Yan Ling Wen

Detection of Intratumoral Vascularity in Small Hepatocellular Carcinoma by Coded Phase Inversion Harmonics

Objective: To investigate the value of contrast-enhanced coded phase inversion harmonic imaging (PIHI) in the depiction of intratumoral vascularity in small hepatocellular carcinoma (HCC). Methods: Eighty-five patients with 106 HCCs ≤3 cm in diameter were evaluated with coded harmonic angio (CHA), a coded PIHI, with use of an intravenous contrast medium, Levovist. Intratumoral vessels were detected in the early arterial phase, and tumor parenchymal stain was demonstrated in the late vascular phase. The detectability of intratumoral vascularity on contrast-enhanced CHA was compared with that on dynamic computed tomography (CT) and digital subtraction angiography (DSA). Results: With a combination of both vessel images and parenchymal flow images demonstrated by contrast-enhanced CHA, 98 of 106 small HCCs were evaluated as being hypervascular or isovascular. Using the results on dynamic CT as a gold standard, the sensitivity, specificity and accuracy were 95.1, 100 and 95.3%, respectively. The detection rate of intratumoral vascularity by contrast-enhanced CHA was 92.5% (98/ 106), compared with 97.2% (103/106) on dynamic CT (p = 0.14) and 88.9% (40/45) on DSA (p = 0.53). Conclusions: Contrast-enhanced coded PIHI is a sensitive tool for depicting intratumoral vascularity of small HCC.

Contrast advanced dynamic flow imaging and contrast pulse subtraction imaging: Preliminary results in hepatic tumors

PurposeTo investigate the usefulness of contrast advanced dynamic flow imaging and contrast pulse subtraction imaging in the intranodular hemodynamics of hepatic tumors.Materials and MethodsTen patients underwent contrast advanced dynamic flow imaging and contrast pulse subtraction imaging using Levovist®, a microbubble contrast agent. Fourteen hepatic tumor nodules were studied: 9 were hepatocellular carcinoma, 1 metastasis, 1 hemangioma, 1 adenomatous hyperplasia, and 2 metastatic lymph nodes of hepatocellular carcinoma. Real-time scanning of contrast advanced dynamic flow imaging and intermittent interval-delay scanning of contrast pulse subtraction imaging were carried out in the early arterial phase, the late vascular phase, and the postvascular phase. The results obtained from contrast advanced dynamic flow imaging and contrast pulse subtraction imaging were compared with those obtained by precontrast power Doppler imaging and three-phase dynamic CT, respectively.ResultsThe rate of detection of intranodular vascularity by contrast advanced dynamic flow imaging (93%) or contrast pulse subtraction imaging (93%) was significantly higher than that of precontrast power Doppler imaging (29%) and was as high as that of dynamic CT. Characteristic intranodular hemodynamics were detected in hepatocellular carcinoma, metastasis, hemangioma, and adenomatous hyperplasia with typical appearance of an intranodular blood vessel image in the early arterial phase, a parenchymal stain image in the late vascular phase, and a perfusion defect image in the post-vascular phase.ConclusionContrast advanced dynamic flow imaging and contrast pulse subtraction imaging clearly show the intranodular hemodynamics in hepatic tumors.

Detection of tumor vascularity in hepatocellular carcinoma with contrast-enhanced Dynamic Flow imaging: Comparison with contrast-enhanced power Doppler imaging

Objective: To compare the effectiveness of contrast-enhanced Dynamic Flow imaging and contrast-enhanced power Doppler imaging using Levovist® as a microbubble contrast agent in evaluating intratumoral vascularity in hepatocellular carcinoma (HCC).Materials and Methods: Twenty-nine patients with 54 hepatocellular carcinoma nodules (before treatment, 31; after treatment, 23) were studied with both Dynamic Flow and power Doppler imaging with intravenous injection of Levovist®. Tumor vascularity was categorized as 0, no blood flow signals within the tumor; 1, dotlike blood flow signals within the tumor; 2, moderate blood flow signals within the tumor; and 3, abundant blood flow signals within the tumor. Detectability of intratumoral vascularity of hepatocellular carcinoma in three groups based on tumor depth, blooming and noise artifacts on contrast-enhanced Dynamic Flow and contrast-enhanced power Doppler imaging were also compared with results obtained using dynamic CT as a the gold standard. The effectiveness of contrast-enhanced Dynamic Flow and contrast-enhanced power Doppler imaging in assessing therapeutic effect were compared at the same time.Results: The ability of contrast-enhanced Dynamic Flow Doppler imaging to detect tumor vascularity in the superficial and intermediate hepatocellular carcinoma groups was close to that of contrast-enhanced power Doppler imaging (p>0.05). However, contrast-enhanced Dynamic Flow imaging demonstrated tumor parenchymal stain in 28 hepatocellular carcinoma nodules (61%), which was not detected by contrast-enhanced power Doppler imaging. Further, significantly fewer artifacts appeared in contrast-enhanced Dynamic Flow imaging than in contrast-enhanced power Doppler imaging (p<0.001). In assessing therapeutic response, the sensitivity of contrast-enhanced Dynamic Flow imaging was similar to that of dynamic CT. In deep areas, however, those more than 6 cm below the surface of the body, contrast-enhanced Dynamic Flow imaging was less sensitivity than contrast-enhanced power Doppler imaging (p=0.005).Conclusion: Contrast-enhanced Dynamic Flow imaging provides an effective approach to assessing intratumoral vascularity and therapeutic response in HCC lesions situated less than 6 cm from the surface of the body. It is superior to contrast-enhanced power Doppler imaging in its ability to detect tumor parenchymal stain and production of fewer artifacts.

Contrast-enhanced agent detection imaging: Early experience in hepatocellular carcinoma

Purpose: To investigate the usefulness of contrast-enhanced Agent Detection Imaging in assessing intratumoral vasculature in hepatocellular carcinoma.Materials and Methods: Fourteen hepatocellular carcinoma nodules in 11 patients were studied with contrast-enhanced Agent Detection Imaging, a wide-band color Doppler imaging method, employing, Levovist®, a microbubble contrast agent. High acoustic power was used with contrast-enhanced Agent Detection Imaging. Intermittent transmission of Agent Detection Imaging was performed at intervals of 200, 500, and 350 milliseconds in the early arterial phase (10 to 40 seconds), late vascular phase (1 to 3 minutes) and postvascular phase (5 to 7 minutes), respectively. The results were compared with those of three-phase dynamic CT.Results: Intratumoral blood vessels in the early arterial phase and tumor parenchymal stain in the late vascular phase were depicted in 12 (88%) of the 14 hepatocellular carcinoma nodules, while all nodules were demonstrated as perfusion defect in the postvascular phase on contrast-enhanced Agent Detection Imaging. The results of Agent Detection Imaging, that were compared with those of dynamic CT, were all 100% : diagnostic sensitivity (12/12), specificity (2/2), and accurary (14/14).Conclusion: Contrast-enhanced Agent Detection Imaging is a promising method for depicting intratumoral vascularity in hepatocellular carcinoma.

Value of new contrast harmonic technique for detecting tumor vascularity in hepatocellular carcinoma: Preliminary results.

Purpose: To investigate the value of a new wide-band contrast harmonic imaging method in depicting intratumoral vascularity in hepatocellular carcinoma.Materials and Methods: Twenty-two patients with 28 hepatocellular carcinoma nodules evaluated with Contrast Harmonic Echo, a new wide-band harmonic imaging method, using Levovist® as a contrast-enhancing agent. Intermittent imaging was carried out in the early arterial phase for 10 to 40 seconds, in the late vascular phase for 1 to 2 minutes, and in the postvascular phase for 5 to 7 minutes. Subtraction images were obtained using the multishot method during the late vascular phase. The ability of Contrast Harmonic Echo imaging to detect vascularity in hepatocellular carcinoma was compared to that of unenhanced color Doppler imaging by analzing results obtained using dynamic CT as a gold standard.Results: Contrast harmonic Echo imaging detected intratumoral vessels, tumor parenchymal stain, and perfusion defect in the early arterial phase, the late vascular phase, and the postvascular phase, respectively. In the late vascular phase, the subtraction image clearly delineated the tumor parenchymal strain. Intratumoral vascularity was detected in 25 (89%) of the hepatocellular carcinoma nodules by Contrast Harmonic Echo, compared with 15 (54%) when color Doppler imaging was used (p<0.05). The diagnostic sensitivity, specificity, and accuracy of Contrast Harmonic Echo were 96.1%, 100% and 96.4%, respectively, corresponding to results obtained using dynamic CT.Conclusion: Contrast Harmonic Echo imaging is superior to unenhanced color Doppler imaging in depicting intratumoral vessels and parenchymal stain, and agrees closely with results obtained with three-phase dynamic CT.

Assessment of image quality of contrast-enhanced power doppler imaging in hepatocellular carcinoma with the personal ultrasound imager: Comparison with the conventional machine.

ObjectiveTo evaluate the usefulness of contrast-enhanced power Doppler imaging with the personal ultrasound imager in depicting intratumoral vascularity in hepatocellular carcinoma.Materials and MethodsContrast-enhanced power Doppler imaging was used to examine 52 hepatocellular carcinoma nodules in 29 patients, using both the personal ultrasound imager and the conventional ultrasound machine in combination with intravenous injection of Levovist®. Results obtained using dynamic CT were used as the gold standard. The ability of the personal ultrasound imager to detect intratumoral vascularity was compared with that of the conventional ultrasound machine, and the usefulness of the personal ultrasound imager in assessing therapeutic effect after nonsurgical treatment was compared with that of dynamic CT at the same time.ResultsThe personal ultrasound imager and the conventional ultrasound machine, using the fundamental power Doppler imaging mode (p=0.13) and contrast-enhanced power Doppler imaging mode (p=0.41), did not differ significantly in depicting the vascularity of the 52 hepatocellular carcinomas. The sensitivity, specificity, and accuracy of contrast-enhanced power Doppler imaging on the personal ultrasound imager were 95.5%, 87.5%, and 94.2%, respectively, in close agreement with results obtained using dynamic CT. After the 22 hepatocellular carcinomas were treated, the personal ultrasound imager provided diagnostic accuracy of 90.9% on residual tumors when compared with results obtained by dynamic CT, and results obtained using the conventional ultrasound machine were similar.ConclusionThe highly portable personal ultrasound imager using Levovist®-enhanced power Doppler imaging can clearly depict the intratumoral vascularity of hepatocellular carcinoma nodules before and after treatment, achieving results very close to those obtained using the conventional diagnostic ultrasound machine. The personal ultrasound imager is an alternative to the conventional ultrasound machine for depicting tumor vascularity.

Sonographic findings of wandering spleen.

patient complained of left hypochondralgia portrayed an enlarged but normally located spleen (Fig. 1D). In the light of these findings, wandering spleen was diagnosed. Consequently, an elective laparoscopic splenopexy was performed. Four months after the treatment, ultrasonography was performed to evaluate the therapeutic effects. The spleen, located in a normal position, was reduced in size, and the splenic vein was clearly shown to be smooth (Fig. 2A). A CT scan showed similar findings (Fig. 2B). There were no further episodes suggesting the recurrence of wandering spleen. Wandering spleen is an uncommon entity.1–4 It occurs more often in females than in males, especially in females after childbirth.1 Its precise cause is uncertain. The entity may be congenital or acquired. It has often been suggested to be associated with maldevelopment of the primary splenic supporting ligaments. Its clinical appearance assumes various forms, with the most common complication being torsion of the spleen. Because this acute torsion often causes infarction of the spleen, and, consequently, an abdominal emergency, splenectomy is inevitable under these circumstances.2,3 If the diagnosis is made before severe complications occur, elective laparoscopic splenopexy is now the treatment of choice. As ultrasonography can be easily repeated, and as it portrays the shape and position of the spleen on a real-time basis, the preoperative diagnosis of wandering spleen is possible. With advances in ultrasonographic technology, such as color Doppler imaging and power Doppler imaging, the occurrence of torsion or infarction can easily be confirmed. Therefore, ultrasonography is a simple and useful method for diagnosing wandering spleen in patients who complain of intermittent left hypochondralgia, especially in women after childbirth. Because the imaging characteristics may differ from patient to patient,3,4 it is important to have accurate information about this entity in order to make a conclusive and correct diagnosis.

Spontaneous regurgitation of portal blood flow normalized by meal intake in a patient with alcoholic liver cirrhosis

We report a case with spontaneous regurgitation of portal blood flow (SRPBF) that was normalized by meal intake. A 41-year-old man with long-term alcohol abuse was admitted with a chief complaint of general fatigue. He was diagnosed as having alcoholic liver cirrhosis since his laboratory tests showed the abnormal liver function. Dynamic computed tomography detected numerous portosystemic shunts. Hepatic arterial portography showed the portal vein was narrow and irregular. Color Doppler imaging portrayed the direction of the blood flows in the branches of the portal vein to be retrograde. However, 30 min after meal intake on the same day, color Doppler study showed the direction of the blood flow in the first branch of right and left portal vein became normal. Color Doppler imaging is a useful technique to detect SRPBF and hemodynamic change in portal venous system after meal intake in patient under a completely physiologic condition.

Evaluation of Image Quality of Personal Ultrasound Imager: Comparison with the Conventional Machine

ObjectiveTo determine if the image quality of a personal ultrasound imager (PUI) is as good as that of a conventional machine (CM).Materials and MethodsNinety patients were studied by the same operator using both the PUI and CM. The quality of the B-mode images obtained from these patients was scored 0, 1 or 2, defined as poor, fair, or good, respectively. Liver-tumor vascularity depicted by power Doppler imaging (PDI) and directional PDI (DPDI) was classified as 0, no blood signal; 1, dot-like blood signal within the tumor; 2, mild blood-flow signal within the tumor; and 3, abundant blood-flow signal within the tumor.ResultsThe mean score of PUI and CM B-mode image quality was 7.47±0.92 and 7.54±0.99 (mean±SD), respectively (p=0.531). On PDI, grade of vascularity of the liver tumors determined with the PUI was 4.44 and 4.68 in those determined with the CM (p=0.78). On DPDI, tumor vascularity was 3.12 when scored by the PUI and 4.29 when scored with the CM (p=0.03). The qualities of images acquired by the PUI and CM were significantly correlated.ConclusionThe quality of B-mode images acquired using the PUI and CM are statistically the same, and they share a similar ability to detect intratumoral blood-flow signals on PDI. Because of its extreme portability, the PUI is expected to become a valuable diagnostic tool in the clinic.

Agenesis of the left lobe of the liver: Radiologic findings

We describe a case of agenesis of the left lobe of the liver. The patient was a 61-year-old man with a chief complaint of a continuous, blunt pain in the left side of the back. Examinations were conducted using ultrasonography (US), enhanced computed tomography (CT), and magnetic resonance angiography (MRA). No liver tissue or falciform ligament were visualized at the left portion of the gallbladder fossa. The portal and hepatic veins lacked left branches, and the right branches of the hepatic vein were dilated. Here we discuss the differential diagnosis of agenesis of the left lobe of the liver.