1. Journal Reading
Intern 陳盈元

2. Differential Diagnosis of Hepatic Tumor by Using Contrast Enhancement Patterns at US
Radiology 2003; 229:
Tetsuo Isozaki, MD, Kazushi Numata, MD, Takayoshi Kiba, MD, Koji Hara, MD, Manabu Morimoto, MD, Takashi Sakaguchi, MD, Hisahiko Sekihara, MD, Toru Kubota, MD, Hiroshi Shimada, MD, Toshio Morizane, MD, Katsuaki Tanaka, MD

3. Introduction Color Doppler US Contrast medium
Noninvasive method of evaluating the hemodynamic characteristics of hepatic tumors
Differentiating between malignant and benign tumors
Deep organ in the abdomen and motion artifacts
Contrast medium
Microbubbles confined to intravascular space
Increase the reflectivity and enhancement
Color blooming and oversaturation

4. Introduction Harmonic US imaging
Contrast-enhanced phase-inverted wideband harmonic gray-scale US
Detection of microbubbles with a high level of sensitivity
Numata et al. (Am J Roentgenol 1993; 160: )
Contrast-enhanced phase-inverted wideband harmonic gray-scale US with SH U 508A
HCC
Presence of intratumoral vessels in the arterial phase
Homogeneous or heterogeneous enhancement in the portal phase

5. Introduction
Purpose
Assess the accuracy of using a classification based on patterns of enhancement on wideband harmonic gray-scale US images in the differential diagnosis of hepatic tumors

6. Materials and Methods Nov. 1999~Oct. 2001
Yokohama City University School of Medicine and its medical center
189 patients
Suspect HCC
Angiography
Dual-phase helical CT
Contrast-enhanced harmonic US
Exclude 6 patients: 10cm beneath the skin
183 patients
Solitary nodule: 138 Multiple nodules: 45
M: 121 (65.3 Y  9.8) F: 62 (64.0 Y  9.9)
183 lesions

7. Materials and Methods 107 cirrhosis 183 lesions 116 HCC 42 metastasis
25 hemangioma
Histologic examination: 4 surgical resection 151 US-guided biopsy 3 autopsy
10 colon cancer 9 pancreatic cancer 5 gastric cancer 4 ovarian cancer 2 malignant melanoma 2 esophageal cancer 3 gallbladder cancer 2 lung cancer 1 rectal cancer 1 laryngeal cancer 1 testicular cancer
CECT MRI No change for 1 Y

8. Materials and Methods Age (years old) Max diameter (mm) HCC
F: 68.4  5.4
28  18
Metastasis
M: 64.5  11.9
F: 59.3  8.0
34  18
Hemangioma
M: 57.3  13.1
F: 52.6  10.6
41  30

9. Procedures Ultrasound: Contrast: Protocol
Sonoline Elegra system with 3.5-MHz convex probe
Contrast:
300mg/mL of the galactose-plamitic acid mixture of SH U 508A
7mL in the rate of 0.5mL/sec
Continuous infusion of 5% glucose
Protocol
Arterial phase: 30sec (20-50)
Portal venous phase: 90sec (80-100)
Late venous phase: 4min

10. Image Evaluation

17. Results
Arterioportal shunt 4: homogeneous pattern in arterial phase 5: early HCC

18. Factors Predicting Diagnosis of Hepatic Tumors

19. Enhancement Pattern Classification
1 relatively small (17mm  3)
5 relatively large (31mm  20)
All has arterioportal shunt

20. Enhancement Pattern Classification
No significant difference in tumor size

21. Enhancement Pattern Classification

22. Sensitivity, Specificity and Accuracy
Solitary
Multiple
HCC
94.8%
94.0%
94.5%
94.3%
Metastasis
90.5%
93.4%
87.5%
94.1%
Hemangioma
88.0%
99.4%
97.8%
85.0%
100%

24. Discussion US contrast agents
Do not disperse in the extracellular space
More accurate demonstration of persistent blood flow in hepatic tumors
Can be used in patient with renal failure and allergy to iodinated contrast agents

25. Discussion Kim et al. (Radiology 2000; 216:411-417)
peripheral globular and rim-like enhancement with progressive centripetal fill-in
 Hemangioma
Tanaka et al. (Am J Roentgenol 2001; 177: )
Ring enhancement in the vascular phase; clear defect in the parenchymal or both phases
 Cholangiocarcinoma or metastasis
Positive enhancement on interval-delay image; lack of postvascular enhancement
 HCC

26. Discussion In our study
Enhancement pattern-based classification in contrast-enhanced US is useful in making the differential diagnosis of hepatic tumors
In arterial phase
HCC  intratumoral vessels
Metastasis  peritumoral vessels
Hemangioma  no tumor vessels

27. Discussion In our study
In portal phase, 73% HCC  homogeneous pattern
Numata et al. (Am J Roentgenol 2001; 176: )
In diagnosing the viability of HCC after TAE, the contrast-enhanced US is superior to helical CT
Viable HCC in homogeneous to parenchyma in portal phase
Observation of the portal phase was important to detect viable portions of HCC after TAE or PEI

28. Discussion HCC with arterioportal shunt Metastasis Hemangioma
Homogenous or heterogeneous pattern in the arterial phase; hypoechoic in the portal phase
 Arterioportal shunt cause early flush out of contrast
Metastasis
48% ring enhancement
Viable tumor in peripheral with central necrosis or fibrosis
43% perfusion defect
Hypovascularity of the lesions
Hemangioma
Compatible with the delayed perfusion into and flush out from its vascular space

29. Discussion Enhancement pattern classification of hepatic tumors
Intratumoral vessels and homogeneous or heterogeneous enhancement  HCC
Ring enhancement and perfusion defect  metastasis
Peripheral nodular enhancement  hemangioma
The parameters in the late phase were not significant predictors
Observation of the vascular phase is important for differential diagnosis

30. Limitation This criterion for diagnosis was not applied prospectively
A prospective study of this enhancement pattern-based classification is needed
The proportion of HCC in our study appears to be relatively higher than that in Western countries

31. Conclusion
Contrast-enhanced wideband harmonic gray-scale US is a useful tool for differentiating among the hepatic tumors studied