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Journal Reading

Journal Reading. Intern 陳盈元. Differential Diagnosis of Hepatic Tumor by Using Contrast Enhancement Patterns at US. Radiology 2003; 229:798-805.

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Journal Reading

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  1. Journal Reading Intern 陳盈元

  2. Differential Diagnosis of Hepatic Tumor by Using Contrast Enhancement Patterns at US Radiology 2003; 229:798-805 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 • 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; 160:515-521) • 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: 138Multiple 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 resection151 US-guided biopsy3 autopsy 10 colon cancer9 pancreatic cancer5 gastric cancer4 ovarian cancer2 malignant melanoma2 esophageal cancer3 gallbladder cancer2 lung cancer1 rectal cancer1 laryngeal cancer1 testicular cancer CECTMRINo change for 1 Y

  8. Materials and Methods

  9. Procedures • Ultrasound: • 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

  11. Results Arterioportal shunt4: homogeneous pattern in arterial phase5: early HCC

  12. Factors Predicting Diagnosis of Hepatic Tumors

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

  14. Enhancement Pattern Classification No significant difference in tumor size

  15. Enhancement Pattern Classification

  16. Sensitivity, Specificity and Accuracy

  17. 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

  18. 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; 177:799-805) • 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

  19. 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

  20. Discussion • In our study • In portal phase, 73% HCC  homogeneous pattern • Numata et al. (Am J Roentgenol 2001; 176:1199-1205) • 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

  21. Discussion • HCC with arterioportal shunt • 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

  22. 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

  23. 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

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

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