Evaluation of Malignant Liver Tumors: Biphasic MS-CT versus Quantitative Contrast Harmonic Imaging Ultrasound

Computed tomography for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease

BACKGROUND

Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and fourth in terms of cancer deaths. In clinical practice, computed tomography (CT) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-foetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study CT or magnetic resonance imaging (MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is valid to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma is, therefore, missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of CT may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CT in people with chronic liver disease, who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma.

OBJECTIVES

Primary: to assess the diagnostic accuracy of multidetector, multiphasic contrast-enhanced CT for the diagnosis of hepatocellular carcinoma of any size and at any stage in adults with chronic liver disease, either in a surveillance programme or in a clinical setting. Secondary: to assess the diagnostic accuracy of CT for the diagnosis of resectable hepatocellular carcinoma in adults with chronic liver disease.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Trials Register, Cochrane Hepato-Biliary Diagnostic-Test-Accuracy Studies Register, the Cochrane Library, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science until 4 May 2021. We applied no language or document-type restrictions.

SELECTION CRITERIA

Studies assessing the diagnostic accuracy of CT for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver and histology of resected or biopsied focal liver lesion with at least a six-month follow-up.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened studies, extracted data, and assessed the risk of bias and applicability concerns, using the QUADAS-2 checklist. We presented the results of sensitivity and specificity, using paired forest plots, and tabulated the results. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs). We double-checked all data extractions and analyses.

MAIN RESULTS

We included 21 studies, with a total of 3101 participants. We judged all studies to be at high risk of bias in at least one domain because most studies used different reference standards, often inappropriate to exclude the presence of the target condition, and the time-interval between the index test and the reference standard was rarely defined. Regarding applicability in the patient selection domain, we judged 14% (3/21) of studies to be at low concern and 86% (18/21) of studies to be at high concern owing to characteristics of the participants who were on waiting lists for orthotopic liver transplantation. CT for hepatocellular carcinoma of any size and stage: sensitivity 77.5% (95% CI 70.9% to 82.9%) and specificity 91.3% (95% CI 86.5% to 94.5%) (21 studies, 3101 participants; low-certainty evidence). CT for resectable hepatocellular carcinoma: sensitivity 71.4% (95% CI 60.3% to 80.4%) and specificity 92.0% (95% CI 86.3% to 95.5%) (10 studies, 1854 participants; low-certainty evidence). In the three studies at low concern for applicability (861 participants), we found sensitivity 76.9% (95% CI 50.8% to 91.5%) and specificity 89.2% (95% CI 57.0% to 98.1%). The observed heterogeneity in the results remains mostly unexplained. The sensitivity analyses, which included only studies with clearly prespecified positivity criteria and only studies in which the reference standard results were interpreted without knowledge of the results of the index test, showed no variation in the results.

AUTHORS' CONCLUSIONS

In the clinical pathway for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, CT has roles as a confirmatory test for hepatocellular carcinoma lesions, and for staging assessment. We found that using CT in detecting hepatocellular carcinoma of any size and stage, 22.5% of people with hepatocellular carcinoma would be missed, and 8.7% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 28.6% of people with resectable hepatocellular carcinoma would improperly not be resected, while 8% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.

Diagnostic Value of CEUS Prompting Liver Biopsy: Histopathological Correlation of Hepatic Lesions with Ambiguous Imaging Characteristics

Background: Contrast-enhanced ultrasound (CEUS) allows for dynamic analysis of vascularization patterns of unclear hepatic lesions. Our study aimed to evaluate the diagnostic performance of CEUS for further characterizing suspicious liver lesions by comparing findings from CEUS examinations with corresponding histopathology. Methods: Between 2005 and 2016, 160 patients with unclear liver lesions underwent CEUS followed by liver biopsy. All examinations were performed by an experienced consultant radiologist (EFSUMB Level 3) and included native B-mode ultrasound, Color Doppler, and CEUS. A second-generation blood pool contrast agent was applied for CEUS. Results: CEUS was successfully performed in all patients without occurrence of any adverse side effects. CEUS showed a sensitivity of 94.5%, a specificity of 70.6%, a true positive rate of 87.3%, and a true negative rate of 85.7% compared to histopathological results as the reference standard. Conclusions: CEUS represents a safe imaging modality with a high diagnostic accuracy in assessing both—benign and malignant—liver lesions compared to corresponding histopathological results.

Prospective evaluation of 4-D contrast-enhanced-ultrasound (CEUS) imaging in bladder tumors

PURPOSE

The evaluation of the potential clinical benefit of four-dimensional ultrasound (4D-US) in the assessment of bladder cancer (BC).

MATERIAL AND METHODS

20 patients with indication for cystoscopy for suspicion of bladder cancer were prospectively included in this study. All patients underwent two-dimensional ultrasound (2D-US), contrast enhanced ultrasound (CEUS) and real-time four-dimensional ultrasound (4D-US). All acquisitions were compared to each other in regard to image quality. This assessment was done using a 6 point scale (1 = best). All patients underwent subsequently cystoscopy with resection of the tumor (TURB), due a histopathological analysis was possible.

RESULTS

All examinations were performed successfully and no patient had to be excluded from the study. Patients acceptance of 4D-US was consistently good. No adverse events occurred. Image quality of real time 4D-US (score: 1.27±0.46) was significantly superior (p < 0.001) to both, conventional 2D-US (score: 2.33±0.62) and also to 2D-CEUS (score: 2.00±0.53). In terms of tumor detection no superiority was evident for 4D-US compared to 2D-US or in utilization of CEUS (sensitivity = 0.89; specificity = 1.00; positive predictive value = 1.00; negative predictive value = 0.50; AUC = 0.944; (95% CI: 07.43-0.998)).

CONCLUSION

The assessment of bladder cancer using real time 4D-US is feasible and improves the image quality and therefore also the precise anatomical consistency of intravesical tumor masses.

Sublingual Nodules: Diagnostic Markers of Metastatic Breast Cancer

OBJECTIVE

To evaluate the diagnostic significance of sublingual nodules for metastasis of patients with breast cancer and further to explore the mechanisms of sublingual nodules.

METHODS

The image data of 117 in-patients with breast cancer in stage I-IV in Tianjin Medical University Cancer Institute and Hospital from December 2009 to September 2011 were assessed retrospectively. All photos of patients' tongue were recorded by the digital camera of uniform type within 1 month after serological examination and regular re-examined by computed tomography (CT), magnetic resonance imaging and positron emission tomography CT. The presence of sublingual nodules was the positive standard. Chi square test and two-independent-sample test were used to determine the diagnostic value between the status of sublingual nodules and Clinico-pathological characteristics. The optimal cut-off of uric acid (UA) level to diagnose sublingual nodules was determined by receiver operating curve (ROC) analysis.

RESULTS

Breast cancer patients with sublingual nodules had a higher risk of recurrence and/or metastasis than patients without it (P<0.001). Sublingual nodules was significantly correlated with increased serum UA level (P=0.001). The optimal cut-off value of UA level to diagnose sublingual nodules was 290 μmol/L. Furthermore, the elevated serum UA level (≥290 μmol/L) was significantly related to breast cancer recurrence and/or metastasis (P<0.001).

CONCLUSIONS

Sublingual nodules were potential diagnostic markers for metastatic breast cancer. The formation of sublingual nodules was associated with elevated level of serum UA.

[Contrast-enhanced ultrasound (CEUS) of the liver : Critical evaluation of use in clinical routine diagnostics]

CLINICAL/METHODICAL ISSUE

Focal liver lesions are common incidental findings in abdominal ultrasound diagnostics.

STANDARD RADIOLOGICAL METHODS

Characterization of focal liver lesions solely based on b‑mode and color duplex is not feasible in all cases.

METHODICAL INNOVATIONS

Using contrast-enhanced ultrasound (CEUS) it is possible to dynamically visualize the vascularization of focal liver lesions, which enables the characterization of benign and malignant liver tumors. The advantages of CEUS are that ultrasound contrast media do not show renal, hepatic or cardiac toxicity and do not influence the thyroid gland. The approach by fusion of CEUS and contrast-enhanced cross-sectional imaging combines the advantages of both imaging modalities.

PERFORMANCE

Using CEUS focal liver lesions can be characterized with a diagnostic accuracy greater than 90%.

ACHIEVEMENTS

The use of CEUS has become an important imaging modality to evaluate unclear liver lesions.

PRACTICAL RECOMMENDATIONS

The use of CEUS provides vital information as a supplement to cross-sectional imaging and it has become an important tool in therapy planning, control and monitoring of malignant liver lesions.

Contrast-enhanced ultrasound (CEUS) prediction of focal liver lesions in patients after liver transplantation in comparison to histopathology results

PURPOSE

To investigate the value of contrast-enhanced ultrasound (CEUS) in histologic prediction of focal liver lesions after liver transplantation.

MATERIALS AND METHODS

10 focal liver lesions in 10 patients after liver transplantation were scanned using CEUS and the CEUS results were compared with the histopathological results.

RESULTS

Among 10 focal liver lesions, 7 proofed to be histopathological benign and 3 lesions proofed to be histopathological malignant. All lesions (100%) were correctly report as benign or malignant in the report of the CEUS examination.

CONCLUSION

CEUS can be helpful in the differentiation of benign and malignant focal liver lesions in patients after liver transplantation and can be used in clinical management of focal liver lesions.

Regional Contrast-Enhanced Ultrasonography (CEUS) Characteristics of Breast Cancer and Correlation with Microvessel Density (MVD)

Background

The aim of this study was to investigate the perfusion characteristics of different breast lesion regions in contrast-enhanced ultrasonography (CEUS).

Material/Methods

A total of 161 malignant and benign breast lesion cases were subjected to CEUS. Perfusion parameters were analyzed and compared between the central and peripheral lesion regions, and surrounding tissue. Mass section was marked with methylene blue. Samples were subjected to immunohistochemistry, and microvessel density (MVD) was calculated.

Results

There were significant differences in perfusion performance between the central and peripheral lesion regions, and surrounding tissue. In the malignant tumors, the fast-in and fast-out pattern was the most common type in the peripheral region (57.98%), while the slow-in and slow-out patterns were the major types in the central region and surrounding tissue (49.58% and 57.98%, respectively). Compared with the surrounding tissue, the peripheral region in the cancers exhibited hyperechoic enhancement and fast-in and slow-out pattern, with large area under the curve (AUC), while the central region showed isoechoic enhancement and equally-in and slow-out pattern, with large AUC. In the benign lesions, the peripheral region exhibited hyperechoic enhancement and fast-in and fast-out pattern, with small AUC, while the central region showed isoechoic enhancement and equally-in and -out pattern, with the same AUC value. Moreover, the perfusion parameters in the central and peripheral regions were significantly associated with MVD.

Conclusions

It is more objective to evaluate the perfusion performance of breast lesions with the reference of surrounding tissue. Compared with the central region, the peripheral region could better reflect the perfusion characteristics of malignant lesions.

Malignancies after liver transplantation: Value of contrast-enhanced ultrasound (CEUS)

PURPOSE

To evaluate the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) and computed tomography (CT) in the diagnosis of malignancies after liver transplantation.

MATERIALS AND METHODS

A total of 23 patients with suspicious liver masses after liver transplantation with initial imaging series between September 2006 and September 2015 were statistically analysed. CEUS and CT were compared in their diagnosis of malignancy with CT being the gold standard. Out of 23 patients 9 patients showed malignant masses in CT, which could also be detected in 7 out 9 of cases using CEUS.

RESULTS

CEUS showed a sensitivity of 77.8%, a specificity of 100.0%, a positive predictive value (PPV) of 100.0% and a negative predictive value (NPV) of 87,5% in comparison with CT being the gold standard. In 2 cases CT showed a malignancy, contrary to the CEUS examination that was reported as normal.

CONCLUSION

CEUS seems to be an alternative option for the evaluation of malignant masses in liver transplant patients. CEUS shows a high specificity and PPV in the detection of malignant liver masses.

Comparison of contrast-enhanced ultrasonography with grey-scale ultrasonography and contrast-enhanced computed tomography in diagnosing focal fatty liver infiltrations and focal fatty sparing

PURPOSE

Fatty liver infiltrations and fatty sparing impair diagnostic performance of grey-scale ultrasonography in differentiating malignant and benign focal liver lesions. In the study, we present our experience in diagnosing focal fatty liver infiltrations and focal fatty sparing with contrastenhanced ultrasonography (CEUS) in comparison to grey-scale ultrasonography and contrast-enhanced computed tomography (CECT).

MATERIAL AND METHOD

The retrospective study group (n=82 patients), included 44 (53.7%) men, 38 (46.3%) women (aged 29- 81 years, mean 55.8 years) with 48 focal fatty liver infiltrations and 34 focal fatty sparing. All patients underwent grey-scale ultrasonography (US), CEUS using SonoVue® and CECT executed within the 7 days.

RESULTS

With US, CEUS and CECT focal fatty liver infiltrations were diagnosed in 22, 46 and 44 cases, respectively. The following values were obtained: sensitivity - 45.8%, 95.8% and 91.7%, specificity - 100% for all, accuracy - 95.2%, 99.6% and 99.3%, respectively. Focal fatty sparing was diagnosed in 16, 31 and 30 cases, respectively. The following values were obtained: sensitivity - 47.1%, 91.2% and 88.2%, specificity - 99.8%, 100% and 100%, accuracy - 95.6%, 99.4% and 99.3%, respectively. No statistically significant differences were found in sensitivity of diagnosing focal fatty liver infiltrations and focal fatty liver sparing between CEUS and CECT. Sensitivity of grey-scale ultrasonography was significantly lower when compared to those of CEUS and CECT (p<0.001).

CONCLUSION

CEUS is as sensitive as CECT in focal fatty infiltrations and focal fatty sparing diagnosing. However, CEUS provides more information than CECT about the vasculature and enhancement pattern of focal fatty liver infiltrations.

Serological diagnosis of liver metastasis in patients with breast cancer

Objective

To diagnose and explore the serological diagnostic factors for liver metastasis in patients with breast cancer before symptoms occur.

Methods

A total of 430 female in-patients with breast cancer of stages 0 to IIIC who came to Tianjin Medical University Cancer Institute and Hospital from January 2003 to January 2004 were studied and followed up until May 2011. Serum levels of biochemical markers for tumor and liver were measured at the time of diagnosis.

Results

Liver metastasis was more likely to occur in patients with stage III cancer or c-erbB-2-positive expression. Alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase (GGT), alkaline phosphatase, lactate dehydrogenase (LDH), and carbohydrate antigen 153 (CA153) levels were significantly higher in patients with liver metastasis than those without liver metastasis. Diagnostic indices of LDH, GGT, and CA153 were 174 U/L, 32 U/L, and 26.48 µg/L, respectively. The areas under the curves of LDH, GGT, and CEA were 0.795, 0.784, and 0.661, respectively, and sensitivities of parallel tests for LDH and CA153 and for GGT and CA153 were 88.6% and 85.7%, respectively. The specificity of serial tests for both pairs of enzymes was 97.7%.

Conclusions

The sensitivity and specificity of combined tumor and biochemical markers could be used as indicators during screening for breast-liver metastasis.

[Contrast-enhanced sonography. Therapy control of radiofrequency ablation and transarterial chemoembolization of hepatocellular carcinoma]

Due to the imaging of dynamic perfusion, hepatocellular carcinoma can be detected with a sensitivity of >90% using contrast-enhanced sonography. The characterization of liver tumors with contrast-enhanced sonography is comparable to the diagnostic accuracy of contrast-enhanced computed tomography. The dynamic detection of microvascularization with contrast-enhanced sonography allows the differentiation between vascularized tumors and non-vascularized necrotic lesions before, during and after transarterial chemoembolization or percutaneous radiofrequency ablation. Image fusion with volume navigation can be useful in the followup control.

[Summary of technical principles of contrast sonography and future perspectives]

Ultrasound contrast agents have considerably expanded the range of ultrasound diagnostics. Up to date ultrasound machines with contrast-specific software allow the selective demonstration and quantification of contrast agents in real-time based on the specific signal signature of oscillating contrast agent microbubbles. After intravenous injection the microbubbles are transported with the bloodstream and distributed purely intravascularly. This allows an artefact-free representation of the vascular architecture and delineation of the vascular lumen, independent of blood flow velocity and with high spatial resolution. Traumatic lesions and active bleeding can be detected with high sensitivity. Blood volume in vessels and organs can be assessed qualitatively and quantitatively. The possibility of short-term destruction of microbubbles within the ultrasound field allows the measurement of blood flow velocity during replenishment and based on that the assessment of perfusion in parenchymal tissue. Target-specific microbubbles for imaging of molecular surface structures as well as drug-loaded microbubbles for local ultrasound-mediated therapy are under development.

First indicators of relapse in breast cancer: evaluation of the follow-up program at our hospital

BACKGROUND

Guidelines for breast cancer patient follow-up have not been widely adopted in Japan. To assess our intensive follow-up program, we evaluated first relapse and its indicators in patients with breast cancer.

PATIENTS

Of 964 patients, 126 relapsed and 43 died in the median follow-up term of 45 months. Follow-ups were scheduled every 6-12 months for imaging and tumor marker (TM) evaluation.

RESULTS

Of 126 relapsed patients, 30 (23.8%) had symptoms of relapse. First indicators of relapse in 96 asymptomatic patients were physical examination in 24 patients (19%); imaging, 57 patients (45.3%); and TMs, 15 patients (11.9%). The most sensitive indicators were physical examination for local relapse, ultrasonography for regional lymph nodes, scintigraphy for bone, computed tomography for lung, and TMs for liver metastasis. During intensive follow-up, 43% of relapsed patients were identified by symptoms or physical examination. These patients had poor prognosis compare to patients identified by imaging or TMs in overall survival and post-relapse survival (p = 0.009 and 0.019, respectively). In all 964 patients, the relapse rates for stage I, IIA, IIB, and III tumors were 7.4, 7.9, 19.9, and 43.5%, respectively. The percentage of first relapse detected by imaging or TMs for stage I, IIA, IIB, and III were 4.7, 5.1, 11.8, and 19.8%, respectively. The cost of our follow-up program for 10 years was approximately 290,000 yen per patient.

CONCLUSION

A routine intensive follow-up program involving imaging and evaluation of TMs in all patients has low efficacy and high expenditure.

[Latest developments in ultrasound of the liver]

Abdominal ultrasound (US) is often the first-line imaging modality used to assess focal liver lesions. Due to various new gray-scaled US techniques, such as tissue harmonic imaging (THI), spatial compounding technique and speckle reduction technique, as well as contrast-enhanced techniques, abdominal ultrasound nowadays has great potential regarding detection and characterization of focal liver lesions. Furthermore, image fusion with computed tomography (CT), magnetic resonance imaging (MRI) and 3D ultrasound will most likely help to improve clinical management before and after interventional procedures. This article illustrates the principles and clinical impact of recently developed techniques in the field of ultrasound.

Screening for liver metastases in women with mammary carcinoma: comparison of contrast-enhanced ultrasound and magnetic resonance imaging

OBJECTIVE

The objective of the present study was to compare conventional B-mode ultrasound (BMU), contrast-enhanced ultrasound (CEUS), and magnetic resonance imaging (MRI) in the detection of liver metastases at the primary staging and follow-up of women with histologically confirmed mammary carcinoma.

PATIENTS AND METHODS

Included in the study were 55 women (aged 57.5 ± 11.0 years, range 27-75 years; mean disease duration 57.5 months, range 5-168 months); of these, 17 women were examined as part of primary staging (staging group) and 38 women at follow-up (follow-up group). All patients underwent BMU (Philips HDI 5000), CEUS (Philips HDI 5000; 4.8 ml SonoVue), and MRI (Siemens Avanto 1.5 T) of the liver.

RESULTS

In the staging group (n = 17), a mass was detected by BMU in 24% (n = 4), by CEUS in 29% (n = 5), and by MRI in 47% (n = 8); masses suspicious for malignancy were identified in 6% of patients with BMU and in 12% each by CEUS and MRI. Malignancy was not confirmed in any case by cytology or surgery. In the follow-up group (n = 38), masses were identified by MRI in 53% of patients with suspicion of malignancy in 18%. Malignancy was confirmed in 16% of cases identified at MRI, in 13% of cases identified with CEUS, and in 11% of cases identified with BMU. The Pearson coefficients of correlation were r = .29 (P = .03) for MRI vs. BMU; r = .42 (P = .002) for MRI vs. CEUS; and r = .75 (P ≤ .001) for BMU vs. CEUS. With respect to malignancy, the Pearson coefficients of correlation were r = .40 (P = .099) for BMU vs. MRI and r = .71 (P = .0009) for CEUS vs. MRI.

CONCLUSIONS

Beginning in tumor stage III, the use of CEUS and MRI is associated with a significantly greater benefit in the detection of malignant tumors of the liver compared with conventional BMU. BMU appears to be adequate for primary staging and the follow-up of lower tumor stages.

Contrast-enhanced ultrasound for surveillance of choroidal carcinoma patients: features of liver metastasis arising several years after treatment of the primary tumor

Choroidal carcinoma is an insidious tumor frequently causing late liver metastases which are associated with a poor outcome. Since metastatic liver lesions are potentially resectable with curative intention, tight follow-up schedules after treatment of primary tumors for the early detection of liver metastasis have been proposed. The methods employed so far, however, have proven to be of limited sensitivity, and it is likely that a combined approach comprising the use of both imaging techniques and biohumoral markers will, in the future, improve the sensitivity of methods aiming at detecting liver metastasis early. Contrast-enhanced ultrasound (CEUS) is increasingly used in the clinic due to its advantage over conventional sonography for the early detection of tumor lesions and thus represents a promising accurate and cost-effective diagnostic tool. Its use for the early diagnosis of metastatic choroidal cancer has never been proposed before in the literature. Here, we describe for the first time the CEUS features of a large liver metastasis originating from choroidal cancer occurring 13 years after diagnosis in comparison to PET-CT, MRI and conventional sonography. Furthermore, we propose CEUS as a routine follow-up method for the early detection of liver metastasis of patients affected by choroidal carcinoma.