Ultraschall Med 2008; 29(5): 488-498
DOI: 10.1055/s-2008-1027195
Review

© Georg Thieme Verlag KG Stuttgart · New York

Sonografische Leberdiagnostik bei Tumorpatienten ohne und mit Kontrastmittel

Baseline and Contrast-Enhanced Ultrasound of the Liver in Tumor PatientsA. Oldenburg1 , T. Albrecht1
  • 1Klinik und Hochschulambulanz für Radiologie und Nuklearmedizin, Charite, Campus Benjamin Franklin
Further Information

Publication History

eingereicht: 7.6.2007

angenommen: 6.12.2007

Publication Date:
22 August 2008 (online)

Zusammenfassung

Die korrekte Detektion und Charakterisierung von Lebermetastasen ist wesentlich für die Therapieplanung bei Patienten mit einer malignen Grunderkrankung. Die Sensitivität des nativen Ultraschalls, der die am häufigsten genutzte Methode zum Leberstaging darstellt, ist im Vergleich zur kontrastmittelgestützten Computertomografie (CT) und Magnetresonanztomografie (MRT) deutlich geringer. Auch die korrekte Charakterisierung fokaler Leberläsionen mittels nativem Ultraschall (US) kann bei Tumorpatienten Schwierigkeiten bereiten. Lebermetastasen stellen sich nativ in der Mehrzahl echoarm dar. Probleme bereitet die Detektion von echogleichen und kleinen Metastasen. Durch den Einsatz von Ultraschallkontrastmitteln (USKM) und spezifischen Bildgebungstechniken konnte die Rolle des Ultraschalls in der Leberdiagnostik deutlich verbessert werden. Levovist und SonoVue sind die in Europa für die Leberdiagnostik zugelassenen Kontrastmittel (KM), wobei SonoVue durch die Möglichkeit der kontinuierlichen Untersuchung in Echtzeit Levovist weitestgehend in der Leberdiagnostik abgelöst hat. Essenziell für die Metastasendetektion sind die portalvenöse und die Spätphase, in denen Metastasen ein Auswaschen des KM zeigen und als echoarme KM-Aussparungen im homogen KM-angereicherten Leberparenchym abgrenzbar sind. Insgesamt konnte in mehreren Studien eine deutliche Sensitivitätssteigerung in der Lebermetastasendetektion durch den Einsatz von USKM nachgewiesen werden, in denen die Sensitivität des KMUS mit der KM-gestützten CT und MRT für die Leberdiagnostik vergleichbar sind. Die typischen Anreicherungsmuster der verschiedenen benignen und malignen Leberläsionen ermöglichen in der Regel auch eine sichere Charakterisierung und Differenzierung gegenüber Lebermetastasen. Dieser Artikel soll als Fortbildungsartikel einen Überblick über die Vorteile und den sinnvollen Einsatz von KM im Ultraschall vermitteln.

Abstract

In patients with known malignancy, correct detection and characterization of liver lesions has important therapeutic consequences. Conventional sonography is the most commonly used modality for liver imaging in tumor patients. However, it has a lower sensitivity for the detection of liver metastases compared to contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). The majority of liver metastases are hypoechoic and well defined in baseline ultrasound (US), while detection of isoechoic or small liver metastases < 1 cm is difficult and the differentiation of liver metastases from benign liver lesions and other malignant liver tumors can be impossible with baseline US. The use of microbubble-based ultrasound contrast agents and contrast-specific imaging techniques advanced the accuracy of ultrasound in liver imaging. Levovist and SonoVue are the US contrast agents approved for liver imaging in Europe. Compared to Levovist, SonoVue allows continuous imaging of the liver in real-time over a period of up to 5 minutes. As a result, SonoVue became the preferred contrast agent for liver imaging in the recent years, while Levovist became less important. Important for the detection of liver metastases are the portal venous and late phases in which metastases show a wash-out and can be detected as hypoechoic lesions in homogeneous enhanced liver parenchyma. The detection of hepatic metastases is substantially improved by CEUS compared to conventional B-mode sonography. Several studies showed sensitivity in detecting liver metastases comparable to that of contrast-enhanced CT and MRI. Furthermore, the typical enhancement patterns of the different benign and malignant liver lesions allow reliable characterization and differentiation from liver metastases in the majority of cases. This paper provides information about the advantages and expedient application of contrast-enhanced ultrasound (CEUS) in tumor patients.

Literatur

  • 1 Edmunson H, Craig J. Neoplasms of the liver. Schiff L Diseases of the liver Philadelphia; Lippincott 1987 8 ed: 1109
  • 2 Karhunen P J. Benign hepatic tumours and tumour like conditions in men.  J Clin Pathol. 1986;  39 183-188
  • 3 Jones E C, Chezmar J L, Nelson R C. et al . The frequency and significance of small (less than or equal to 15 mm) hepatic lesions detected by CT.  Am J Roentgenol. 1992;  158 535-539
  • 4 Kreft B, Pauleit D, Bachmann R. et al . Häufigkeit und Bedeutung von kleinen fokalen Leberläsionen.  Fortschr Röntgenstr. 2001;  173 424-429
  • 5 Ishak K G, Rabin L. Benign tumors of the liver.  Med Clin North Am. 1975;  59 995-1013
  • 6 Wanless I R, Albrecht S, Bilbao J. et al . Multiple focal nodular hyperplasia of the liver associated with vascular malformations of various organs and neoplasia of the brain: a new syndrome.  Mod Pathol. 1989;  2 456-462
  • 7 Harvey C J, Albrecht T. Ultrasound of focal liver lesions.  Eur Radiol. 2001;  11 1578-1593
  • 8 Hohmann J, Skrok J, Puls R. et al . Characterization of focal liver lesions with contrast-enhanced low MI real time ultrasound and SonoVue.  Fortschr Röntgenstr. 2003;  175 835-843
  • 9 Schonland M M, Milward-Sadler G H. et al .Hepatic tumours. Wright R, Alberti KG, Karran S, Milward-Sadler GH Liver and biliary diseases London; Saunders 919
  • 10 Wernecke K, Vassallo P, Bick U. et al . The distinction between benign and malignant tumors and sonography: value of a hypoechoic halo.  AJR. 1992;  159 1005-1009
  • 11 Clarke M P, Kane R A, Steele G . et al . Prospective comparison of preoperative imaging and intraoperative ultrasonography in the detection of liver tumors.  Surgery. 1989;  106 849-855
  • 12 Wernecke Jr K, Rummeny E, Bongartz G. et al . Detection of hepatic masses in patients with carcinoma: comparative sensitivities of sonography, CT, and MR imaging.  Am J Roentgenol. 1991;  157 731-739
  • 13 Ohlsson B, Tranberg K G, Lundstedt C. et al . Detection of hepatic metastases in colorectal cancer: a prospective study of laboratory and imaging methods.  Eur J Surg. 1993;  159 275-281
  • 14 Albrecht T, Hoffmann C, Schmitz S. et al . Detection of liver metastases: comparison of contrast-enhanced phase inversion ultrasound and dual phase spiral CT with intraoperative sonographic correlation.  Radiology. 2000;  207 (P) 459
  • 15 Konopke R, Kersting S, Saeger H D. et al . Detection of liver lesions by contrast-enhanced ultrasound – comparison to intraoperative findings.  Ultraschall in Med. 2005;  26 107-113
  • 16 Albrecht T, Blomley M, Bolondi L. et al . Guidelines for the use of contrast agents in ultrasound. January 2004.  Ultraschall in Med. 2004;  25 249-256
  • 17 Dietrich C F, Ignee A, Trojan J. et al . Improved characterisation of histologically proven liver tumours by contrast enhanced ultrasonography during the portal venous and specific late phase of SHU 508A.  Gut. 2004;  53 401-405
  • 18 Strobel D, Raeker S, Martus P. et al . Phase inversion harmonic imaging versus contrast-enhanced power Doppler sonography for the characterization of focal liver lesions.  Int J Colorectal Dis. 2003;  18 63-72
  • 19 Quaia E, Calliada F, Bertolotto M. et al . Characterization of focal liver lesions with contrast-specific US modes and a sulfur hexafluoride-filled microbubble contrast agent: diagnostic performance and confidence.  Radiology. 2004;  232 420-430
  • 20 Albrecht T, Hoffmann C W, Schmitz S A. et al . Phase-inversion sonography during the liver-specific late phase of contrast enhancement: improved detection of liver metastases.  Am J Roentgenol. 2001;  176 1191-1198
  • 21 Albrecht T, Blomley M J, Burns P N. et al . Improved detection of hepatic metastases with pulse-inversion US during the liver-specific phase of SHU 508A: multicenter study.  Radiology. 2003;  227 361-370
  • 22 Oldenburg A, Hohmann J, Foert E. et al . Detection of hepatic metastases with low MI real time contrast enhanced sonography and SonoVue.  Ultraschall in Med. 2005;  26 277-284
  • 23 Bernatik T, Becker D, Neureiter D. et al . Detection of liver metastases – comparison of contrast – enhanced ultrasound using first versus second generation contrast agents.  Ultraschall in Med. 2003;  24 175-179
  • 24 Blakeborough A, Ward J, Wilson D. et al . Hepatic lesion detection at MR imaging: a comparative study with four sequences.  Radiology. 1997;  203 759-765
  • 25 Soyer P, Levesque M, Caudron C. et al . MRI of liver metastases from colorectal cancer vs. CT during arterial portography.  J Comput Assist Tomogr. 1993;  17 67-74
  • 26 Valls C, Andia E, Sanchez A. et al . Hepatic metastases from colorectal cancer: preoperative detection and assessment of resectability with helical CT.  Radiology. 2001;  218 55-60
  • 27 Ward J, Naik K S, Guthrie J A. et al . Hepatic lesion detection: comparison of MR imaging after the administration of superparamagnetic iron oxide with dual-phase CT by using alternative-free response receiver operating characteristic analysis.  Radiology. 1999;  210 459-466
  • 28 Srivastava D N, Mahajan A. et al . Colour Doppler flow imaging of focal hepatic lesions.  Australasian Radiology. 2000;  44 285-289
  • 29 Wang Y, Wang W P. et al . Resistance index in differential diagnosis of liver lesions by color doppler ultrasonography.  World J Gastroenterol. 2004;  10 965-967
  • 30 Gonzales-Anon M, Cervera-Deval J, Garcia-Vila J H. et al . Characterization of solid liver lesions with color and pulsed Doppler imaging.  Abdominal Imaging. 1999;  24 137-143
  • 31 Liang P, Cao B, Wang Y. et al . Differential diagnosis of hepatic cystic lesions with gray-scale and color doppler sonography.  Journal of Clinical Ultrasound. 2005;  33 100-105
  • 32 Lencioni R, Donati F, Cioni D. et al . Detection of colorectal liver metastases: prospective comparison of unenhanced and ferumoxides-enhanced magnetic resonance imaging at 1.5T, dual-phase spiral CT, and spiral CT during arterial portography.  MAGMA. 1998;  7 76-87
  • 33 Ward J, Chen F, Guthrie J A. et al . Hepatic lesion detection after superparamagnetic iron oxid enhancement: comparison of five T 2-weighted sequences at 1.0T by using alternative-free response receiver operating characteristic analysis.  Radiology. 2000;  214 159-166
  • 34 Dietrich C F, Kratzer W, Strobel D. et al . Assessment of metastatic liver disease in patients with primary extrahepatic tumors by contrast-enhanced sonography versus CT and MRI.  World J Gastroenterol. 2006;  12 1699-1705
  • 35 Bartolozzi C, Donati F, Cioni D. et al . Detection of colorectal liver metastases: a prospective multicenter trial comparing unenhanced MRI, MnDPDP-enhanced MRI and spiral CT.  Eur Radiol. 2004;  14 14-20
  • 36 Regge D, Campanella D, Anselmetti G C. et al . Diagnostic accuracy of portal-phase CT and MRI with mangafodipir trisodium in detecting liver metastases from colorectal carcinoma.  Clinical Radiology. 2006;  61 338-347
  • 37 Rickes S, Ocran K, Schulze S. et al . Evaluierung dopplersonographischer Kriterien zur Differenzialdiagnostik von hepatozellulären Karzinomen und Regeneratknoten bei Leberzirrhose.  Ultraschall in Med. 2002;  23 83-90
  • 38 Strobel D, Kleinecke C, Hänsler J. et al . Contrast-Enhanced Sonography of Hepatocellular Carcinomas – Correlation with Histological Diffrerentiation.  Ultraschall in Med. 2005;  26 270-276
  • 39 Dietrich C F, Schuessler G, Trojan J. et al . Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound.  The British Journal of Radiology. 2005;  78 704-707
  • 40 Bauditz J, Schade T, Wermke W. Sonografische Diagnostik des hilären cholangiozellulären Karzinoms mittels Echosignalverstärker.  Ultraschall in Med. 2007;  28 161-167
  • 41 Caseiro-Alves F, Brito J, Araujo A E. et al . Liver hemangioma: common and uncommon findings and how to improve the differential diagnosis.  Eur Radiol. 2007;  17 1544-1554
  • 42 Vilgrain V, Boulos L, Vullierme M P. et al . Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation.  RadioGraphics. 2000;  20 379-397
  • 43 Vilgrain V. Focal nodular hyperplasia.  European Journal of Radiology. 2006;  58 236-245
  • 44 Bartolotta T V, Taibbi A, Galia M. et al . Characterization of hypoechoic focal hepatic lesions in patients with fatty liver: diagnostic performance and confidence of contrast-enhanced ultrasound.  Eur Radiol. 2007;  17 650-661
  • 45 Bleuzen A, Huang C, Olar M. et al . Diagnostic Accuracy of Contrast-Enhanced Ultrasound in Focal Lesions of the Liver Using Cadence Contrast Pulse Sequencing.  Ultraschall in Med. 2006;  27 40-48
  • 46 Bartolotta T V, Taibbi A, Galia M. et al . Centrifugal (inside-out) enhancement of liver hemangiomas: A possible atypical appearance on contrast-enhanced US.  Eur J Radiol. 2007;  in press
  • 47 Dietrich C F, Mertens J C, Braden B. et al . Contrast-Enhanced Ultrasound of Histologically Proven Liver Hemangiomas.  Hepatology. 2007;  45 1139-1145
  • 48 Nguyen B, Flejou J F, Benoit T. et al . Focal Noduar Hyperplasia of the Liver: A Comprehensive Study of 305 Lesions and Recognition of New Histologic Forms.  American Journal of Surgical Pathology. 1999;  23 1441
  • 49 Rickes S, Ocran K W, Gerstenhauer G. et al . Evaluation of Diagnostic Criteria for Liver Metastases of Adenocarcinomas and Neuroendocrine Tumours at Conventional Ultrasound, Unenhanced Power Doppler Sonography and Echo-Enhanced Ultrasound.  Dig Dis. 2004;  22 81-86
  • 50 Larsen L P, Rosenkilde M, Christensen H. et al . The value of contrast enhanced ultrasonography in detection of liver metastases from colorectal cancer: a prospective double-blinded study.  Eur J Radiol. 2007;  62 302-307

Dr. Anja Oldenburg

Klinik und Hochschulambulanz für Radiologie und Nuklearmedizin, Charite, Campus Benjamin Franklin

Hindenburgdamm 30

12200 Berlin

Phone: ++ 49/30/84 45 64 73 20

Fax: ++ 49/30/84 45 44 74

Email: anja.oldenburg@charite.de