B-flow imaging of vascular structure for the diagnosis of liver tumor

Purpose

B-flow is a non-Doppler-based technology for visualizing blood flow and has a high spatial resolution. The aim of this study is to evaluate the blood flow information of liver tumors using B-flow in comparison with color Doppler sonography (CDS).

Methods

Seventy-nine patients with 82 hepatic nodules were studied using B-flow and CDS. The study group included 45 HCC nodules, 23 liver metastasis nodules, four intrahepatic cholangiocarcinomas (ICC), and 13 hemangiomas. The visualized vascularity and morphological findings of the hepatic tumor vessel were evaluated.

Results

B-flow showed multiple vessels in 48 nodules (58.5 %) and a single vessel in 13 nodules (15.9 %). CDS showed multiple vessels in 44 nodules (53.7 %) and a single vessel in 23 nodules (28.0 %). Multivariate analysis showed basket pattern was significant for HCC (OR 49.263; p = 0.0002), and penetrating vessel was significant for liver metastasis or ICC (OR 14.545; p < 0.0001).

Conclusion

B-flow detects hepatic tumor blood flow with sensitivity as high as that of CDS. Vascular structure information obtained using B-flow could be potentially used to diagnose liver tumors.     

Proximal bifurcation of hepatic artery: Novel findings on hepatic arteries demonstrated by ultrasound Doppler imaging, B-flow, and US angiography

Purpose It has generally been held that each portal branch is always accompanied by a single arterial branch in the liver. During Doppler ultrasound examination, however, we sometimes encounter a portal branch that appears to be associated with two arterial branches, a phenomenon referred to below asthis finding orthis phenomenon. Here we attempt to confirm that this finding is based on a correct interpretation of the image and to disclose its basic mechanism. Material and Methods Five cases of chronic liver disease in which this phenomenon appeared were analyzed with B-flow imaging. Videotapes obtained from 30 patients who had chronic liver disease and had undergone ultrasound angiography (USAG) with arterial infusion of CO₂ micro bubbles were reviewed in order to look for similar findings. Sixty-nine healthy controls were also examined with Doppler sonography for this purpose. Histopathologic specimens from 7 patients who had undergone hepatectomy (3 with hepatocellular carcinoma, 3 with metastatic tumor, and 1 with focal nodular hyperplasia) were examined to study the basic structure of the hepatic vessels. Results and Discussion Three parallel color signals (two pulsatile and one of a constant waveform) observed on Doppler examination were confirmed by the B-flow method to be three independent vessels in all five cases in which both Doppler sonography and B-flow imaging were used. In 13 (43%) of the 30 cases of USAG, two vessels along a portal branch were visualized by the inflow of micro bubbles, indicating that the two vessels were arteries. The trio of one portal and two arterial branches was also detected with Doppler sonography in 12 (17%) of the 69 healthy controls. In 10 (59%) of the 17 cases (5 of liver disease and 12 normal) that showed this finding on Doppler examination, bifurcations of the hepatic artery and portal vein were both visualized. Hepatic arterial branches were found to bifurcate slightly more proximal to the hepatic hilus than the accompanying portal branch. Histopathologic study revealed Glisson’s areas that contained one portal branch and two arterial vessels in nontumorous parts of specimens from all 7 patients with hepatectomy. Conclusion Two arterial branches can be demonstrated along a portal branch as a result of a more-proximal bifurcation of the hepatic artery than of the portal vein.     

Afferent and efferent vessels of premalignant and overt hepatocellular carcinoma: observation by color Doppler imaging

Afferent and efferent vessels of premalignant and overt hepatocellular carcinoma (HCC) were analyzed using color Doppler imaging. With afferent blood flow, constant waveform signals reflecting portal inflow are a characteristic finding in dysplastic nodules and early well-differentiated HCC. Among advanced HCCs lacking portal blood flow, inflow of arterial pulsatile blood flow signals is characteristic for advanced HCC with increased arterial vascularity. Efferent blood flow enters the hepatic vein of the lowest pressure system in dysplastic nodules and early well-differentiated HCC with afferent portal blood flow. Analysis of waveforms of efferent blood flow signals in advanced HCC detects in the opposite direction adjacent to an accompanying afferent arterial pulsatile blood flow signal. In conclusion, during multistep human hepatocarcinogenesis hemodynamics show characteristic changes; the state of afferent portal blood with low arterial vascularity loses the portal blood flow, and arterial vascularity gradually increases. The efferent blood flow pathway also changes with the pathological multistep development process.     

Color and power Doppler sonography of liver hemangiomas: a dream unfulfilled?

PURPOSE: The aim of this study was to determine whether color Doppler or power Doppler sonography can aid in the diagnosis of hepatic cavernous hemangiomas. METHODS: We imaged 25 hepatic cavernous hemangiomas in 17 patients with gray-scale, color Doppler, and power Doppler sonography. Five malignant lesions were also imaged in the same manner for reference. Hemangiomas had been previously diagnosed by biopsy in 8 patients (15 lesions) and by CT, MRI, and/or tagged red blood cell scanning in 9 patients (10 lesions). RESULTS: Of the 25 hemangiomas, color or power Doppler imaging showed no internal blood flow in 23. Of these 23 lesions, 11 showed a peripheral flow pattern believed to represent flow in displaced blood vessels. This pattern was better visualized with power Doppler imaging in 3 lesions and equally well visualized with color and power Doppler imaging in 8 lesions. Two hemangiomas that had unusual central fibrosis with large vessels in 1 patient showed diffusely increased blood flow on power Doppler study. All 5 malignant lesions showed flow in peripheral vessels, and 1 showed internal vascularity as well. CONCLUSIONS: Neither color nor power Doppler imaging improved the capability of sonography for making a specific diagnosis of benign hepatic cavernous hemangioma.     

三维能量多普勒超声与血管造影对比观察肿瘤血管

目的：与血管造影对比。评价三维能量多普勒超声在观察肿瘤血上的可靠性和对肿瘤定性诊断的准确性。方法：58例经病理证实的腹部肿瘤患者接受三维能量多普勒超声检查,其中肝细胞性肝癌25例。肾癌5例。肝转移癌16例,肝血管瘤8例,肾血管瘤4例。58例中28例在一周内进行血管造影。结果：三维多普勒超声显示出肿瘤周连粗大、弯曲的供血动脉向肿瘤内部延伸,在肝转移瘤病例,可见肿瘤周边正常粗细的敌国管受压变形、移位并环绕肿瘤,在肝血管瘤,表现为肿瘤内部无明显血管,肿瘤周围可见部分血管环绕。结论：肿瘤三维能量多普勒超声图像与篾这造影动脉期图像非常相似,能准确显示肿瘤内部及周连的血流情况。三维能量多普勒超声显示肿瘤积压流的明显差异有助于鉴别肿瘤的性质。     

Value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis.

OBJECTIVE: The purpose of this study was to evaluate the value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis. METHODS: Abdominal sonographic and liver Doppler studies were performed in 3 groups: 36 patients with chronic viral hepatitis, 63 patients with cirrhosis, and 30 control subjects with no evidence of liver disease. A series of Doppler indices of hepatic vascularity, including portal vein velocity, portal vein pulsatility score, flow volume of the portal vein, resistive and pulsatility indices of the hepatic artery, modified hepatic index, hepatic vascular index, waveform of the hepatic vein, and focal acceleration of flow, were measured and correlated with liver and spleen size, portal and splenic vein diameter, and presence of ascites and collateral vessels. These indices were compared across the 3 study groups and within the patient groups with respect to presence of inflammation, fibrosis, and steatosis, as determined by histologic evaluation. RESULTS: The most useful indices were portal vein velocity, the modified hepatic index, and nontriphasic flow in the hepatic vein, which were helpful in distinguishing patients from control subjects. Hepatic vascular and modified hepatic indices were useful for differential diagnosis of cirrhosis and chronic viral hepatitis. However, all measurements were limited in their ability to determine the severity of chronic hepatitis. CONCLUSIONS: Doppler sonography is sensitive to hemodynamic alterations resulting from inflammation and fibrosis, and if sonography is the study of choice to follow the progression of hepatitis, it will not be adequate without Doppler imaging. Doppler sonography has high diagnostic accuracy in cirrhosis despite some false-positive conditions. However, it has a limited role in clinical grading.     

Hepatic computed tomography for simultaneous depiction of hepatocellular carcinoma, intrahepatic portal veins, and hepatic veins in real-time virtual sonography: initial experience.

OBJECTIVE: The aim of this study was to examine a double-step injection of contrast material in hepatic computed tomography (CT) for the simultaneous depiction of hepatocellular carcinoma (HCC), intrahepatic portal veins, and hepatic veins in real-time virtual sonography. METHODS: This study consisted of 6 patients with solitary HCC nodules with early enhancement on dynamic contrast-enhanced CT. Computed tomographic scanning was performed in a combined late arterial/hepatic phase after 2 sequential contrast material injections. RESULTS: In all 6 patients, the solitary HCC nodule, intrahepatic portal veins, and hepatic veins were simultaneously visualized with enhancement, for which CT values were appreciably higher than that of the liver parenchyma. In virtual sonography, HCC nodules and intrahepatic vessels were simultaneously shown, and the HCC lesions were treated by radio frequency ablation without vascular injury. CONCLUSIONS: A double-step injection of contrast material in hepatic CT was helpful in the identification of the relationship between the HCC nodule and intrahepatic vessels under virtual sonography and contributed to the accurate and safe performance of radio frequency ablation for HCC.     

原发性肝癌的门静脉血流动态—声学造影与彩色多普勒所见

为了评价门静脉栓塞（ＰＶＥ）在治疗原发性肝癌（ＨＣＣ）中的作用及我们最近设计的经细针ＰＶＥ法的合理性，对ＨＣＣ病人采用门静脉（ＰＶ）声学造影（ｎ＝２７）和彩色多普勒超声（ｎ＝４４）观察ＰＶ的血流动态，发现近２０％瘤内存在ＰＶ供血，肝动脉栓塞或结扎后ＰＶ成为肿瘤的主要血供来源，检出率达７０．６％。瘤周ＰＶ血流逆流见于１／３的病例，其发生与否和肿瘤的部位、大小、有无肝硬化及动、门静脉分流有关。     

彩色多普勒在门静脉穿刺注药治疗肝癌中的应用

本文探讨了彩色多普勒在门静脉穿刺注药治疗肝癌中的应用价值。对15例原发性肝癌和1例继发性肝癌患者门静脉穿刺注药前后及注药过程中彩色多普勒的应用表明;注药前彩色多普勒对肝肿瘤病灶及门脉血流动力学的检查有助于本治疗适应证的选择;注药过程中的彩色多普勒应用,有助于提高静脉穿刺注药的准确性和观察药液在肝内的弥散;注药后彩色多普勒检查及其穿刺活检有助于对肝癌疗效的观察;超声引导下的门静脉穿刺导向化疗,作为肝癌综合治疗的方法之一,值得进一步探讨。     

Peripheral bone metastasis from hepatocellular carcinoma: sonographic findings

BACKGROUND AND METHODS: We reviewed medical and radiologic records of five patients with bone metastasis from hepatocellular carcinoma (HCC) to evaluate the role of sonography (US) in the diagnosis of this bone metastasis. RESULTS: The metastatic lesions were clearly visualized by US as expansive, homogeneous, soft tissue masses with bony destruction, and color Doppler US showed fine vessels within the lesions. After treatment, US showed a decrease in tumor size with an increase in echogenicity and a decrease in blood flow. Hepatic US at the time of bone metastasis showed a portal tumor thrombus in all cases. CONCLUSION: When US detects a portal venous tumor thrombus in HCC patients, attention should be directed not only to the liver but also to bone to improve patient care. US is useful not only in detecting the metastatic lesion but also in evaluating the treatment effect.     

超声诊断外周血管动静脉瘘的价值

目的探讨超声诊断外周血管动静脉瘘的价值.方法回顾性分析9例经临床证实的动静脉瘘患者二维超声、彩色多普勒超声、灰阶血流成像对动静脉瘘及周围组织显示情况.结果 9例患者超声对瘘口均正确诊断,表现为瘘口处高速湍流、瘘口近端动脉血流为低阻型、远端为高阻型、静脉内血流动脉化;二维超声、彩色多普勒超声结合灰阶血流成像更清晰显示动静脉瘘.结论超声对外周血管动静脉瘘有较高的诊断价值.     

Color Doppler sonographic signs of respiration-dependent hepatofugal portal flow

PURPOSE: The role of respiration in modulating blood flow in the portal vein is unclear. The aim of this study was to investigate the phenomenon of respiration-dependent periodic hepatofugal portal venous blood flow as detected on color Doppler sonography. METHODS: Within 1 year, we identified 13 patients with respiration-dependent reversal of blood flow in the portal vein that was diagnosed on color Doppler sonography. This phenomenon was investigated by color Doppler sonographic examination of the portal venous flow during both mid-inspiration breath-holding and a respiratory cycle including deep inspiration; evaluation of hepatic vein Doppler waveforms as normal (triphasic) or decreased (flattened); and echocardiographic examination to determine the presence or absence of tricuspid regurgitation. RESULTS: The patients' median age was 53 years (range, 26-87 years). Seven of the 13 patients had heart disease (tricuspid regurgitation) with or without liver disease, 3 had liver disease without heart disease, and 3 had other diseases with no evidence of heart or liver disease. On Doppler sonography, 10 of the 13 patients had increased portal venous pulsatility (7 of the 10 had tricuspid regurgitation; the other 3 did not); the remaining 3 patients had neither increased pulsatility nor tricuspid regurgitation. Sonographic follow-up within 4 weeks in 4 of the 13 patients revealed loss of the respiration-dependent hepatofugal portal flow. CONCLUSIONS: Respiration-dependent hepatofugal portal flow is a rare finding associated with periodic portal hypertension in patients with right heart insufficiency and liver disease. Its clinical significance is unclear. Among our patients, its occurrence was predominantly associated with an increased venous pulsatility index due to tricuspid regurgitation or venous outflow obstruction. Further study is needed to investigate whether periodic respiration-dependent hepatofugal portal flow is predictive of the occurrence of continuous flow reversal.     

肝硬化食管静脉曲张破裂出血患者门静脉血流参数的变化

目的 探讨彩色多普勒超声预测肝硬化门静脉高压症(cirrhotic portal hypertension)患者食管静脉曲张破裂出血的应用价值.方法 肝硬化门静脉高压症患者81例,根据有无出血史分为出血组(36例),非出血组(45例).应用彩色多普勒超声分别检测两组的门静脉(pv)和脾静脉(sv)内径(Dpv、Dsv)、血流动力学参数并进行对比分析.结果 门静脉和脾静脉的内径、血流速度(Vpv、Vsv)及脾静脉的血流量(Qsv)在两组间差异均有统计学意义(P<0.05),但门静脉血流量(Qpv)在两组间差异无统计学意义(P>0.05).结论 彩色多普勒超声检测肝硬化门静脉高压症患者门静脉和脾静脉内径及血流动力学参数,对预测肝硬化门静脉高压时食管静脉曲张破裂出血是有价值的.     

Nature of Doppler perfusion index changes in patients with colorectal cancer liver metastases.

OBJECTIVE: Occult hepatic metastases from colorectal cancer result in an increase of the ratio of arterial hepatic blood flow to total hepatic blood flow, described as the Doppler perfusion index. Whether this alteration is due to an increase in arterial blood flow or a decrease in portal venous inflow has not yet been unequivocally determined. The purpose of this study was to analyze changes in hepatic perfusion in patients with liver metastases from colorectal cancer by standardization of hemodynamic parameters to body surface area. METHODS: Hemodynamic parameters (crosssectional area, blood flow, and congestive index) were measured for the common hepatic artery and portal vein with duplex color Doppler sonography in 20 patients with liver metastases and 20 healthy control subjects and evaluated relative to body surface area. RESULTS: No statistically significant differences in age, body surface area, cross-sectional area of the common hepatic artery, and congestion index of the common hepatic artery and portal vein were observed between control subjects and patients with liver metastases. Patients with liver metastases had significantly greater arterial hepatic blood flow and Doppler perfusion index and significantly smaller portal cross-sectional area portal blood flow as well as total liver blood flow (P <.001). CONCLUSIONS: This study supports the theory that the primary mechanism of alteration in liver perfusion is the reduction of portal inflow with subsequently increased arterial hepatic blood flow.     

Spectral and color Doppler sonography.

Color Doppler sonography has become an integral part of modern hepatic sonography. Color Doppler can enhance the conspicuity of focal lesions and bile ducts in jaundiced patients by illuminating normal vessels with flow. Spectral and color Doppler may prove useful in limiting the sonographic differential diagnosis of focal liver lesions. Color flow sonography effectively evaluates pseudoaneurysms, A-V fistulae, collaterals, and flow reversal in portal hypertension, venous clot and tumor invasion, Budd-Chiari syndrome, hereditary hemorrhagic telangiectasis, and many other hepatic vascular lesions. We have found it invaluable in evaluating cirrhotic and liver transplant patients.     

彩色多普勒超声诊断原发性肝癌并门静脉癌栓的价值

目的探讨彩色多普勒超声诊断原发性肝癌(HCC)并门静脉癌栓(PVTT)的价值。方法回顾性分析彩色多普勒超声诊断HCC并PVTT 50例患者的超声检查资料,并与50例正常组(无肝胆疾病)的超声检查结果对照。结果声像图表现为门静脉内径明显增宽,血流束变细或充盈缺损,甚至中断;癌栓内探及动脉血流频谱12例(24.0%),门静脉海绵样变性18例(36.0%)。结论彩色多普勒超声不仅可以较准确地诊断HCC,而且还能反映门静脉及肝动脉的形态及血流动力学变化,对HCC并PVTT的诊断具有重要的临床价值。     

Contrast-enhanced ultrasound improves hepatic vessel visualization after orthotopic liver transplantation

BACKGROUND: We investigated whether color-coded Doppler sonography combined with an ultrasound contrast medium would improve the assessment of liver-supplying vessels after orthotopic liver transplantation. METHODS: Forty-seven patients after orthotopic liver transplantation participated. Examinations were done without and then with the ultrasound contrast medium Levovist. Visualization of the liver-supplying vessels was assessed with a scoring system. RESULTS: Visualization of the portal vein was similar without and with contrast medium. Hepatic arteries were visualized in 39 patients without contrast medium and 46 patients with contrast medium. The remaining patient showed hepatic artery thrombosis, which was confirmed angiographically. With the use of Levovist, the examination took 3.7 min rather than the usual 6.4 min. CONCLUSION: Imaging of hepatic arteries after liver transplantation improved significantly with the use of ultrasound contrast medium. These findings are important because the early detection of blood flow through the liver after transplantation affects prognosis.     

Power Doppler sonography of hepatocellular carcinomas with portal-vein blood supply

We report the power Doppler imaging (PDI) findings in 2 cases of hepatocellular carcinoma (HCC) with a portal-vein blood supply. Gray-scale sonography in both cases showed a well-circumscribed nodule, hypoechoic in case 1 and hyperechoic in case 2. PDI revealed an afferent tumor vessel with constant flow in both nodules, and CT during arterial portography demonstrated a portal-vein supply to both nodules. The nodules were diagnosed by percutaneous core biopsies as highly differentiated HCC. We also examined with PDI another 64 patients with 76 HCC nodules, and none of the nodules showed a constant-flow afferent tumor vessel. The presence of a constant-flow afferent tumor vessel indicates a supplying portal vein; but this is not diagnostic of HCC, and biopsy remains necessary to establish a final diagnosis.     

Liver tumors in children and young patients: sonographic and color Doppler findings

BACKGROUND: Liver tumors are a relatively rare pathologic condition in children and young patients. The aim of the present study was to categorize the sonographic (US) and color Doppler results of liver tumors in these patients. METHODS: We retrospectively reviewed the US findings of 23 such cases: malignant tumor (13 cases)-hepatoblastoma (four cases), hepatocellular carcinoma (HCC; four cases), and hepatic metastasis (five cases); benign tumor (10 cases)-hepatocellular adenoma (four cases), focal nodular hyperplasia (two cases), mesenchymal hamartoma (two cases), cystadenoma (one case), and hemangioendothelioma (one case). RESULTS: There was no specific US findings for each tumor type. HCC usually developed on a normal liver and was imaged as multiple nodules. Color Doppler US helped in differentiating multiple metastatic nodules (hypovascular) from multiple HCC nodules (hypervascular). Presence of intratumoral cystic areas was usually suggestive of benign tumors. Follow-up US was useful for detecting small nodules in high-risk groups (congenital biliary atresia, glycogen storage disease). Color Doppler US helped in diagnosing portal thrombus or intratumoral shunt. CONCLUSION: Although there were no highly specific findings, US and color Doppler results contributed, to a certain degree, to the diagnosis of liver tumors in children and young adults by showing intratumoral cystic areas or vascularity.     

彩超新方法检测肝癌

目的 本文设计一种新彩色多普勒影像处理方法以突出展现肝细胞癌（ＨＣＣ）的异常涡流。方法 计算两项新（双－向,低峰）指数检测ＨＣＣ特征血流。结果 在实验资料,由狭窄形成的涡流其两项指数较高。在临床方法向,ＨＣＣＲ 两项指数显著高于慢性肝病患者门脉及肝静脉内的相应测值。７７％ＨＣＣ２可检出该涡流,而很少见于门脉或肝静脉。结论该项新可用来ＨＣＣ涡流。