Ultrasound of focal liver lesions Odd Helge Gilja, MD, PhD Professor Department of Medicine Haukeland University Hospital Bergen, Norway
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
FLL Classification
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
Ultrasound of the Liver -What do we look for? Size, capsule and form Liverparenchyma lesions? Liver veins Portal vein Arteria hepatica Intrahepatic bile ducts
The Liver capsule Normal Cirrhosis
Doppler is useful!
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
Segmentation of the liver
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.
Detection and characterization of Focal Liver Lesions Hausken, Gilja et al., 1999
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)
Liver cysts
Liver cysts
Polycystic liver disease 15
Contrast Agents - World View IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol. 60, no. 1, January 2013
f 0 2f 0 f 0 Microbubbles
Sonazoid Membrane is hydrogenated egg phosphatidylserine sodium (HEPSNa) The gas is perfluorobutane (PFB)
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.
New Guidelines for CEUS 2011 Ultraschall Med / EJU Aug. 2011
4 Phases in liver perfusion Arterial phase 0-30 sec. Portal phase 30-120 sec. Sinusoidal phase 2-4 min Post-vascular phase 4-30 min
Focal Liver Lesions
Referred from the CT-Lab Haemangioma?
Peripheral Globular Enhancement with slow sentripetal filling
Time Intensity Curves
Lesion in Liver S7
Haemangioma High Res
Portal Phase - Sonazoid
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)
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
FNH
FNH- Arterial Phase
FNH
FNH Late Phase (Sinosoidal)
FLL with Doppler
CEUS Sonazoid - FNH
Arterial Phase: 12 sec.
Arterial Phase: 13 sec
Arterial Phase: 13 sec
Arterial Phase: 15 sec
CEUS Flash Central scarring
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
CEUS - Real-time Perfusion Dynamic abilities outperforms CT and MR
Fatty liver Dangerous!
A common problem: Focal Lesions in Fatty Livers
CEUS in FLL
Ultrasound in HCC Diagnosis B-mode Doppler CEUS US-guided biopsy Per-operative guiding of ablation Follow-up and monitoring of treatment Surveillance / Screening
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: 289-294
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
HCC in Cirrhosis
A 61 year old man with cirrhosis and encephalopathy Tumor Characterisation
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, 2005. (based on CT-arterioportal-angiography)
CEUS in AIH HCC?
CEUS in AIH HCC? Arterial Phase
Portal Vein Thrombosis
CEUS in a cirrhotic liver
Late Phase
FNH versus HCC FNH HCC
Liver Metastasis? Before contrast injection
Liver Metastasis? After contrast injection
Parenchymal Phase ( 4 min)
High-Frequency 9 MHz LA
Kuppfer Phase 14 min
Cholangiocarcinoma
Cholangiocarcinoma
Cholangiocarcinoma Late Phase
Lymphoma of the Liver
Late phase of Lymphoma
Abcess
Abcess in Arterial Phase
Abcess Late Phase Culture: Staph. Aureus
Focal Liver Lesions
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
Safety
Regarding Safety
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
Dangerous or not? Photo: OH Gilja, Masai Mara, Kenya
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