Contrast-Enhanced Ultrasound (CEUS) for Differentiating Between Hepatocellular and Cholangiocellular Carcinoma

Abstract

Purpose: HCC and CC are the most common primary malignancies of the liver. There is only minimal evidence as to whether these two entities can be reliably differentiated by contrast-enhanced ultrasound.

Materials and Methods: We retrospectively analyzed the CEUS pattern of 39 patients with HCC, 11 patients with intrahepatic cholangiocarcinoma (ICC), 3 patients with Klatskin tumor, and 4 patients with gallbladder carcinoma. CEUS was performed using a standardized protocol (low MI, SonoVue^®) with documentation of the arterial, portal-venous, and late phase. Besides the contrast enhancement compared to the adjacent normal liver tissue in every phase, the specific contrast pattern during the arterial phase (complete filling, incomplete filling of different grade, rim sign) was analyzed.

Results: Most HCC and ICC showed hyperenhancement during the arterial phase, with hypoenhancement or isoenhancement in the portal-venous and late phase. Hyperenhancement during the portal-venous phase was only observed in some cases of HCC, but not in ICC. In the case of arterial hyperenhancement, HCC showed complete filling more often than ICC. In the case of incomplete filling, the area of contrast-enhanced tumor in most HCCs was larger than in ICCs. A rim sign was present in only less than half ICCs, but in no HCCs.

Conclusion: HCC and ICC differ to some extent in their CEUS enhancement pattern. Incomplete arterial hyperenhancement is more often seen in ICC than in HCC. A rim sign seems to be specific for ICC, but is only rarely present. However, in a case-to-case decision, due to overlapping characteristics, a reliable differentiation between the two tumor types by CEUS alone is very often not possible.

Zusammenfassung

Ziel: Hepatozelluläres Karzinom und Cholangiokarziom sind die häufigsten primären Malignome der Leber. Es gibt nur wenige Daten, ob mittels kontrastverstärkten Ultraschalls sicher zwischen diesen beiden Tumortypen unterschieden werden kann.

Material und Methoden: Wir analysierten retrospektiv das Ultraschallkontrastverhalten bei 39 Patienten mit HCC, 11 Patienten mit intrahepatischem Cholangiokarzinom (ICC), 3 Patienten mit Klatskintumor und 4 Patienten mit Gallenblasenkarzinom (low-MI-Mode, Sonovue^®). Analysiert wurde das Kontrastverhalten in der arteriellen, portal-venösen und Spätphase im Vergleich zum Kontrastaufnahme im umgebenden Lebergewebe. Darüber hinaus wurden verschiedene Kontrastierungsmuster in der arteriellen Phase unterschieden (komplette Kontrastierung, inkomplette Kontrastierung unterschiedlichen Ausmaßes, Vorhandensein eines „rim-sign“).

Ergebnisse: In der überwiegenden Mehrzahl zeigten sowohl HCC als auch ICC während der arteriellen Phase eine stärkere und in der portal-venösen und Spätphase eine verminderte KM-Aufnahme im Vergleich zum umgebenden Gewebe. Einzelne HCC, aber kein ICC wiesen auch in der portal-venösen Phase eine vermehrte Kontrastierung auf. HCC waren im Vergleich zu ICC arteriell häufiger komplett vermehrt kontrastiert. Sofern eine nur inkomplette Kontrastierung gefunden wurde, umfasste diese bei den HCC im Vergleich zu den ICC zumeist größere Tumorflächenanteile. Weniger als die Hälfte der ICC, jedoch kein HCC zeigten ein arterielles „rim-sign“.

Schlussfolgerung: ICC weisen im Gegensatz zu HCC in der arteriellen Phase häufiger eine nur inkomplette Kontrastmittelaufnahme auf. Das „rim-sign“ scheint für ICC spezifisch zu sein, findet sich aber nur selten. Im Einzelfall ist eine sichere Differenzierung zwischen HCC und ICC anhand der CEUS alleine oftmals nicht möglich.

Key words

contrast-enhanced ultrasound - ultrasound - microbubbles - hepatocellular carcinoma - cholangio carcinoma

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