Ultrasound of focal liver lesions

Transkript

1 Ultrasound of focal liver lesions Odd Helge Gilja, MD, PhD Professor Department of Medicine Haukeland University Hospital Bergen, Norway

2 Agenda General aspects of liver US Diffuse Liver diseases Fatty liver disease Liver cirrhosis Focal Liver diseases Benign focal liver lesions Malignant liver diseases Hepatocellular carcinoma Liver metastases CEUS (Contrast Enhanced UltraSound) Elastography Strain Imaging 2

3 FLL Classification

4 Ultrasonographic work-up Ultrasound of liver 2D og 3D Doppler Color Doppler Pulsed Doppler Elastography Strain imaging Shear wave Contrast-US (CEUS) UL-guided liverbiopsy

5 Ultrasound of the Liver -What do we look for? Size, capsule and form Liverparenchyma lesions? Liver veins Portal vein Arteria hepatica Intrahepatic bile ducts

6 The Liver capsule Normal Cirrhosis

7 Doppler is useful!

8 NORMAL ANATOMI 2 lober høyre og venstre 8 segmenter: lobus caudatus 1 venstre lobe 2,3 høyre lobe 4-8 Ligamentum teres Ligamentum venosum Ligamentum falciforme

9 Segmentation of the liver

10 6+ A systematic examination of abdominal organs Stasjon 1 Tverrsnitt i epigastriet. Man orienterer seg etter de kjente anatomiske landemerker: Aorta, vena cava, art. mesenterica superior, pancreas og lever. Man skanner systematisk gjennom det meste av lever og pancreas. Ofte lurt å be pasienten til å puste dypt inn for å få med hele leveren. Å be pasienten blåse opp magen eller gi 2 glass vann å drikke kan noen ganger bedre innsynet til pancreas. Stasjon 2 Lengdesnitt epigastriet. Man undersøker v.cava, aorta med avgående kar i lengderetning og retroperitoneale lymfeknuter. Det er også lett å avbilde magesekken (antrum) i samme lengdesnittet. Stasjon 3 Skråsnitt subcostalt. Galleblæren kan ha varierende leie noe som gjør at man noen ganger har vanskeligheter med å finne den. Pasienten bør i slike tilfelle undersøkes fastende. Galleblæren ser man som regel godt både fra ventral subcostal vinkling og intercostalt fra lateralsiden. Stasjon 4 Tverr- og lengdesnitt fra hø lateralflate. Så skifter man posisjon og grep om lydhodet og skanner lever, portalområde, galleveier og høyre nyre fra lateralflaten samt intercostalt. Stasjon 5 Snitt fra venstre lateralflate. Deretter flytter man lydhodet til venstre flanke og lokaliserer milten intercostalt bak midtaxillærlinjen. Deretter tilstreber man en fremstilling av nyre fra pol til pol i både tverr- og lengdesnitt. Halepartiet av pancreas vil ofte kunne sees fra venstre flanke gjennom milten. Stasjon 6 Tverr- og lengdesnitt over symfysen. Det lille bekken undersøkes best når urinblæren er fylt. Både prostata, rektum, uterus og evt. eggstokkene kan da som regel sees. Stasjon + Til slutt er det av og til relevant å gjøre en orienterende skanning av tarmer for å se etter target lesions eller fortykket tarmvegg. Man kan da starte i høyre fossa iliaca og identifisere distale ileum og evt appendix. Så følger man colon helt fra coecum og i distal retning ned til sigmoideum.

11 Detection and characterization of Focal Liver Lesions Hausken, Gilja et al., 1999

12 Liver cysts ultrasound is highly accurate in diagnosing liver cysts anechoic with a clear posterior demarcation (but no wall) posterior enhancement often round in shape and smooth occasionally RUQ pain due to mass effect or bleeding DD: abscess, echinococcal cysts, tumours with central necrosis, hematomas polycystic liver disease autosomal dominant disorder often multiple renal cysts (>50%) variation in size and shape hepatomegaly, cholestasis and portal hypertension (PHT)

13 Liver cysts

14 Liver cysts

15 Polycystic liver disease 15

16 Contrast Agents - World View IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol. 60, no. 1, January 2013

17 f 0 2f 0 f 0 Microbubbles

18 Sonazoid Membrane is hydrogenated egg phosphatidylserine sodium (HEPSNa) The gas is perfluorobutane (PFB)

19 Some properties of Sonazoid Narrow Size distribution Very robust: Allow for high-mi scan (0,2-0,3) Perform a post-vascular scan Use higher frequencies Phagocytosis by Kupffer cells in the liver Yanagisawa et al.

20 New Guidelines for CEUS 2011 Ultraschall Med / EJU Aug. 2011

21 4 Phases in liver perfusion Arterial phase 0-30 sec. Portal phase sec. Sinusoidal phase 2-4 min Post-vascular phase 4-30 min

22 Focal Liver Lesions

23 Referred from the CT-Lab Haemangioma?

24 Peripheral Globular Enhancement with slow sentripetal filling

25 Time Intensity Curves

26 Lesion in Liver S7

27 Haemangioma High Res

28 Portal Phase - Sonazoid

29 In Haemangiomas, be aware not to use too high MI not to focus on one lesion in all phases to scan longer than 5 min. some h. never totally fill in, but it is still benign big h. may behave atypically (thrombosis)

30 Focal Nodular Hyperplasia - FNH FNH- a centrifugal stellate branching in early arterial phase Spoke wheel pattern in approx 40% Intense homogenous uptake Iso- or hyperechoic lesion is seen in portal venous phase. With these characteristic features: sensitivity and specificity of contrast-enhanced low MI real-time US are 87.6% and 94.5%, respectively Di Stasi 1996

31 FNH

32 FNH- Arterial Phase

33 FNH

34 FNH Late Phase (Sinosoidal)

35 FLL with Doppler

36 CEUS Sonazoid - FNH

37 Arterial Phase: 12 sec.

38 Arterial Phase: 13 sec

39 Arterial Phase: 13 sec

40 Arterial Phase: 15 sec

41 CEUS Flash Central scarring

42 Liver cell adenoma Liver cell adenoma (LCA) is a rare primary benign neoplasm found mainly in young women with a history of oral contraceptive use The hypervascularity of adenomas can be demonstrated on Doppler,- sentripetal CEUS identification of the early and homogeneous hyperechoic enhancement in the periphery of the tumor, reflecting the presence of the subcapsular feeding arteries. The enhancement of LCA in the portal and late phases is nearly comparable with that of liver parenchyma, but LCA can remain slightly hypoechoic in relation to the adjacent liver

43 CEUS - Real-time Perfusion Dynamic abilities outperforms CT and MR

44 Fatty liver Dangerous!

45 A common problem: Focal Lesions in Fatty Livers

46 CEUS in FLL

47 Ultrasound in HCC Diagnosis B-mode Doppler CEUS US-guided biopsy Per-operative guiding of ablation Follow-up and monitoring of treatment Surveillance / Screening

48 US-Diagnosis of HCC The ultrasound appearance with conventional B-mode of hepatocellular carcinoma: hypoechoic in 48 % isoechoic in 9 % hyperechoic in 19 % in 25 % a mixture between hyper- and hypoechoic appearance was found compared to the surrounding liver tissue. Ignee et al, Z Gastroenterol 2005; 43:

49 Probability of HCC in Cirrhosis Which nature is expected to have a focal liver lesion newly detected in a cirrhotic liver? From a likelyhood approach: 65% HCC if 1-2cm, 85% HCC if 2-3cm, >90-95% if >3 cm If not an HCC, consider: 1.Regenerative dysplastic nodule 2.Hemangioma 3.Cholangiocellular carcinoma 4.Lymphoma

50 HCC in Cirrhosis

51 A 61 year old man with cirrhosis and encephalopathy Tumor Characterisation

52 The Sequence of HCC Development hepatic arterial supply abnormal arterial supply Arterial supply Portal supply portal supply LRN ~ LGDN ~ HGDN ~ e-hcc ~ wdhcc ~ classical HCC early HCC from: Matsui, Clin Hep Gastro, (based on CT-arterioportal-angiography)

53 CEUS in AIH HCC?

54 CEUS in AIH HCC? Arterial Phase

55 Portal Vein Thrombosis

56 CEUS in a cirrhotic liver

57 Late Phase

58 FNH versus HCC FNH HCC

59 Liver Metastasis? Before contrast injection

60 Liver Metastasis? After contrast injection

61 Parenchymal Phase ( 4 min)

62 High-Frequency 9 MHz LA

63 Kuppfer Phase 14 min

64 Cholangiocarcinoma

65 Cholangiocarcinoma

66 Cholangiocarcinoma Late Phase

67 Lymphoma of the Liver

68 Late phase of Lymphoma

69 Abcess

70 Abcess in Arterial Phase

71 Abcess Late Phase Culture: Staph. Aureus

72 Focal Liver Lesions

73 Safety Considerations In general, UCA are extremely safe with a low incidence of side effects They are neither nephrotoxic nor cardiotoxic The incidence of hypersensitivity or allergic events are much lower than current X-ray or MR contrast agents It is not necessary to perform laboratory tests of renal function before administering them Contraindications: Serious cardiopulmonary disease, known allergic reaction to the agent, pregnancy

74 Safety

75 Regarding Safety

76 Conclusion Using 2. generation ultrasound contrast agents, the method is established as an important clinical tool SonoVue is easy to apply in a clinical setting and does not prolong the exam with more than 10 min Attention to Mechanical Index is crucial during CEUS Benign and malignant lesions of the liver can be detected and characterized with high sensitivity and accuracy

77 Dangerous or not? Photo: OH Gilja, Masai Mara, Kenya

78 Books from National Center