acoustic shadowing in benign breast lesions: sonographic-pathologic correlation.

OBJECTIVE: To show a variety of benign breast lesions that exhibit posterior acoustic shadowing on sonography. METHODS: The cases illustrate a variety of pathologic breast conditions that were collected at a referral breast center at a tertiary medical center. RESULTS: A variety of pathologic conditions are discussed, with pathologic-imaging correlation. CONCLUSIONS: Although posterior acoustic shadowing is a sonographic feature that is most commonly associated with mammary malignancies, this sonographic finding may also be seen with benign breast lesions.     

The role of contrast-enhanced sonography for radiofrequency ablation of liver tumors.

OBJECTIVE: To assess the feasibility and usefulness of contrast-enhanced sonography for tumor detection and guidance of liver VX2 tumor ablation and to evaluate post radiofrequency ablation effectiveness. METHODS: VX2 tumors were implanted into the livers of 6 rabbits. Both conventional and harmonic gray scale and power Doppler imaging were performed with a commercially available scanner to evaluate the liver tumors before and after intravenous injection of a sonographic contrast agent before and after radiofrequency ablation. Contrast-enhanced imaging was used to detect the tumors before ablation, to guide needle insertion, and to measure the ablation sites after radiofrequency ablation. Pathologic examination was performed for comparison. RESULTS: Three tumors were seen without contrast enhancement, whereas 10 tumors (<1 cm) were detected with contrast enhancement. Intentionally, 2 tumors were completely ablated and 5 tumors were partially ablated. In 3 cases, incompletely ablated tumors could only be identified on contrast-enhanced Doppler imaging by enhancing the detection of residual tumor vascularity. There was excellent concordance between sonographic imaging and gross pathologic findings. CONCLUSIONS: Contrast-enhanced sonographic imaging appears useful for detection of liver tumors and for guiding and monitoring tumor ablation therapies.     

Abdominal pain and preeclampsia: sonographic findings in the maternal liver.

OBJECTIVE: To describe sonographic findings in livers of pregnant women with severe preeclampsia and abdominal pain. METHODS: Over a 12-month period, we performed serial sonographic examinations on 32 pregnant women with severe preeclampsia and acute right upper quadrant and epigastric pain. On each sonogram we observed the liver size and texture, "periportal halo" sign, gallbladder wall, Glisson capsule thickness, painful compression of the liver and gallbladder, and ascites. The pancreas, spleen, kidneys, and uterus were also studied. Sonography was repeated after delivery. RESULTS: Initial sonograms showed liver abnormalities in 28 patients. Abnormalities consisted of liver hypertrophy (n = 24), hyperechoic thickening of the periportal area (periportal halo sign; n = 23), striated thickening of the gallbladder wall (n = 27), hyperechoic thickening of the Glisson capsule (n = 11), liver areas of increased echogenicity (n = 11), subcapsular hematoma (n = 1), and subcapsular calcification (n = 1). Probe compression of the liver enhanced abdominal pain (n = 13), whereas the gallbladder was painless in all cases. No gallbladder stones were detected. Ascites (n = 16) and pleural effusion (n = 11) were also present. In no case did we detect abnormalities of the pancreas, kidneys, or spleen. All patients eventually had hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome according to the American College of Obstetricians and Gynecologists classification. In 7 cases, HELLP syndrome developed postpartum. Three patients also had eclampsia. Follow-up sonograms highlighted quick regression of abnormalities after delivery. CONCLUSIONS: The livers of women with severe preeclampsia who had HELLP syndrome showed sonographic abnormalities before biological abnormalities. Serial sonographic examinations could therefore contribute to the obstetric care of these women. Preeclampsia and HELLP syndrome should be routinely checked for in all pregnant women with acute abdominal pain.     

Sonographic findings in type I glycogen storage disease.

PURPOSE: The aim of this study was to document the sonographic appearance and dimensions of the liver and spleen in patients affected by type I glycogen storage disease and to correlate those findings with laboratory data to evaluate the potential role of sonography in diagnosing that disease. METHODS: Fourteen patients (age range, 3-26 years; 10 patients younger than 18 years) with type I glycogen storage disease proved by liver biopsy were studied prospectively with gray-scale sonography, color Doppler sonography, and spectral analysis. The liver, kidneys, spleen, portal system, hepatic veins, and hepatic arteries were evaluated. Laboratory data were correlated with sonographic findings. RESULTS: In 13 (93%), of 14 patients, the liver was enlarged, and in 11 patients (79%), hepatic echogenicity was increased. In 9 patients (64%), both kidneys were enlarged, and in 6 cases (43%), the spleen was enlarged. In all patients, flow in the portal, splenic, and superior mesenteric veins was hepatopetal, and flow in the hepatic veins was triphasic. In 5 patients (36%), both triglyceride and total cholesterol levels were higher than normal. No focal hepatic lesions were identified. Analysis found no significant association between sonographic findings and laboratory data. CONCLUSIONS: The most frequent sonographic findings in patients with type I glycogen storage disease were hepatomegaly, increased hepatic echogenicity, and enlarged kidneys. Sonography may help in the diagnosis of type I glycogen storage disease, but a liver biopsy is required for a definitive diagnosis.