Contrast-Enhanced Ultrasound in Focal Liver Lesions: Where Do We Stand?

Comprehensive review of clinical presentation, diagnosis, management, and prognosis of ruptured hepatocellular carcinoma

BACKGROUND

Spontaneous rupture of hepatocellular carcinoma (rHCC) is a life-threatening complication that occurs in 3 % to 15 % of patients with hepatocellular carcinoma (HCC). This review aimed to discuss the most recent updates in the epidemiology, pathophysiology, risk factors, diagnosis as well as presentation, management, and prognostic factors of rHCC.

METHODS

A comprehensive systematic review was conducted using Medline/PubMed and Web of Science databases with the end of search date being December 1, 2023 regarding rHCC diagnosis, imaging, and management.

RESULTS

Achieving adequate hemostasis and stabilization of the patient remains the primary objective in the management of patients with rHCC. In earlier studies, the mortality rate in the acute phase of rHCC was reported to be 25 % to 75 %. However, more recent studies have demonstrated that transcatheter arterial embolization (TAE)/transcatheter arterial chemoembolization (TACE) followed by elective hepatectomy in select patients may offer improved survival benefits and decrease perioperative complications compared with TAE/TACE alone or emergent/1-stage hepatectomy.

CONCLUSION

Although the prognosis for rHCC remains the worst among causes of death related to HCC, more recent studies have demonstrated that improved short- and long-term patient outcomes may be achieved through active surveillance efforts for HCC combined with advanced multimodal diagnostic tools and multidisciplinary management strategies.

Percutaneous ablation of liver metastases from colorectal cancer: a comparison between the outcomes of ultrasound guidance and CT guidance using propensity score matching

PURPOSE

The aim of this study was to compare the effectiveness and outcomes of percutaneous ablation guided by ultrasonography (US) and computed tomography (CT) in colorectal liver oligometastases (CLOM).

METHODS

This study included patients with CLOM treated with percutaneous ablation from January 2008 to January 2021 in this observational study. Only lesions visualized on both CT and US images were further analyzed according to whether patients' initial ablation treatments utilized US guidance or CT guidance. The Kaplan-Meier method was used to estimate local tumor progression (LTP)-free survival after propensity score matching (PSM). The LTP-free survival and treatment-related outcomes were compared between these two groups.

RESULTS

PSM identified 116 patients from each group, with 269 and 238 lesions in the USguided and CT-guided groups, respectively. US-guided ablation had a shorter average procedure time and lower cost than CT-guided ablation (27.54±12.06 minutes vs. 32.70±13.88 minutes, P=0.003; $2,175.13±618.17 vs. $2,455.49±710.25, P=0.002). For patients >60 years of age, the cumulative LTP rate at 1 year was lower in the US-guided group than in the CT-guided group (17.8% vs. 25.1%, P=0.038). For patients with perivascular liver lesions, the cumulative LTP rate at 1 year was lower in the US-guided group (14.4% vs. 28.2%, P=0.040).

CONCLUSION

For patients whose age is >60 years or who have perivascular liver lesions, USguided ablation is better than CT-guided ablation, with a shorter treatment time and lower costs when both ablation methods are feasible for patients.

Histopathological and immunological study of rats liver hydatid cysts isolated from human, sheep, goat and cows

In endemic places, liver hydatidosis is a life-threatening health issue. Many consequences such as hepatomegaly, infiltration with inflammatory cells and histopathological changes might arise as a result of liver hydatidosis. This study aimed to look into pathogenic changes in the livers of the rats that experimentally infected with hydatid cysts. These hydatid cysts were isolated from naturally infected humans, sheep, goats and cows. Liver hydatid cysts were collected from the main abattoir of Al-Muthanna province while human hydatid cysts were collected from Al-Hussein Teaching Hospital in Al-Muthanna province. The hydatid cysts were grossly and histology examined for inspection of hydatid cysts. The in vivo experiments were done by injection of hydatid protoscoleces or sand (fluid) in rats intraperitoneally. The results showed that the gross signs were same in all infected livers which range from paleness, hepatomegaly, hemorrhage and calcification. The hydatid cysts isolated from sheep and goat livers were highly fertile compared to others isolated from humans and cows. Injection of hydatid protoscoleces and hydatid fluid isolated from sheep and goat livers in rats induced the highest immune response compared to that isolated from humans and cows. The liver sections of rats that were injected with human, goat and sheep hydatid protoscoleces and fluids showed hyperplasia in the bile duct, aggregation nonnuclear cells with congested blood vessels. While liver sections of rats were received goat hydatid fluid, cow hydatid protoscoleces and hydatid fluid showed normal liver tissue. These findings suggested that the immunogenicity of hydatid materials is different according to the host and the component of hydatid cysts.

Loco-regional treatment of hepatocellular carcinoma: Role of contrast-enhanced ultrasonography

Hepatocellular carcinoma (HCC) is one of the few cancers for which locoregional treatments (LRTs) are included in international guidelines and are considered as a valid alternative to conventional surgery. According to Barcelona Clinic Liver Cancer classification, percutaneous treatments such as percutaneous ethanol injection, radiofrequency ablation and microwave ablation are the therapy of choice among curative treatments in patients categorized as very early and early stage, while transcatheter arterial chemoembolization is considered the better option for intermediate stage HCC. A precise assessment of treatment efficacy and surveillance is essential to optimize survival rate, whereas residual tumor requires additional treatment. Imaging modalities play a key role in this task. Currently, contrast-enhanced computed tomography/magnetic resonance imaging are considered the standard imaging modalities for this purpose. Contrast enhanced ultrasound (CEUS), using second generation contrast agents, plays an increasingly important role in detecting residual disease after LRTs. CEUS is a straightforward to perform, repeatable and cost-effective imaging modality for patients with renal failure or iodine allergies. Due to the ability to focus on single regions, CEUS can also provide high temporal resolution. Moreover, several studies have reported the same or better diagnostic accuracy as contrast-enhanced computed tomography for assessing tumor vascularity 1 mo after LRTs, and recently three-dimensional (3D)-CEUS has been reported as a promising technique to improve the evaluation of tumor response to therapy. Furthermore, CEUS could be used early after procedures in monitoring HCC treatments, but nowadays this indication is still debated, and data from literature are conflicting, especially after transcatheter arterial chemoembolization procedure.

Focal liver lesions in cirrhosis: Role of contrast-enhanced ultrasonography

Contrast-enhanced ultrasound (CEUS) represents a great innovation for the evaluation of focal liver lesions (FLLs). The main advantage of CEUS is the real-time imaging examination and the very low toxicity in patients with renal failure. Liver cirrhosis has been recognized as a major risk factor for the onset of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). HCC in liver cirrhosis develops as the last step of a complex that leads to the gradual transformation from regenerative nodule through dysplastic nodule to HCC. In patients with liver cirrhosis, a surveillance program is recommended consisting of ultrasound (US) for detecting small focal lesions. A wide spectrum of benign and malignant lesions other than HCC may be found in the cirrhotic liver and their differentiation is important to avoid errors in staging diseases that may preclude potentially curative therapies. Several published studies have explored the value of CEUS in liver cirrhosis and they have been shown to have excellent diagnostic and prognostic performances for the evaluation of non-invasive and efficient diagnosis of FLLs in patients at high risk for liver malignancies. The purpose of this article is to describe and discuss CEUS imaging findings of FLLs including HCC and ICC, all of which occur in cirrhotic livers with varying prevalence.

Advances in liver US, CT, and MRI: moving toward the future

Over the past two decades, the epidemiology of chronic liver disease has changed with an increase in the prevalence of nonalcoholic fatty liver disease in parallel to the advent of curative treatments for hepatitis C. Recent developments provided new tools for diagnosis and monitoring of liver diseases based on ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), as applied for assessing steatosis, fibrosis, and focal lesions. This narrative review aims to discuss the emerging approaches for qualitative and quantitative liver imaging, focusing on those expected to become adopted in clinical practice in the next 5 to 10 years. While radiomics is an emerging tool for many of these applications, dedicated techniques have been investigated for US (controlled attenuation parameter, backscatter coefficient, elastography methods such as point shear wave elastography [pSWE] and transient elastography [TE], novel Doppler techniques, and three-dimensional contrast-enhanced ultrasound [3D-CEUS]), CT (dual-energy, spectral photon counting, extracellular volume fraction, perfusion, and surface nodularity), and MRI (proton density fat fraction [PDFF], elastography [MRE], contrast enhancement index, relative enhancement, T1 mapping on the hepatobiliary phase, perfusion). Concurrently, the advent of abbreviated MRI protocols will help fulfill an increasing number of examination requests in an era of healthcare resource constraints.

Ultrasound and contrast-enhanced ultrasound (CEUS) in infective liver lesions

Infektiöse fokale Leberläsionen (FLL) treten in der klinischen Praxis häufig auf, wobei bakterielle Leberabszesse die Hälfte ausmachen. Eine genaue Diagnose der FLL ist für die Auswahl der am besten geeigneten Therapie und zur Vorbeugung von Komplikationen unerlässlich. Ziel der aktuellen Arbeit ist es, den Nutzen von Ultraschall und kontrastmittelverstärktem Ultraschall (CEUS) zur Erkennung und Charakterisierung infektiöser Leberläsionen zu beschreiben.

New frontiers in liver ultrasound: From mono to multi parametricity

Modern liver ultrasonography (US) has become a "one-stop shop" able to provide not only anatomic and morphologic but also functional information about vascularity, stiffness and other various liver tissue properties. Modern US techniques allow a quantitative assessment of various liver diseases. US scanning is no more limited to the visualized plane, but three-dimensional, volumetric acquisition and consequent post-processing are also possible. Further, US scan can be consistently merged and visualized in real time with Computed Tomography and Magnetic Resonance Imaging examinations. Effective and safe microbubble-based contrast agents allow a real time, dynamic study of contrast kinetic for the detection and characterization of focal liver lesions. Ultrasound can be used to guide loco-regional treatment of liver malignancies and to assess tumoral response either to interventional procedures or medical therapies. Microbubbles may also carry and deliver drugs under ultrasound exposure. US plays a crucial role in diagnosing, treating and monitoring focal and diffuse liver disease. On the basis of personal experience and literature data, this paper is aimed to review the main topics involving recent advances in the field of liver ultrasound.

Quantitative Analysis of the Time-Intensity Curve of Contrast-Enhanced Ultrasound of the Liver: Differentiation of Benign and Malignant Liver Lesions

Background: To evaluate the diagnostic accuracy of quantitative perfusion parameters in contrast-enhanced ultrasound to differentiate malignant from benign liver lesions. Methods: In this retrospective study 134 patients with a total of 139 focal liver lesions were included who underwent contrast enhanced ultrasound (CEUS) between 2008 and 2018. All examinations were performed by a single radiologist with more than 15 years of experience using a second-generation blood pool contrast agent. The standard of reference was histopathology (n = 60), MRI or CT (n = 75) or long-term CEUS follow up (n = 4). For post processing regions of interests were drawn both inside of target lesions and the liver background. Time–intensity curves were fitted to the CEUS DICOM dataset and the rise time (RT) of contrast enhancement until peak enhancement, and a late-phase ratio (LPR) of signal intensities within the lesion and the background tissue, were calculated and compared between malignant and benign liver lesion using Student’s t-test. Quantitative parameters were evaluated with respect to their diagnostic accuracy using receiver operator characteristic curves. Both features were then combined in a logistic regression model and the cumulated accuracy was assessed. Results: RT of benign lesions (14.8 ± 13.8 s, p = 0.005), and in a subgroup analysis, particular hemangiomas (23.4 ± 16.2 s, p < 0.001) differed significantly to malignant lesions (9.3 ± 3.8 s). The LPR was significantly different between benign (1.59 ± 1.59, p < 0.001) and malignant lesions (0.38 ± 0.23). Logistic regression analysis with RT and LPR combined showed a high diagnostic accuracy of quantitative CEUS parameters with areas under the curve of 0.923 (benign vs. malignant) and 0.929 (hemangioma vs. malignant. Conclusions: Quantified CEUS parameters are helpful to differentiate malignant from benign liver lesions, in particular in case of atypical hemangiomas.

Interobserver agreement for contrast-enhanced ultrasound of liver imaging reporting and data system: A systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma is the most common primary liver malignancy. From the results of previous studies, Liver Imaging Reporting and Data System (LI-RADS) on contrast-enhanced ultrasound (CEUS) has shown satisfactory diagnostic value. However, a unified conclusion on the interobserver stability of this innovative ultrasound imaging has not been determined. The present meta-analysis examined the interobserver agreement of CEUS LI-RADS to provide some reference for subsequent related research.

AIM

To evaluate the interobserver agreement of LI-RADS on CEUS and analyze the sources of heterogeneity between studies.

METHODS

Relevant papers on the subject of interobserver agreement on CEUS LI-RADS published before March 1, 2020 in China and other countries were analyzed. The studies were filtered, and the diagnostic criteria were evaluated. The selected references were analyzed using the “meta” and “metafor” packages of R software version 3.6.2.

RESULTS

Eight studies were ultimately included in the present analysis. Meta-analysis results revealed that the summary Kappa value of included studies was 0.76 [95% confidence interval, 0.67-0.83], which shows substantial agreement. Higgins I² statistics also confirmed the substantial heterogeneity (I² = 91.30%, 95% confidence interval, 85.3%-94.9%, P < 0.01). Meta-regression identified the variables, including the method of patient enrollment, method of consistency testing, and patient race, which explained the substantial study heterogeneity.

CONCLUSION

CEUS LI-RADS demonstrated overall substantial interobserver agreement, but heterogeneous results between studies were also obvious. Further clinical investigations should consider a modified recommendation about the experimental design.

Focal liver lesions: interobserver and intraobserver agreement of three-dimensional contrast-enhanced ultrasound-assisted volume measurements

PURPOSE

This study was conducted to assess the interobserver and intraobserver agreement of three-dimensional contrast-enhanced ultrasound (3D-CEUS) volume calculations of focal liver lesions (FLLs).

METHODS

Thirty-nine patients (15 men and 24 women; mean age, 55.4 years) with 39 FLLs (mean size, 3.1±1.8 cm; size range, 1 to 8 cm) prospectively underwent 3D-CEUS. Four readers calculated the volume of each lesion in an independent and blinded fashion in two separate sessions by means of a semi-automatic, commercially available proprietary software. The differences in lesion volumes (cm3) among sessions and readers were assessed using the Mann-Whitney U test and the Kruskal-Wallis test. Bland-Altman analysis was also performed. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) were calculated. The statistical significance level was set at P<0.05.

RESULTS

Among readers, there were no statistically significant differences in the first (P=0.953) and second (P=0.592) reading sessions for volume calculations of the 39 FLLs, with almost perfect inter-reader agreement (ICC values of the first reading session, 0.996; 95% CI, 0.992 to 0.998 and ICC value of the second reading session, 0.994; 95% CI, 0.990 to 0.997, respectively). For each of the four readers, there were no significant differences in volume calculations between the two sessions (P=0.503-0.924), and the intrareader agreement was almost perfect for each reader (R1: ICC, 0.995; 95% CI, 0.991 to 0.998; R2: ICC, 0.995; 95% CI, 0.988 to 0.997; R3: ICC, 0.996; 95% CI, 0.992 to 0.998; R4: ICC, 0.985; 95% CI, 0.971 to 0.992).

CONCLUSION

3D-CEUS volume calculations provided consistent measurements across different readers with almost perfect intrareader agreement.

Photo- and Sono-Dynamic Therapy: A Review of Mechanisms and Considerations for Pharmacological Agents Used in Therapy Incorporating Light and Sound

As irreplaceable energy sources of minimally invasive treatment, light and sound have, separately, laid solid foundations in their clinic applications. Constrained by the relatively shallow penetration depth of light, photodynamic therapy (PDT) typically involves involves superficial targets such as shallow seated skin conditions, head and neck cancers, eye disorders, early-stage cancer of esophagus, etc. For ultrasound-driven sonodynamic therapy (SDT), however, to various organs is facilitated by the superior... transmission and focusing ability of ultrasound in biological tissues, enabling multiple therapeutic applications including treating glioma, breast cancer, hematologic tumor and opening blood-brain-barrier (BBB). Considering the emergence of theranostics and precision therapy, these two classic energy sources and corresponding sensitizers are worth reevaluating. In this review, three typical therapies using light and sound as a trigger, PDT, SDT, and combined PDT and SDT are introduced. The therapeutic dynamics and current designs of pharmacological sensitizers involved in these therapies are presented. By introducing both the history of the field and the most up-to-date design strategies, this review provides a systemic summary on the development of PDT and SDT and fosters inspiration for researchers working on 'multi-modal' therapies involving light and sound.

CEUS LI-RADS: a pictorial review

Contrast-enhanced ultrasound (CEUS) greatly improved the diagnostic accuracy of US in the detection and characterization of focal liver lesions (FLLs), and it is suggested and often included in many international guidelines as an important diagnostic tool in the imaging work-up of cirrhotic patients at risk for developing hepatocellular carcinoma (HCC). In particular, CEUS Liver Imaging Reporting and Data System (LI-RADS) provides standardized terminology, interpretation, and reporting for the diagnosis of HCC. The aim of this pictorial essay is to illustrate CEUS features of nodules discovered at US in cirrhotic liver according to LI-RADS categorization.

Complications of hepatic echinococcosis: multimodality imaging approach

Hydatid disease is a worldwide zoonosis endemic in many countries. Liver echinococcosis accounts for 60-75% of cases and may be responsible for a wide spectrum of complications in about one third of patients. Some of these complications are potentially life-threatening and require prompt diagnosis and urgent intervention. In this article, we present our experience with common and uncommon complications of hepatic hydatid cysts which include rupture, bacterial superinfection, and mass effect-related complications. Specifically, the aim of this review is to provide key imaging features and diagnostic clues to guide the imaging diagnosis using a multimodality imaging approach, including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and endoscopic retrograde cholangiopancreatography (ERCP).

Contrast-enhanced ultrasound of hepatocellular carcinoma: where do we stand?

Contrast-enhanced ultrasound (CEUS) represents a significant breakthrough in ultrasonography (US), and it is being increasingly used for the evaluation of focal liver lesions (FLLs). CEUS is unique in that it allows non-invasively assessment of liver perfusion in real time throughout the vascular phase, which has led to dramatic improvements in the diagnostic accuracy of US in the detection and characterization of FLLs, the choice of therapeutic procedures, and the evaluation of response. Currently, CEUS is included as a part of the suggested diagnostic work-up of FLLs, including in cirrhotic patients with hepatocellular carcinoma, resulting in better patient management and cost-effective delivery of therapy.

Imaging performance and clinical value of contrast-enhanced ultrasonography and computed tomography in the diagnosis of liver cancer

The imaging performance and clinical value of contrast-enhanced ultrasonography (CEUS) combined with CT in diagnosis of liver cancer were investigated. A total of 426 liver cancer patients treated in Yuhuangding Hospital (Yantai, China) from February 2011 to May 2016 were selected. Among them, 222 patients underwent CEUS examination, 204 patients underwent CT examination, and 102 patients underwent CEUS combined with CT examination. Sensitivity and specificity of the three methods were examined. CT showed a low density in 92.6% of patients (189 patients) and a high-low hybrid density in 6.4% (13 patients), with calcification seen in 2.5% of patients (5 patients) and bleeding in 3.4% (7 patients). Lesions: 76.5% (156 cases) of patients with multiple type, 23.5% (48 cases) with single type. CEUS showed overall enhancement in 53.2% patients (118 cases), heterogenous enhancement in 16.7% (37 cases), peripheral enhancement in 18.9% of patients (42 cases), necrosis of liquefaction in 11.3% (25 cases). In 65.3% (145 cases) of patients, the portal venous phase and the delayed phase showed a low enhancement, while 34.7% (77 cases) showed no enhancement. The sensitivity and specificity rates of CEUS combined with CT detection of liver cancer were 87.8, 88.2 and 94.1%, respectively. The ROC curve analysis showed that the sensitivity and specificity of CEUS in the diagnosis of liver cancer were 76.8 and 78.9%, respectively. The sensitivity and specificity of CT were 81.2 and 85.5%, respectively. The sensitivity and specificity of CEUS combined with CT were 90.4 and 92.7%, respectively. CEUS combined with CT detection can make-up for the deficiencies of each other and effectively improve the coincidence rate of liver cancer diagnosis, which can be used as an effective examination method for the diagnosis of liver cancer.

Acoustic Characterization and Enhanced Ultrasound Imaging of Long-Circulating Lipid-Coated Microbubbles

OBJECTIVES

A long-circulating lipid-coated ultrasound (US) contrast agent was fabricated to achieve a longer wash-out time and gain more resistance against higher-mechanical index sonication. Systemic physical, acoustic, and in vivo imaging experiments were performed to better understand the underlying mechanism enabling the improvement of contrast agent performance by adjusting the physical and acoustic properties of contrast agent microbubbles.

METHODS

By simply altering the gas core, a kind of US contrast agent microbubble was synthesized with a similar lipid-coating shell as SonoVue microbubbles (Bracco SpA, Milan, Italy) to achieve a longer wash-out time and higher inertial cavitation threshold. To bridge the structure-performance relationship of the synthesized microbubbles, the imaging performance of the microbubbles was assessed in vivo with SonoVue as a control group. The size distribution and inertial cavitation threshold of the synthesized microbubbles were characterized, and the shell parameters of the microbubbles were determined by acoustic attenuation measurements. All of the measurements were compared with SonoVue microbubbles.

RESULTS

The synthesized microbubbles had a spherical shape, a smooth, consistent membrane, and a uniform distribution, with an average diameter of 1.484 μm. According to the measured attenuation curve, the synthesized microbubbles resonated at around 2.8 MHz. Although the bubble's shell elasticity (0.2 ± 0.09 N/m) was comparable with SonoVue, it had relatively greater viscosity and inertial cavitation because of the different gas core. Imaging studies showed that the synthesized microbubbles had a longer circulation time and a better chance of fighting against rapid collapse than SonoVue.

CONCLUSIONS

Nano/micrometer long-circulating lipid-coated microbubbles could be fabricated by simply altering the core composition of SonoVue microbubbles with a higher-molecular weight gas. The smaller diameter and higher inertial cavitation threshold of the synthesized microbubbles might make it easier to access deep-seated organs and give prolonged imaging enhancement in the liver.

Contrast-enhanced ultrasound of malignant liver lesions

Contrast-enhanced ultrasound (CEUS) is a safe, relatively inexpensive, and widely available imaging technique using dedicated imaging ultrasound sequences and FDA-approved contrast microbubbles that allow detection and characterization of malignant focal liver lesions with high diagnostic accuracy. CEUS provides dynamic real-time imaging with high spatial and temporal capability, allowing for unique contributions to the already established protocols for diagnosing focal liver lesions using CT and MR imaging. In patients with lesions indeterminate on CT and MRI, CEUS is a helpful problem-solving complementary tool that improves patient management. Furthermore, CEUS assists guidance of liver biopsies and local treatment. Variations of CEUS such as DCE-US and ultrasound molecular imaging are emerging for quantitative monitoring of treatment effects and possible earlier detection of cancer. In this review, basic principles of CEUS techniques and ultrasound contrast agents along with a description of the enhancement patterns of malignant liver lesions are summarized. Also, a discussion of the role of CEUS for treatment guidance and monitoring, intraoperative CEUS, and an outlook on emerging applications is provided.

Applications of contrast-enhanced ultrasound in the pediatric abdomen

Contrast-enhanced ultrasound (CEUS) is a radiation-free, safe, and in specific clinical settings, highly sensitive imaging modality. Over the recent decades, there is cumulating experience and a large volume of published safety and efficacy data on pediatric CEUS applications. Many of these applications have been directly translated from adults, while others are unique to the pediatric population. The most frequently reported intravenous abdominal applications of CEUS in children are the characterization of focal liver lesions, monitoring of solid abdominal tumor response to treatment, and the evaluation of intra-abdominal parenchymal injuries in selected cases of blunt abdominal trauma. The intravesical CEUS application, namely contrast-enhanced voiding urosonography (ceVUS), is a well-established, pediatric-specific imaging technique entailing the intravesical administration of ultrasound contrast agents for detection and grading of vesicoureteral reflux. In Europe, all pediatric CEUS applications remain off-label. In 2016, the United States Food and Drug Administration (FDA) approved the most commonly used worldwide second-generation ultrasound contrast SonoVue®/Lumason® for pediatric liver and intravesical applications, giving new impetus to pediatric CEUS worldwide.

Diffuse Liver Diseases: Role of imaging

Nowadays, the most common imaging techniques allow to study focal liver lesions with high diagnostic accuracy but a relatively recent emerging field of interest is represented by diffuse liver disease. They include a variegated series of storage and metabolic pathologies (ie, iron overload disorders and steatosis) requiring a precise diagnosis not always possible at imaging due to the overlapping of findings at conventional ultrasound, CT, or MR studies. In recent years, several imaging tecniques and specific softwares have been developed, especially for ultrasound and MR imaging, in order to identify different parameters useful in the noninvasive recognition and follow-up of these diffuse processes involving the liver. The aim of this article is to describe the most common and useful imaging findings of the most common and uncommon diffuse liver diseases illustrating the newest imaging technologies and developments at our disposal with corresponding advantages, limitations, and pitfalls.

Computational Modeling in Liver Surgery

The need for extended liver resection is increasing due to the growing incidence of liver tumors in aging societies. Individualized surgical planning is the key for identifying the optimal resection strategy and to minimize the risk of postoperative liver failure and tumor recurrence. Current computational tools provide virtual planning of liver resection by taking into account the spatial relationship between the tumor and the hepatic vascular trees, as well as the size of the future liver remnant. However, size and function of the liver are not necessarily equivalent. Hence, determining the future liver volume might misestimate the future liver function, especially in cases of hepatic comorbidities such as hepatic steatosis. A systems medicine approach could be applied, including biological, medical, and surgical aspects, by integrating all available anatomical and functional information of the individual patient. Such an approach holds promise for better prediction of postoperative liver function and hence improved risk assessment. This review provides an overview of mathematical models related to the liver and its function and explores their potential relevance for computational liver surgery. We first summarize key facts of hepatic anatomy, physiology, and pathology relevant for hepatic surgery, followed by a description of the computational tools currently used in liver surgical planning. Then we present selected state-of-the-art computational liver models potentially useful to support liver surgery. Finally, we discuss the main challenges that will need to be addressed when developing advanced computational planning tools in the context of liver surgery.

Detection of liver metastases in cancer patients with geographic fatty infiltration of the liver: the added value of contrast-enhanced sonography

Purpose

The aim of this study is to assess the role of contrast-enhanced ultrasonography (CEUS) in the detection of liver metastases in cancer patients with geographic liver fatty deposition on greyscale ultrasonography (US).

Methods

Thirty-seven consecutive cancer patients (24 women and 13 men; age, 33 to 80 years; mean, 58.1 years) with geographic liver fatty deposition, but without any detectable focal liver lesion on greyscale US, underwent sulphur hexafluoride-enhanced US. Two readers reported by consensus the presence, size, and location of any detected lesion. All patients underwent magnetic resonance imaging (MRI) as a confirmatory study. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy were calculated.

Results

Seven focal liver lesions (size, 4 to 10 mm; mean, 6.1 mm) were detected in 4/37 patients (10.8%): four metastases (size, 5 to 10 mm; mean, 6.7 mm) were detected both by CEUS and MRI, with one hemangioma and two cysts (size range, 4 to 6 mm; mean, 5.3 mm) detected by MRI only. In 1/37 patients (2.7%), CEUS misdiagnosed geographic fatty change as three metastases. In 32/37 patients (86.5%), no lesions were detected. Sensitivity, specificity, PPV, NPV, and accuracy of CEUS were 100% (95% confidence Interval [CI], 1.000 to 1.000), 97.1% (95% CI, 0.914 to 1.027), 75%, 100%, and 97.3%, respectively. No statistically significant differences were found between CEUS and MRI in the detection of focal liver lesions (P=0.480), whereas both of them performed better than baseline US (P<0.001).

Conclusion

CEUS improves the detection of liver metastases in cancer patients with geographic liver fatty deposition on greyscale US.