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Bitterer F, Bauer A, Glehr G, Brunner S, Schmidt K, Schlitt HJ, Jung EM, Hackl C. Intraoperative contrast-enhanced ultrasound has an outcome-relevant impact on surgery of primary and metastatic liver lesions. Ultraschall Med 2024. [PMID: 38335990 DOI: 10.1055/a-2249-6791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
PURPOSE Complete resection of the affected tissue remains the best curative treatment option for liver-derived tumors and colorectal liver metastases. In addition to preoperative cross-sectional imaging, contrast-enhanced intraoperative ultrasound (CE-IOUS) plays a crucial role in the detection and localization of all liver lesions. However, its exact role is unclear. This study was designed to evaluate the clinical and oncological impact of using CE-IOUS in the surgical treatment of these diseases. MATERIALS AND METHODS Over the three-year study period, 206 patients with primary liver tumors and hepatic metastases were enrolled in this prospective, monocentric study to evaluate the impact of CE-IOUS in liver surgery. Secondary outcomes included comparing the sensitivity and specificity of CE-IOUS with existing preoperative imaging modalities and identifying preoperative parameters that could predict a strategic impact of CE-IOUS. In addition, the oncological significance of CE-IOUS was evaluated using a case-cohort design with a minimum follow-up of 18 months. RESULTS CE-IOUS findings led to a change in surgical strategy in 34% of cases (n=70/206). The accuracy in cases with a major change could be confirmed histopathologically in 71.4% of cases (n=25/35). The impact could not be predicted using parameters assumed to be clinically relevant. An oncological benefit of a CE-IOUS adapted surgical approach was demonstrated in patients suffering from HCC and colorectal liver metastases. CONCLUSION CE-IOUS may significantly increase R0 resection rates and should therefore be used routinely as an additional staging method, especially in complex liver surgery.
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Affiliation(s)
- Florian Bitterer
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Andreas Bauer
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Gunther Glehr
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Stefan Brunner
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Katharina Schmidt
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Hans Jürgen Schlitt
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
| | - Ernst Michael Jung
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Christina Hackl
- Department of Surgery, University Hospital Regensburg Clinic and Polyclinic for Surgery, Regensburg, Germany
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Jonsson J, Hemmingsson O, Strengbom R, Axelsson J, Riklund K, Nyström H. Does 18F-FDG PET/CT change the surgical management of potentially resectable colorectal liver metastases? Scand J Surg 2022; 111:14574969221083144. [PMID: 35348393 DOI: 10.1177/14574969221083144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE Resectability assessment of patients with colorectal liver metastases is based on computed tomography and liver magnetic resonance imaging. Addition of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography has been recommended, but the impact of the added information remains unclear. The primary aim of this study was to determine how preoperative positron emission tomography/computed tomography changed management in patients with potentially resectable colorectal liver metastases. The secondary aim was to investigate whether findings on positron emission tomography/computed tomography correlated to metastatic disease in cases with extended surgery and influenced oncological outcomes. METHODS A retrospective observational study of the impact of adding positron emission tomography/computed tomography to conventional imaging in the surgical decision-making of colorectal liver metastases. All patients with colorectal liver metastases diagnosed by conventional imaging were included and assessed by a multidisciplinary team conference at Umeå University Hospital between June 2013 and December 2017. Eligibility criteria were all patients with potentially resectable colorectal liver metastases. Patients who underwent preoperative positron emission tomography/computed tomography in addition to conventional radiology were compared with those who underwent conventional imaging only. RESULTS 151/220 patients underwent preoperative positron emission tomography/computed tomography. Findings on positron emission tomography/computed tomography changed the management in 10.6% of the patients. Eight patients were excluded from surgery after detection by positron emission tomography/computed tomography of extrahepatic disease. Eight patients underwent more extended surgery than initially planned due to positron emission tomography/computed tomography. Five of these positron emission tomography-positive resected sites were verified by pathology as metastatic disease. No difference in overall survival was seen following surgical resection in patients with and without a preoperative positron emission tomography/computed tomography. CONCLUSIONS Preoperative positron emission tomography/computed tomography resulted in a changed surgical management in 10.6% of cases in a selected cohort.
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Affiliation(s)
- Josefin Jonsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Rebecca Strengbom
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Jan Axelsson
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Katrine Riklund
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
| | - Hanna Nyström
- Umeå University Hospital Kirurgcentrum By 10A SE-901 85 Umeå Sweden.,Department of Surgical and Perioperative Sciences, Surgery Umeå University Umeå Sweden.,Wallenberg Centre for Molecular Medicine Umeå University Umeå Sweden
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Fergadi MP, Magouliotis DE, Vlychou M, Rountas C, Athanasiou T, Zacharoulis D. A meta-analysis evaluating contrast-enhanced intraoperative ultrasound (CE-IOUS) in the context of surgery for colorectal liver metastases. Abdom Radiol (NY) 2021; 46:4178-4188. [PMID: 33969446 DOI: 10.1007/s00261-021-03096-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/09/2021] [Accepted: 04/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to assess the outcomes of contrast-enhanced intraoperative ultrasound (CE-IOUS) for patients with colorectal liver metastases (CRLMs) undergoing surgery. METHOD A thorough literature search was performed in PubMed, Scopus, and Cochrane databases, in accordance with the PRISMA guidelines. The Odds Ratio, Weighted Mean Difference, and 95% Confidence Interval were evaluated, by means of Random-Effects model. RESULTS Eleven articles met the inclusion criteria and incorporated 497 patients. The present study shows that CE-IOUS is associated with higher sensitivity and accuracy compared with multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and intraoperative ultrasound (IOUS) in identifying CRLMs (p < 0.05). The positive predictive value was similar among the different modalities. Furthermore, new CRLMs were identified by CE-IOUS, thus affecting the surgical plan in 128 patients (51.8% of the patients with new CRLMs). Moreover, 91 patients (71%) underwent a more extensive hepatectomy and 15 patients (11.7%) were considered non-operable. Two alternative contrast agents, Sonazoid and Sonovue, were employed with similar sensitivity (p > 0.05). CONCLUSION These outcomes suggest the superiority of the CE-IOUS over MDCT, MRI, and IOUS for the staging of patients with CRLMs undergoing surgery. However, they should be treated with caution given the small number of the included studies.
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Affiliation(s)
- Maria P Fergadi
- Department of Radiology, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Dimitrios E Magouliotis
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, UCL, London, UK
- Department of Surgery, University of Thessaly, Biopolis, 41110, Larissa, Greece
| | - Marianna Vlychou
- Department of Radiology, University of Thessaly, Biopolis, Larissa, Greece
| | - Christos Rountas
- Department of Radiology, University of Thessaly, Biopolis, Larissa, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, W2 1NY, UK
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Werner JM, Zidek M, Kammerer S, da Silva NPB, Jung F, Schlitt HJ, Hornung M, Jung EM. Intraoperative contrast-enhanced ultrasound can have a crucial role in surgical decision-making during hepato-pancreatico-biliary surgery - Analysis of impact and input. Clin Hemorheol Microcirc 2021; 78:103-116. [PMID: 33554890 DOI: 10.3233/ch-201031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess the impact and procedural input of intraoperative ultrasound (IOUS) with contrast-enhanced ultrasound (CEUS) and ultrasound elastography on surgical decision making during the procedure and consequently the outcome after hepato-pancreatico-biliary (HPB) surgery. MATERIALS AND METHODS Data of 50 consecutive patients, who underwent HPB surgery from 04/2018 to 07/2018 were prospectively collected for this study. During surgery, IOUS with a high-resolution ultrasound device using CEUS after bolus injection of 2.4-5 ml dulphur hexafluoride microbubbles using a 6-9 MHz probe and a share wave and strain elastography was performed by an experienced examiner. Process and time analysis were carried out using mobile phone timer. RESULTS The IOUS with CEUS and elastography correctly identified 42 malignant tumors and 4 benign lesions. In 3 cases, the examination provided false positive result (identifying 3 benign lesions as malignant) and in 1 case a malignant lesion was incorrectly assessed as benign (sensitivity 97,7%, specificity 57,1%, PPV 93,3% and NPV 80%).The specific question by the surgeon could be answered successfully in 98% of the cases. In 76% of the cases, there was a modification (42%) or a fundamental change (34%) of the planned surgical approach due to the information provided by the IOUS. Within the last group, the IOUS had a major impact on therapy outcome. In 7 patients an additional tumor resection was required, in 5 patients the tumor was assessed as inoperable, and in total in 5 patients an intraoperative RFA (4/5) or postoperative RITA (1/5) was required.Regarding procedural input, there was only a slight, but significant difference between the transport and set-up times before the intraoperative use (mean: 14 min 22 s) and the return transport (mean 13 min 6 s), (p = 0,038). The average examination time was 14 minutes, which makes only one third of the overall time demand. CONCLUSION Combination of IOUS with CEUS and elastography in oncological HPB surgery provides valuable information that affects surgical decision-making. The procedural input of about 45 minutes seems to be a good investment considering the improvement of the surgical procedure and a significant modification of the therapy approach in the majority of the cases.
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Affiliation(s)
- Jens Martin Werner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Zidek
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Sylvia Kammerer
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Friedrich Jung
- Institute of Biotechnology, Molecular Cell Biology, Brandenburg University of Technology, Senftenberg, Germany
| | | | - Matthias Hornung
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Ernst-Michael Jung
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
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Russolillo N, Borello A, Langella S, Casella M, Lo Tesoriere R, Ferrero A. Comparison of laparoscopic ultrasound and liver-specific magnetic resonance imaging for staging colorectal liver metastases. Surg Endosc 2021; 35:3547-53. [PMID: 32710215 DOI: 10.1007/s00464-020-07817-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI. METHODS All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results. RESULTS Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2-10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS). CONCLUSIONS Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.
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Desolneux G, Isambert M, Mathoulin-pelissier S, Dupré A, Rivoire M, Cattena V, Palussière J, Dinart D, Bellera C, Evrard S. Contrast-enhanced intra-operative ultrasound as a clinical decision making tool during surgery for colorectal liver metastases: The ULIIS study. Eur J Surg Oncol 2019; 45:1212-8. [DOI: 10.1016/j.ejso.2019.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 02/07/2023] Open
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Ratajczak P, Serafin Z, Sławińska A, Słupski M, Leszczyński W. Improved imaging of colorectal liver metastases using single-source, fast kVp-switching, dual-energy CT: preliminary results. Pol J Radiol 2018; 83:e643-9. [PMID: 30800204 DOI: 10.5114/pjr.2018.80347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/05/2018] [Indexed: 12/03/2022] Open
Abstract
Purpose Computed tomography remains the first-choice modality for assessment of colorectal cancer liver metastases (CRLM). Dual-energy computed tomography (DECT) is a relatively new technique that is becoming increasingly available. One of the advantages of DECT is the ability to maximise iodine detection. Our aim was to test whether single-source, fast kVp-switching DECT can improve imaging quality of CRLM compared to conventional (polychromatic) CT. Material and methods Twenty consecutive patients were enrolled into a preliminary prospective study. The scanning protocol consisted of four phases: non-contrast with standard 120 kV tube voltage and three post-contrast phases with rapid voltage switching. As a result, three sets of images were reconstructed: pre- and postcontrast polychromatic (PR), monochromatic (MR), and iodine concentration map (IM). To compare the sensitivity of the tested reconstructions, the number of CRLMs and the maximum diameter of the largest lesion were calculated. Objective image quality was measured as signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). The radiation dose was expressed as CTDIvol. Results Imaging was successfully performed in all patients. The number of detected lesions was significantly lower on PR images than on IM and MR 50-70 keV (mean number: 4.20 and 4.45, respectively). IM and MR at 70 keV presented the highest quality. SNR was significantly higher for IM and 70 keV images than for other reconstructions. The mean radiation dose was 14.61 mGy for non-contrast 120 kV scan and 17.89 mGy for single DECT scan (p < 0.05). Conclusions DECT is a promising tool for CRLM imaging. IM and low-photon energy MR present the highest differences in contrast between metastases and the normal liver parenchyma.
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Granata V, Fusco R, Avallone A, Catalano O, Piccirillo M, Palaia R, Nasti G, Petrillo A, Izzo F. A radiologist's point of view in the presurgical and intraoperative setting of colorectal liver metastases. Future Oncol 2018; 14:2189-2206. [PMID: 30084273 DOI: 10.2217/fon-2018-0080] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Multidisciplinary management of patients with metastatic colorectal cancer requires in each phase an adequate choice of the most appropriate imaging modality. The first challenging step is liver lesions detection and characterization, using several imaging modality ultrasound, computed tomography, magnetic resonance and positron emission tomography. The criteria to establish the metastases resectability have been modified. Not only the lesions number and site but also the functional volume remnant after surgery and the quality of the nontumoral liver must be taken into account. Radiologists should identify the liver functional volume remnant and during liver surgical procedures should collaborate with the surgeon to identify all lesions, including those that disappeared after the therapy, using intraoperative ultrasound with or without contrast medium.
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Affiliation(s)
- Vincenza Granata
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Roberta Fusco
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Antonio Avallone
- Abdominal Oncology Division, Istitutonazionale Tumori - IRCSS - Fondazione G Pascale, Napoli, Italia
| | - Orlando Catalano
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Mauro Piccirillo
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Raffaele Palaia
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Guglielmo Nasti
- Abdominal Oncology Division, Istitutonazionale Tumori - IRCSS - Fondazione G Pascale, Napoli, Italia
| | - Antonella Petrillo
- Radiology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
| | - Francesco Izzo
- Hepatobiliary Surgical Oncology Division, Istitutonazionale Tumori - IRCCS - Fondazione G Pascale, Napoli, Italia
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Pang EHT, Chan A, Ho SG, Harris AC. Contrast-Enhanced Ultrasound of the Liver: Optimizing Technique and Clinical Applications. AJR Am J Roentgenol. 2018;210:320-332. [PMID: 29220210 DOI: 10.2214/ajr.17.17843] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this article is to review the general principles, technique, and clinical applications of contrast-enhanced ultrasound of the liver. CONCLUSION Proper technique and optimization of contrast-enhanced ultrasound require a balance between maintaining the integrity of the microbubble contrast agent and preserving the ultrasound signal. Established and emerging applications in the liver include diagnosis of focal lesions, aiding ultrasound-guided intervention, monitoring of therapy, and aiding surgical management.
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Jones A, Wilton J. Can intra-operative fluorescence play a significant role in hepatobiliary surgery? Eur J Surg Oncol 2017; 43:1622-1627. [DOI: 10.1016/j.ejso.2017.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 01/02/2023] Open
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Walker TLJ, Bamford R, Finch-Jones M. Intraoperative ultrasound for the colorectal surgeon: current trends and barriers. ANZ J Surg 2017; 87:671-676. [PMID: 28771975 DOI: 10.1111/ans.14124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 05/12/2017] [Accepted: 05/28/2017] [Indexed: 12/14/2022]
Abstract
Up to two thirds of patients diagnosed with colorectal cancer (CRC) develop colorectal liver metastases (CRLMs) and one quarter of patients present with synchronous metastases. Early detection of CRLM widens the scope of potential treatment. Surgery for CRLM offers the best chance of a cure. Current preoperative staging of CRC relies on computerized tomography and magnetic resonance imaging. Intraoperative ultrasound (IOUS) scans and contrast-enhanced IOUS (CE-IOUS) have been demonstrated to detect additional metastases not seen on routine preoperative imaging. IOUS is not widely used by colorectal surgeons during primary resection for CRC. Confident use of IOUS/CE-IOUS during primary resection of CRC may improve decision-making by providing the most sensitive form of liver staging even when compared with magnetic resonance imaging. This may be particularly important in the era of laparoscopic resections, where the colorectal surgeon loses the opportunity to palpate the liver. There are several implied barriers to the routine use of IOUS/CE-IOUS by colorectal surgeons. These include time pressure, familiarity with techniques, a perceived learning curve, cost implications and limitation of the modality due to operator variations. Inclusion of IOUS in the training of colorectal surgeons and further investigation of potential benefits of IOUS/CE-IOUS could potentially reduce these barriers, enabling usage during primary resection for CRC to become more widespread.
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Affiliation(s)
- Thomas L J Walker
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal Infirmary, University Hospitals Bristol, Bristol, UK
| | - Richard Bamford
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal Infirmary, University Hospitals Bristol, Bristol, UK
| | - Margaret Finch-Jones
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal Infirmary, University Hospitals Bristol, Bristol, UK
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Hoareau J, Venara A, Lebigot J, Hamel JF, Lermite E, Caroli-Bosc FX, Aube C. Intraoperative Contrast-Enhanced Ultrasound in Colorectal Liver Metastasis Surgery Improves the Identification and Characterization of Nodules. World J Surg 2016; 40:190-7. [PMID: 26470698 DOI: 10.1007/s00268-015-3269-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The sensitivity of preoperative assessment of colorectal liver metastases (CRLM) ranges from 74 to 80%. Intraoperative ultrasound (IOUS) associated with contrast-enhanced intraoperative ultrasound (CE-IOUS) may be able to improve this. Thus, the aims of this study were to assess the value of IOUS and CE-IOUS for the surgical approach and to determine risk factors both for the detection of new nodules and for the modification of the surgical strategy. MATERIALS AND METHODS Forty-three patients who underwent CRLM surgery were included. These patients had an MRI in the 8 weeks preceding surgery and benefited from intraoperative IOUS and CE-IOUS. RESULTS AND DISCUSSION The use of IOUS/CE-IOUS permitted the identification of 43 additional lesions and an improved characterization of nodules in 23 patients with a resulting modification of surgical strategy. Lesions were down-staged in six patients and up-staged in six patients. Chemotherapy (p = 0.02) and the presence of nodules in the left lobe (p = 0.04) were predictive factors for finding new nodules at IOUS/CE-IOUS. The discovery of a new nodule systematically modified surgical management. IOUS/CE-IOUS improved intraoperative management of liver metastases. The techniques enable pertinent modification of surgical resections and a reduction of residual lesions.
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Dervenis C, Xynos E, Sotiropoulos G, Gouvas N, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Chrysou E, Emmanouilidis C, Georgiou P, Karachaliou N, Katopodi O, Kountourakis P, Kyriazanos I, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Tekkis P, Triantopoulou C, Tzardi M, Vassiliou V, Vini L, Xynogalos S, Ziras N, Souglakos J. Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:390-416. [PMID: 27708505 PMCID: PMC5049546 DOI: 10.20524/aog.2016.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/10/2016] [Indexed: 12/12/2022] Open
Abstract
There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.
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Affiliation(s)
- Christos Dervenis
- General Surgery, "Konstantopouleio" Hospital of Athens, Greece (Christos Dervenis)
| | - Evaghelos Xynos
- General Surgery, "InterClinic" Hospital of Heraklion, Greece (Evangelos Xynos)
| | | | - Nikolaos Gouvas
- General Surgery, "METROPOLITAN" Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Ioannis Boukovinas
- Medical Oncology, "Bioclinic" of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, "Venizeleion" Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Christos Emmanouilidis
- Medical Oncology, "Interbalkan" Medical Center, Thessaloniki, Greece (Christos Emmanoulidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institut, Barcelona, Spain (Niki Carachaliou)
| | - Ourania Katopodi
- Medical Oncology, "Iaso" General Hospital, Athens, Greece (Ourania Katopoidi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - Ioannis Kyriazanos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, "Ippokrateion" Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, "Theageneion" Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, "Agioi Anargyroi" Hospital of Athens, Greece (Joseph Sgouros)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | | | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Louiza Vini
- Radiation Oncology, "Iatriko" Center of Athens, Greece (Lousa Vini)
| | - Spyridon Xynogalos
- Medical Oncology, "George Gennimatas" General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Nikolaos Ziras
- Medical Oncology, "Metaxas" Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Postlewait LM, Maithel SK. Current Status of Imaging to Evaluate Liver Metastases From Colorectal Cancer. Curr Colorectal Cancer Rep 2015; 11:168-177. [DOI: 10.1007/s11888-015-0272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Labori KJ, Schulz A, Drolsum A, Guren MG, Kløw NE, Bjørnbeth BA. Radiofrequency ablation of unresectable colorectal liver metastases: trends in management and outcome during a decade at a single center. Acta Radiol Open 2015; 4:2058460115580877. [PMID: 26346740 PMCID: PMC4548748 DOI: 10.1177/2058460115580877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 03/17/2015] [Indexed: 01/10/2023] Open
Abstract
Background Radiofrequency ablation (RFA) is widely used for treatment of colorectal liver metastases (CRLM). Purpose To evaluate the effect of increased experience in RFA of CRLM on morbidity and survival, and the trends in patient management and outcomes during the last decade. Material and Methods Hospital records of the initial 52 consecutive patients who underwent RFA (56 procedures/70 lesions) were retrospectively reviewed. The patients were divided into two groups according to time period of treatment, period I (2001–2006: n = 26) and period II (2007–2011: n = 26). Results Concomitant liver resection was performed in 15 patients in each period. Operative morbidity decreased from 47% to 19% (P = 0.047). Most complications were found in patients who underwent a concomitant liver resection and not related to the ablation per se. Local recurrence rate decreased from 19.4% to 12.9% (P = 0.526). At least one risk factor for recurrence was found in patients with local recurrence (n = 11): subcapsular localization (n = 4), tumor size >3 cm and subcapsular localization (n = 2), and perivascular localization (portal veins/hepatic veins) (n = 5). Median overall survival was 32 months in period I and 49 months in period II, whereas estimated 5-year survival was 19% and 36%, respectively (P = 0.09). Adjuvant chemotherapy was given to four patients (15.4%) in period I and 13 patients (50%) in period II (P = 0.017). Conclusion RFA alone or in combination with liver resection is a potentially curative treatment to selected patients with CRLM. Over time, the morbidity and survival have improved in RFA of CRLM. Although a possible effect of a learning curve should be taken into consideration in the appraisal of this improvement, it is more likely to be attributable to optimization of indication, development in surgical techniques, and increased use of perioperative chemotherapy.
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Affiliation(s)
- Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology, Oslo University Hospital, Oslo, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anders Drolsum
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | | | - Nils Einar Kløw
- Department of Radiology, Oslo University Hospital, Oslo, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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Hoch G, Croise-Laurent V, Germain A, Brunaud L, Bresler L, Ayav A. Is intraoperative ultrasound still useful for the detection of colorectal cancer liver metastases? HPB (Oxford) 2015; 17:514-9. [PMID: 25728974 PMCID: PMC4430782 DOI: 10.1111/hpb.12393] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Debate on the optimal mode of preoperative imaging in the management of colorectal liver metastases (CRLM) is ongoing and, despite its longstanding use, the precise role of intraoperative ultrasonography (IOUS) is not well established. This study evaluates the impact of IOUS in the era of high-quality, cross-sectional imaging techniques. METHODS All patients who underwent liver resection for CRLM in a tertiary care referral centre from January 2006 to December 2013 were included. All patients were submitted to computed tomography (CT) and/or liver magnetic resonance imaging (MRI) before surgery. Intraoperative US was performed mainly to detect previously non-diagnosed tumours that would change the surgical strategy. RESULTS A total of 225 liver resections were performed. Liver MRI and CT scans were available for 202 patients (89.8%) and 225 patients (100%), respectively. Radiological reports recorded 632 liver tumours in 219 patients (i.e. 2.9 lesions per patient). The median time between preoperative liver MRI and surgical resection was 36 days. Intraoperative inspection, palpation and US found 20 additional lesions in 18 patients (8.0%), in three of whom lesions were diagnosed only on IOUS (1.4%). Overall, only 12 of the 20 lesions were malignant. CONCLUSIONS Although CT and liver MRI are commonly used, IOUS alone allows the discovery of a few additional lesions that result in a change of surgical strategy in 1.4% of cases.
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Affiliation(s)
- Guillaume Hoch
- Department of Hepatopancreatobiliary Surgery, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France
| | - Valérie Croise-Laurent
- Department of Radiology, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France
| | - Adeline Germain
- Department of Hepatopancreatobiliary Surgery, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France
| | - Laurent Brunaud
- Department of Hepatopancreatobiliary Surgery, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France
| | - Laurent Bresler
- Department of Hepatopancreatobiliary Surgery, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France
| | - Ahmet Ayav
- Department of Hepatopancreatobiliary Surgery, Nancy-Brabois Hospital, Faculty of Medicine, University of NancyNancy, France,Correspondence Ahmet Ayav, Department of Hepatopancreatobiliary Surgery, Hôpitaux de Brabois, Allées du Morvan, 54505 Vandoeuvre-les-Nancy, France. Tel: + 33 3 83 15 31 20. Fax: + 33 3 83 15 31 19. E-mail:
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Schulz A, Godt JC, Dormagen JB, Holtedahl JE, Bogsrud TV, Labori KJ, Kløw NE, Bach-Gansmo T. Respiratory gated PET/CT of the liver: A novel method and its impact on the detection of colorectal liver metastases. Eur J Radiol 2015; 84:1424-1431. [PMID: 26044293 DOI: 10.1016/j.ejrad.2015.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/05/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of a new method for respiratory gated positron emission tomography (rgPET/CT) for colorectal liver metastases (CRLM), secondly, to assess its additional value to standard PET/CT (PET/CT). MATERIALS AND METHODS Forty-three patients scheduled for resection of suspected CRLM were prospectively included from September 2011 to January 2013. None of the patients had previously undergone treatment for their CRLM. All patients underwent PET/CT and rgPET/CT in the same session. For rgPET/CT an in-house developed electronic circuit was used which displayed a color-coded countdown for the patient. The patients held their breath according to the countdown and only the data from the inspiration breath-hold period was used for image reconstruction. Two independent and blinded readers evaluated both PET/CT and rgPET/CT separately. The reference standard was histopathological confirmation for 73 out of 131 CRLM and follow-up otherwise. RESULTS Reference standard identified 131 CRLM in 39/43 patients. Nine patients accounted for 25 mucinous CRLM. The overall per-lesion sensitivity for detection of CRLM was for PET/CT 60.0%, for rgPET/CT 63.1%, and for standard+rgPET/CT 67.7%, respectively. Standard+rgPET/CT was overall significantly more sensitive for CRLM compared to PET/CT (p=0.002) and rgPET/CT (p=0.031). The overall positive predictive value (PPV) for detection of CRLM was for PET/CT 97.5%, for rgPET/CT 95.3%, and for standard+rgPET/CT 93.6%, respectively. CONCLUSION Combination of PET/CT and rgPET/CT improved the sensitivity significantly for CRLM. However, high patient compliance is mandatory to achieve optimal performance and further improvements are needed to overcome these limitations. The diagnostic performance of the evaluated new method for rgPET/CT was comparable to earlier reported technically more complex and expensive methods.
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Affiliation(s)
- Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway.
| | - Johannes Clemens Godt
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway.
| | - Johann Baptist Dormagen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway.
| | - Jon Erik Holtedahl
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
| | - Trond Velde Bogsrud
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway; Department of Nuclear Medicine and PET-Center, Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus C, Denmark.
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
| | - Nils-Einar Kløw
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway.
| | - Tore Bach-Gansmo
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Postboks Pb 4956 Nydalen, 0424 Oslo, Norway.
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Joo I. The role of intraoperative ultrasonography in the diagnosis and management of focal hepatic lesions. Ultrasonography 2015; 34:246-57. [PMID: 25971896 PMCID: PMC4603208 DOI: 10.14366/usg.15014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/06/2015] [Accepted: 04/06/2015] [Indexed: 12/12/2022] Open
Abstract
Intraoperative ultrasonography (IOUS) has been widely utilized in hepatic surgery both as a diagnostic technique and in the course of treatment. Since IOUS involves direct-contact imaging of the target organ, it can provide high spatial resolution without interference from the surrounding structures. Therefore, IOUS may improve the detection, characterization, localization, and local staging of hepatic tumors. IOUS is also a real-time imaging modality capable of providing interactive information and valuable guidance in a range of procedures. Recently, contrast-enhanced IOUS, IOUS elastography, and IOUS-guided hepatic surgery have attracted increasing interest and are expected to lead to the broader implementation of IOUS. Herein, we review the various applications of IOUS in the diagnosis and management of focal hepatic lesions.
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Affiliation(s)
- Ijin Joo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Samim M, El-Haddad GE, Molenaar IQ, Prevoo W, van den Bosch MA, Alavi A, Lam MG. [18F]Fluorodeoxyglucose PET for Interventional Oncology in Liver Malignancy. PET Clin 2014; 9:469-95, vi. [PMID: 26050948 DOI: 10.1016/j.cpet.2014.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
[(18)F]Fluorodeoxyglucose (FDG) PET is a functional imaging tool that provides metabolic information, which has the potential to detect a lesion before it becomes anatomically apparent. This ability constitutes a strong argument for using FDG-PET/computed tomography (CT) in the management of oncology patients. Many studies have investigated the accuracy of FDG-PET or FDG-PET/CT for these purposes, but with small sample sizes based on retrospective cohorts. This article provides an overview of the role of FDG-PET or FDG-PET/CT in patients with liver malignancies treated by means of surgical resection, ablative therapy, chemoembolization, radioembolization, and brachytherapy, all being liver-directed oncologic interventions.
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Sahani DV, Bajwa MA, Andrabi Y, Bajpai S, Cusack JC. Current status of imaging and emerging techniques to evaluate liver metastases from colorectal carcinoma. Ann Surg. 2014;259:861-872. [PMID: 24509207 DOI: 10.1097/sla.0000000000000525] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. Liver is a common site of tumor spread and in approximately 30% of the cases; synchronous liver disease is present at the time of diagnosis. Early detection of liver metastases is crucial to appropriately select patients who may benefit from hepatic resection among those needing chemotherapy, to improve 5-year survival. Advances in imaging techniques have contributed greatly to the management of these patients. Multidetector computed tomography is the most useful test for initial staging and in posttreatment surveillance settings. Magnetic resonance imaging is considered superior to multidetector computed tomography and positron emission tomography for the detection and characterization of small lesions and for liver evaluation in the presence of background fatty liver changes. Positron emission tomography-computed tomography has a problem-solving role in the detection of distant metastasis and in posttreatment evaluation. The advanced imaging methods also serve a role in selecting appropriate patients for radiologically targeted therapies and in monitoring response to conventional and novel therapies.
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Brudvik KW, Bains SJ, Seeberg LT, Labori KJ, Waage A, Taskén K, Aandahl EM, Bjørnbeth BA. Aggressive treatment of patients with metastatic colorectal cancer increases survival: a scandinavian single-center experience. HPB Surg 2013; 2013:727095. [PMID: 23840074 DOI: 10.1155/2013/727095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 04/22/2013] [Accepted: 05/20/2013] [Indexed: 12/21/2022]
Abstract
Background. We examined overall and disease-free survivals in a cohort of patients subjected to resection of liver metastasis from colorectal cancer (CRLM) in a 10-year period when new treatment strategies were implemented. Methods. Data from 239 consecutive patients selected for liver resection of CRLM during the period from 2002 to 2011 at a single center were used to estimate overall and disease-free survival. The results were assessed against new treatment strategies and established risk factors. Results. The 5-year cumulative overall and disease-free survivals were 46 and 24%. The overall survival was the same after reresection, independently of the number of prior resections and irrespectively of the location of the recurrent disease. The time intervals between each recurrence were similar (11 ± 1 months). Patients with high tumor load given neoadjuvant chemotherapy had comparable survival to those with less extensive disease without neoadjuvant chemotherapy. Positive resection margin or resectable extrahepatic disease did not affect overall survival. Conclusion. Our data support that one still, and perhaps to an even greater extent, should seek an aggressive therapeutic strategy to achieve resectable status for recurrent hepatic and extrahepatic metastases. The data should be viewed in the context of recent advances in the understanding of cancer biology and the metastatic process.
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Song ZZ, Zhang F, Hou CJ, Wang J. Contrast-enhanced intraoperative ultrasound. Acta Radiol 2013; 54:533. [PMID: 24879879 DOI: 10.1177/0284185113485502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ze-Zhou Song
- Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Fan Zhang
- Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Chun-Jie Hou
- Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Jing Wang
- Department of Ultrasound, Zhejiang Provincial People's Hospital, Hangzhou, China
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