Characterization of Focal Liver Lesions Using SonoVue, Contrast-enhanced Ultrasound

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1 Originl Artile Print ISSN: Online ISSN: X DOI: /ijss/2017/418 Chrteriztion of Fol Liver Lesions Using SonoVue, Contrst-enhned Ultrsound P Mnikndn 1, A Mhookhn 2, Heer Anndn 3 1 Assistnt Professor, Deprtment of Rdiology, Trihy Medil College, Tiruhirpplli, Tmil Ndu, Indi, 2 Assistnt Professor, Deprtment of Rdiology, Tirunelveli Medil College, Tirunelveli, Tmil Ndu, Indi, 3 Senior Clinil Sientist, Deprtment of Clinil Reserh, Dr. Agrwl s Helthre Limited, Tirunelveli, Tmil Ndu, Indi Astrt Introdution: Fol liver lesions re frequently disovered in dily prtie owing to extensive use of imging methods. Their nture must e eluidted for prognosis ssessment nd to deide on therpeuti strtegy. Aim: The im of this rtile is to study the sonogrphi hrteriztion of fol liver lesions n e improved using SonoVue -enhnement. Mterils nd Methods: This prospetive study ws onduted in 30 ptients with fol liver lesions identified in onventionl gry-sle ultrsound t Brnrd Institute of Rdiology, Mdrs Medil College. Results: Out of totl 30 ses, ontrst-enhned rel-time ultrsonogrphy (CEUS) identified 9 heptoellulr ner (HCC) ses nd 8 ses were onfirmed y fine-needle spirtion ytology (FNAC) s HCC. Four ses of HCC were identified y oth ontrst-enhned omputed tomogrphy (CECT) nd onventionl gry-sle ultrsonogrphy (USG). Out of the 17 ses of metstti deposits onfirmed y FNAC CEUS, CECT nd onventionl gry-sle USG identified 16 (94%), 14 (82%), nd 11 (65%) ses, respetively. Conlusion: CEUS is promising pproh in the non-invsive hrteriztion of fol liver lesions nd n e useful s first-line imging tehnique linilly when fol liver lesion is detetle on USG. Key words: Contrst-enhned ultrsound, Enhnement pttern, Fol liver lesions, Ultrsound ontrst gents INTRODUCTION The hrteriztion of fol liver lesions forms key element in the mjority of rdiologil prties. While B-mode imging is useful for the identifition of fol liver lesions, it is often diffiult, even with the use of olor Doppler, to urtely hrterize fol liver lesion. 1 Contrst-enhned rel-time ultrsonogrphy (CEUS) is promising pproh in the non-invsive hrteriztion of fol liver lesions nd n e useful s first-line imging tehnique linilly when fol liver lesion is detetle on ultrsonogrphy (USG). 2 Miroule CEUS utilizes Aess this rtile online Month of Sumission : Month of Peer Review : Month of Aeptne : Month of Pulishing : ultrsound ontrst gents (UCAs), whih perform s lood pool trers, hve overome the limittions of onventionl B-mode nd olor or power Doppler ultrsound (US) nd enle the disply of prenhyml mirovsulture. 3 Dependent on ontrst gent nd US-mode, the dynmi lesion enhnement pttern is visulized during intermittent or ontinuous insontion. Enhnement ptterns re desried during susequent vsulr phses (e.g. rteril, portl-venous, nd lte phse for liver lesions), similr to ontrst-enhned omputer tomogrphy (CECT) nd/or ontrst-enhned mgneti resonne imging (MRI). 4 UCA remins in the intrvsulr spe, wheres the mjority of urrently pproved ontrst gents for CT nd MRI re rpidly lered from the lood pool into the extrellulr spe. An inherent dvntge of CEUS is the possiility to ssess the ontrst enhnement ptterns in rel time, without the neessity to predefine sn-time points or to perform olus-trking nd the possiility to perform repeted exmintions due to the exellent ptient tolertion of UCA. 5-7 Corresponding Author: A Mhookhn, Deprtment of Rdiology, Tirunelveli Medil College, Tirunelveli, Tmil Ndu, Indi. Phone: E-mil: mhookhn@gmil.om 177 Interntionl Journl of Sientifi Study August 2017 Vol 5 Issue 5

2 Mnikndn, et l.: Chrteriztion of Fol Liver Lesions Aim The im of this study is to hrterize fol liver lesions y CEUS using SonoVue, n UCA, nd to ssess sensitivity, speifiity, nd positive preditive vlue of CEUS in deteting enign nd mlignnt fol liver lesions in omprison with CECT nd histopthologil orreltion. MATERIALS AND METHODS This prospetive study ws onduted in 30 ptients with fol liver lesions identified in onventionl gry-sle US t Brnrd Institute of Rdiology, Mdrs Medil College. Inlusion Criteri Those with fol liver lesions deteted y onventionl USG domen nd those in renl or hepti filure were inluded in the study. Exlusion Criteri Pregnnt nd restfeeding women, severe hypersensitivity or previous llergi retions, ritilly ill ptients, severe oronry rtery disese, post-extrorporel shok wve lithotripsy ptients within 24 h, under 18 yers, unontrolled systemi hypertension, nd dult respirtory distress syndrome were exluded from the study. Triplephse CECT domen ws done for 23 ptients, nd enhnement ptterns of fol liver lesions were otined nd nlyzed during rteril, portl venous, nd delyed phses. CECT domen ws not done for 7 ptients (5 hd renl filure, nd 2 hd hepti filure) sine intrvenous ontrst ws ontrindited in them. Then, olus of ml of SonoVue ws dministered intrvenously for ll the 30 ptients inluding those with hepti nd renl filure, sine SonoVue is not ontrindited in ptients with hepti nd renl filure. Rel-time imging of fol liver lesions ws done ontinuously for 3 min using hrmoni imging mode with low mehnil index (MI) ( ) in Siemens Auson Antres USG mhine, nd enhnement ptterns of fol liver lesions in CEUS were otined, reorded, nd nlyzed during rteril, portl venous, nd delyed phses. Therefter, oth the results were ompred. Out of 30 ptients, 25 ptients were sujeted to pthologil exmintion nd results otined. Five ptients with hemngiom were not sujeted to pthologil exmintion sine those lesions re highly vsulr. RESULTS The study popultion onsisted of 30 onseutive ptients with suspeted fol liver lesions. The study group onsisted of 18 mle nd 12 femle ptients, etween the ge of 11 nd 70 yers (with men ge of 40 yers). Out of the 30 ptients, 5 ptients hd renl filure, nd 2 ptients hd hepti filure, so CECT not done. In Tle 1, out of totl 30 ses, CEUS identified 9 heptoellulr ner (HCC) ses, nd 8 ses were onfirmed y fine-needle spirtion ytology (FNAC) s HCC. Four ses of HCC were identified y oth CECT nd onventionl gry-sle USG. Out of the 17 ses of metstti deposits onfirmed y FNAC CEUS, CECT, nd onventionl gry-sle USG identified 16 (94%), 14 (82%), nd 11 (65%) ses, respetively. 12 of the 16 metstses in CEUS were hypovsulr nd showed rim enhnement in the rteril phse; the most ommon primries in this group were oloretl (n = 7), stomh (n = 2), nd ronhogeni rinom (n = 3). The remining 4 metstses were hypervsulr on rteril phse imging with homogeneous enhnement; the primries in these ptients were smll-ell lung ner (n = 1), thyroid rinom (n = 2), nd renl ner (n = 1). In the portl venous nd delyed phse, ll 16 metstses were hypoehoi ompred with norml liver. Five ses of hemngiom were identified y oth CECT nd CEUS, nd 4 ses were identified y onventionl grysle USG. The results of this study show tht SonoVue improves sensitivity nd speifiity in disrimintion etween enign nd mlignnt fol liver lesions when ompred with seline B-mode sonogrphy. Out of totl 30 ses, 5 of the lesions were enign; orret dignosis of enignity ws mde in 4 (80%) of these on seline US nd in 5 (100%) fter SonoVue. One enign lesion ws misinterpreted s mlignnt fter ontrst: One enign yst whih did not fill with ontrst fter the rteril phse. Homogeneous SonoVue enhnement in the lte phse is prmeter for enign lesions, wheres more onspiuousness of the lesion due to wshout in the lte phse is prmeter for mlignnt lesions. Lte-phse imging with SonoVue is importnt for differentition etween enign nd mlignnt lesions nd erly-phse imging is importnt for hrterizing finl dignosis of the lesions. Peripherl gloulr-nodulr enhnement is preditive for hemngiom nd ws found in 17% (5 ses) of hemngiom ses in this study. This prmeter is omprle with the peripherl gloulr nodulr Tle 1: Distriution of dignosis Dignosis Gry sle USG CECT CEUS Finl dignosis HCC HCC/metstsis 5 Metstsis Hemngiom Norml 5 Begin yst 1 Totl 30 23* CECT: Contrst enhned omputed tomogrphy, CEUS: Contrst enhned rel time ultrsonogrphy, HCC: Heptoellulr ner, USG: Ultrsonogrphy Interntionl Journl of Sientifi Study August 2017 Vol 5 Issue 5 178

3 Mnikndn, et l.: Chrteriztion of Fol Liver Lesions enhnement found on CT. However, the results oserved with rel-time exmintion of SonoVue re etter thn findings reported with gry-sle USG, whih showed only 4 of 5 ptients with hemngiom. The higher sensitivity of SonoVue is due to the dvntges of the low-mi rel-time exmintion with seond-genertion ontrst gent. The typil enhnement pttern of primry liver rinom ws n erly intrnodulr enhnement nd erly wshout with whole-lesion or mosi enhnement. On CEUS, the typil hemodynmi pttern of HCC ws the whole-lesion enhnement or mosi enhnement in the rteril phse with wshout in the lte phse (sensitivity 100%; speifiity 77%; nd positive preditive vlue 61%). Dignosti ury of ontrst enhnement ptterns in hrterizing HCC in CEUS (sensitivity 100%; speifiity 77%; nd positive preditive vlue 61%) is higher when ompred to tht of CECT (sensitivity 80%; speifiity 73%; nd positive preditive vlue 44%). On CEUS, the typil hemodynmi pttern of metstsis ws the whole-lesion or peripherl rim enhnement in the rteril phse with wshout in the lte phse (sensitivity 100%; speifiity 61.5%; nd positive preditive vlue 77.3%). Dignosti ury of ontrst enhnement ptterns in hrterizing metstsis in CEUS (sensitivity 100%; speifiity 61.5%; nd positive preditive vlue 77.3%) is higher when ompred to tht of CECT (sensitivity 100%; speifiity 30%; nd positive preditive vlue 65%). Homogeneous enhnement in the lte phse ws preditive for enign lesions (P < ). Dignosti ury of hrterizing enign lesions in CEUS (sensitivity 100%; speifiity 100%; nd positive preditive vlue 100%) is higher when ompred to tht of grysle USG (sensitivity 40%; speifiity 88%; nd positive preditive vlue 40%). Dignosti ury of hrterizing metstsis in CEUS (sensitivity 94%; speifiity 100%; nd positive preditive vlue 100%) is higher when ompred to tht of CECT (sensitivity 92%; speifiity 79%; nd positive preditive vlue 85%) nd gry-sle USG (sensitivity 65%; speifiity 62%; nd positive preditive vlue 69%) (Figures 1 nd 2). Dignosti ury of hrterizing hemngiom is similr in CEUS nd CECT (sensitivity 100%; speifiity 100%; nd positive preditive vlue 100%), nd it is higher when ompred to tht of gry-sle USG (sensitivity 40%; speifiity 92%; nd positive preditive vlue 50%) (Figures 3-5). DISCUSSION The hrteriztion of fol liver lesion requires the ssessment of morphologil hrteristis s well s vsulrity nd enhnement ptterns within the lesion. Therefore, the dministrtion of ontrst gent, Figure 1: ( nd ) Conventionl gry-sle ultrsonogrphy - lrge heteroehoi lesion in right loe of the liver with high vsulrity. Hypervsulr metstsis Conversely, no ontrst enhnement in the lte phse ws preditive for mlignnt lesions (P < ). Dignosti ury of hrterizing mlignnt lesions in CEUS (sensitivity 100%; speifiity 100%; nd positive preditive vlue 100%) is higher when ompred to tht of grysle USG (sensitivity 72%; speifiity 60%; nd positive preditive vlue 90%). Dignosti ury of hrterizing HCC in CEUS (sensitivity 87%; speifiity 90.9%; nd positive preditive vlue 80%) is higher when ompred to tht of CECT (sensitivity 37.5%; speifiity 93.3%; nd positive preditive vlue 75%) nd gry-sle USG (sensitivity 25%; speifiity 68.18%; nd positive preditive vlue 22.2%). d Figure 2: (-d) Contrst-enhned rel-time ultrsonogrphy - hypervsulr metstsis - rteril phse: Hyperenhning, omplete; portl vein phse: Iso- to hypo-enhning; prenhyml phse: Hypoenhning or wshout. Hypervsulr metstsis 179 Interntionl Journl of Sientifi Study August 2017 Vol 5 Issue 5

4 Mnikndn, et l.: Chrteriztion of Fol Liver Lesions Figure 3: ( nd ) Conventionl gry-sle ultrsonogrphy lrge hyperehoi lesion noted involving oth loes of the liver. Typil hemngiom Figure 5: (-) Contrst-enhned rel-time ultrsonogrphy Arteril phse: Peripherl nodulr or gloulr enhnement, no entrl enhnement, rim enhnement; portl vein phse: Prtil/omplete entripetl filling; prenhyml phse: Persistent enhnement. Typil hemngiom CEUS for fol liver lesion hrteriztion whih is lerly superior to tht of unenhned US, s shown lredy in other studies with SonoVue nd other miroule ontrst gents d Figure 4: (-d) Contrst-enhned omputer tomogrphy Arteril phse: Peripherl nodulr or gloulr enhnement, no entrl enhnement, rim enhnement; portl vein phse: Prtil/omplete entripetl filling; prenhyml phse: Persistent enhnement. Typil hemngiom demonstrting the intrtumorl vsulrity nd lood flow, gives essentil informtion for the hrteriztion of fol liver lesions. Contrst-enhned imging with US hs two mjor dvntges.5 The miroule ontrst gents re rel lood-pool gents, not leving the intrvsulr spe, nd6 ontinuous imging over the whole-enhnement period with high temporl resolution is possile, not limited to distint, pre-defined time points.8,9 Furthermore, CEUS hs mny other dvntges, suh no exposure to rdition, nd sene of nephrotoxi ontrst gents nd lrge vilility of mhines. There re lredy severl studies pulished, demonstrting the sfety nd effiy of this method for the dignosis of fol liver lesions; however, most of these studies were single-enter studies performed with just one type of mhine. The results of this study onfirm the exellent performne of rel-time CONCLUSION Conventionl US, eing redily ville, eonomil, nd sfe, remins the imging modlity most widespred worldwide in deteting hepti fol lesions. CEUS gs hs greter sensitivity, speifiity, nd positive preditive vlue in hrterizing fol liver lesions thn CECT nd onventionl gry-sle USG. SonoVue-enhned sonogrphy hs greter sensitivity nd speifiity thn seline sonogrphy for the differentition of enign nd mlignnt liver lesions. CEUS is promising pproh in the non-invsive hrteriztion of fol liver lesions nd n e useful s first-line imging tehnique linilly when fol liver lesion is detetle on USG. REFERENCES Interntionl Journl of Sientifi Study August 2017 Vol 5 Issue 5 Dietrih CF, Krtzer W, Stroe D, Dnse E, Fessl R, Bunk A, et l. Assessment of metstti liver disese in ptients with primry extrhepti tumors y ontrst-enhned sonogrphy versus CT nd MRI. World J Gstroenterol 2006;12: Pisgli F, Lenioni R, Sgrini E, Pin CD, Cioni D, Vidili G, et l. Chrteriztion of fol liver lesions with ontrst-enhned ultrsound. Ultrsound Med Biol 2010;36: Rösh T, Meining A, Frühmorgen S, Zillinger C, Shusdzirr V, Hellerhoff K, et l. A prospetive omprison of the dignosti ury of ERCP, MRCP, CT, nd EUS in iliry stritures. Gstrointest Endos 2002;55: Wrd J, Guthrie JA, Sott DJ, Athley J, Wilson D, Dvies MH, et l. Heptoellulr rinom in the irrhoti liver: Doule-ontrst MR imging for dignosis. Rdiology 2000;216: Reinhold C, Hmmers L, Tylor CR, Quedens-Cse CL, Hollnd CK, 180

5 Mnikndn, et l.: Chrteriztion of Fol Liver Lesions Tylor KJ. Chrteriztion of fol hepti lesions with duplex sonogrphy: Findings in 198 ptients. AJR Am J Roentgenol 1995;164: Lee MG, Auh YH, Cho KS, Chung YH, Lee IC, Kng EM. Color Doppler flow imging of heptoellulr rinoms. Comprison with metstti tumors nd hemngioms y three-step grding for olor hues. Clin Imging 1996;20: Werneke K, Rummeny E, Bongrtz G, Vssllo P, Kivelitz D, Wiesmnn W, et l. Detetion of hepti msses in ptients with rinom: Comprtive sensitivities of sonogrphy, CT, nd MR imging. AJR Am J Roentgenol 1991;157: Niolu C, Viln R, Ctlá V, Binhi L, Gilert R, Grí A, et l. Importne of evluting ll vsulr phses on ontrst-enhned sonogrphy in the differentition of enign from mlignnt fol liver lesions. Am J Roentgenol 2006;186: Wilson SR, Burns PN. An lgorithm for the dignosis of fol liver msses using miroule ontrst-enhned pulse-inversion sonogrphy. Am J Roentgenol 2006;186: Spinzzi A, Llull JB. Dignosti performne of SonoVue-enhned olor duplex sonogrphy of vsulr strutures. Ad Rdiol 2002;9 Suppl 1:S Leen E, Angerson WJ, Yrmenitis S, Bongrtz G, Blomley M, Del Mshio A, et l. Multi-entre linil study evluting the effiy of SonoVue (BR1), new ultrsound ontrst gent in Doppler investigtion of fol hepti lesions. Eur J Rdiol 2002;41: Leen E, Ceotti P, Klogeropoulou C, Angerson WJ, Moug SJ, Horgn PG. Prospetive multienter tril evluting novel method of hrterizing fol liver lesions using ontrst-enhned sonogrphy. Am J Roentgenol 2006;186: Ctl V, Niolu C, Viln R, Pges M, Binhi L, Snhez M, et l. Chrteriztion of fol liver lesions: Comprtive study of ontrstenhned ultrsound versus spirl omputed tomogrphy. Eur Rdiol 2007;17: How to ite this rtile: Mnikndn P, Mhookhn A, Anndn H. Chrteriztion of Fol Liver Lesions Using SonoVue, Contrst-enhned Ultrsound. Int J Si Stud 2017;5(5): Soure of Support: Nil, Conflit of Interest: None delred. 181 Interntionl Journl of Sientifi Study August 2017 Vol 5 Issue 5