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DOI: 10.1055/a-2219-4726
Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions
Artikel in mehreren Sprachen: English | deutschAbstract
Background
Over the past 20 years, contrast-enhanced ultrasound (CEUS) has become established as a procedure that is complementary to B-mode ultrasound and color Doppler sonography.
Method
The aim of this review is to provide the fundamental knowledge required for examining the liver with CEUS. Additionally, the characteristic CEUS patterns of frequent focal liver lesions are described.
Results and Conclusion
Considering the limitations of ultrasound, CEUS offers an equivalent alternative to other imaging modalities, such as computed tomography and magnetic resonance imaging, for evaluating focal liver lesions. It should be utilized as a primary modality due to its lack of radiation exposure and rapid availability.
Key Points
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CEUS plays an important role particularly in the detection and evaluation of incidentally detected liver lesions.
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Considering the limitations of ultrasound, CEUS offers an equivalent alternative to other imaging modalities, such as CT and MRI, for evaluating focal liver lesions.
Citation Format
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Safai Zadeh E, Prosch H, Ba-Ssalamah A et al. Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions. Fortschr Röntgenstr 2024; 196: 807 – 818
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1 Introduction
Contrast-enhanced ultrasound (CEUS) has become established in the last 20 years as a supplementary method to B-mode ultrasound (B-US) and color Doppler sonography (FDS) and is now routinely performed in corresponding medical issues. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) is continuously updating the possible uses and indications for CEUS and the corresponding procedures [1]. Particularly in the case of the detection and characterization of incidentally discovered focal liver lesions, CEUS has a high recommendation rate (evidence level 1) in the region of the liver [1]. An important characteristic of ultrasound contrast agent is that it remains strictly intravasal, allowing precise visualization of the vascular network in the arterial phase and reliable differentiation between perfused and non-perfused tissue [1].
The present study provides the necessary basic information for examining the liver with ultrasound contrast agent. Moreover, the classic CEUS patterns of common liver lesions are described.
1.1 Basic principles of CEUS
The use and interpretation of CEUS are to be performed under consideration of the patient's clinical background. Therefore, it is decisive for determining the tumor status, e. g., of a focal liver lesion, whether the lesion is observed as an incidental finding during tumor staging or in known liver cirrhosis [2]. The examiner should have a basic understanding of B-mode US and FDS [1]. CEUS is only indicated when the lesion cannot be sufficiently clinically classified on B-mode US and FDS. If there are still uncertainties after CEUS examination, the diagnosis can be determined in consideration of the clinical background by supplementary magnetic resonance imaging (MRI) and if the finding is still unclear with ultrasound-guided biopsy [3].
The contrast agent SonoVue is currently the most commonly used ultrasound contrast agent [1]. It is a second generation contrast agent. The CEUS examination is performed with a low mechanical index (MI) to avoid destruction of the bubbles. SonoVue is a microbubble-based contrast agent comprised of a suspension of microscopic gas bubbles filled with sulfur hexafluoride gas and a phospholipid layer in an aqueous solution [4]. The bubbles are a size of approx. 1–10 μm and resonance vibration occurs during scanning [4]. The bubbles thus act as effective scattering bodies, increase the reflection of ultrasound waves by approximately 1000 fold, and therefore provide better visualization of tissue and tumor perfusion [4]. The contrast agent is eliminated by the lungs [4]. There are no contraindications for the use of CEUS in patients with impaired renal function, cardiac insufficiency, or impaired thyroid function [1] [5]. Its use is contraindicated by known allergic reactions to the contrast agent, acute respiratory distress syndrome (ARDS), severe pulmonary hypertension, uncontrolled systemic hypertension, and a known right-left shunt [5] [6]. Severe anaphylactic reaction to SonoVue is observed in approximately 1 out of 10,000 applications (0.01 %) [1]. In Europe, CEUS is used off label in pediatric patients like many other medications [6]. Initial clinical data indicates that CEUS is safe for use during pregnancy [1]. However, the data regarding the safety of this examination in pregnancy is currently insufficient. The first prospective multicenter study is planned [7].
The requirements for performing CEUS are as follows: 1 – The ultrasound device must have a contrast mode, 2 – the patient must be informed of possible risks and complications and have provided informed written consent, 3 – there should be no contraindications for the examination.
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1.2 Performing CEUS of the liver
The best patient position and the best acoustic window for CEUS should be determined on B-mode US. In general, every peripheral or central vein access can be used for contrast administration. The left arm, usually the antecubital vein, is preferably used for access to avoid contact between the injector and a right-handed examiner. The contrast agent is usually administered as a bolus injection followed by a 10-ml sodium chaser [8]. The dose depends decisively on the type of US device and is usually 1.2–2.4 ml [8].
CEUS of the liver has 3 phases [1]:
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In the arterial phase , the contrast enters the liver through the hepatic artery after administration ([Fig. 1A]). The arterial phase begins with perfusion of the hepatic artery and approx. 10–20 s after administration of the contrast agent and lasts approx. 30–45 s [1].
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In the portal venous phase (liver-specific phase), the contrast agent is initially visible in the portal vein on the image of the hepatic hilum ([Fig. 1B]). The portal venous phase begins with perfusion of the portal vein and approx. 25–45 s after administration of the contrast agent and lasts approx. 120 s [1] [9].
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In the late phase (parenchymal phase), the contrast distributes homogeneously and in a long-lasting manner in the liver after approx. 120 s ([Fig. 1C]) [1] [10].
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It must be taken into consideration that in patients with central access and impaired cardiac function there can be mild to moderate deviations in the times of contrast wash-in and washout [1].
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1.3 Significance of liver vascularization and liver perfusion patterns for CEUS
The liver parenchyma is supplied by a dual vascular system with the majority of the blood flow (approx. 70–75 %) coming from the portal vein and the remaining portion (approx. 25–30 %) being provided by the hepatic artery [1]. In contrast to the provision of nutrition to the liver's own tissue, blood is supplied to pathological liver processes like primary malignant liver tumors, metastases, granulomatous lesions, and inflammatory processes almost exclusively via angiogenesis from branches of the hepatic artery [11]. The vascularization pattern of lesions with neoangiogenesis is characterized by a secondary chaotic vascular pattern often of small vessels [12]. Thus, chaotic perfusion usually in the early arterial phase on CEUS (angiogenesis pattern, [Fig. 2A]) and/or a lack of portal venous, liver-specific perfusion with parenchymal hypoenhancement (washout phenomenon, [Fig. 2B]) indicates non-liver tissue among other things.
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2 Focal fat distribution disorder
As a rule, sonographic findings are to be evaluated in consideration of the clinical background.
2.1 Cystic liver lesions
In 5.8 % of sonographic liver examinations, liver cysts are observed as incidental findings (incidentalomas) [13]. B-mode US is considered the US gold standard for the diagnosis of simple liver cysts [14]. However, CEUS can be used as a diagnostic method for further differentiation in septated cysts or cysts with echogenic content (complicated cysts) [1]. In echogenic cysts, CEUS is used to differentiate between non-perfused content (e. g., hemorrhagic cysts, [Fig. 3A–C]) and perfused content (e. g., metastases with a “cystic” appearance) [1] [15]. Simultaneous peripheral enhancement of the lesion with corresponding clinical symptoms can be an indication of a liver abscess. Hepatobiliary cystadenoma is extremely rare and is potentially precancerous [1] [15].
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In the case of clinical suspicion of cystic echinococcosis of the liver, the outer wall (laminar layer) shows significant enhancement while the inner layer (germinal layer) and the intralesional walls, corresponding to inward pointing daughter cysts, show no enhancement ([Fig. 3D]) [16]. Depending on the stage and the underlying parasites, focal lesions with a solid appearance can also occur. Corresponding to the recommendation of the World Health Organization (WHO), cystic echinococcosis can be classified in five sonomorphological groups [17] [18]. In alveolar echinococcosis the lesions can have an irregular hyperechoic solid margin on B-mode US due to daughter cysts with outward infiltrating growth, with a lack of enhancement in all phases on CEUS ([Fig. 3E]) [19].
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2.2 Focal fat distribution disorder
Focal fat distribution disorders are usually observed as an incidental finding, can be hyperechoic or hypoechoic, and usually have map-like margins on B-mode US. Fat distribution disorders typically manifest along the portal vein or in the immediate vicinity of the gallbladder. If the fat is distributed in a wedge shape or the vessels run normally through the lesion on FDS, CEUS is not necessary [3]. In the case of the morphology of a nodule with simultaneous presence of a malignant primary disease, CEUS is indicated [1]. The enhancement of focal fat distribution disorders is the same as the liver in all phases and they cannot be differentiated from normal liver tissue ([Fig. 4A–C]) [1]. They are rarely an indication of a primary focal lesion (“observation tumor”) [20].
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2.3 Hemangioma
As an incidental finding in a liver that is otherwise morphologically unremarkable on B-mode US, circumscribed, round, usually hyperechoic lesions less than 3 cm in size without a halo sign and without intralesional vessels on FDS are diagnosed as hemangioma [1]. CEUS is indicated when the lesion is greater than 3 cm [1], B-mode US and FDS are not definitive, or a malignant primary disease (e. g., neuroendocrine tumor) is present or possible. The characteristic CEUS feature of a hemangioma is peripheral, iris diaphragm-like ([Fig. 5A]) or tongue-shaped nodular peripheral enhancement ([Fig. 5B]) in the early arterial phase followed by progressive centripetal partial or complete filling in the portal venous and parenchymal phase [1]. The perfusion pattern is described as an iris diaphragm phenomenon similar to computed tomography (CT) and MRI [3]. Lesions with rapid complete wash-in within 30 s are referred to as “high flow” hemangiomas ([Fig. 5C]) [21]. “High flow” hemangiomas comprise approx. 20 % of all hemangiomas [22].
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2.4 Focal nodular hyperplasia (FNH)
Focal nodular hyperplasia (FNH) is usually diagnosed as an incidental finding and has a spoke wheel parenchymal pattern with a central artery visible on FDS in 40 % of cases on B-mode US and FDS [23] [24]. In the case of an atypical pattern and the presence of a primary disease, CEUS is recommended [1]. On CEUS, FNH is typically perfused by a large artery in a central or peripheral location and hyperenhancement is seen on CEUS within several seconds, i. e., the “light bulb phenomenon” [1] ([Fig. 6A–B]). Another common characteristic of FNH in the arterial phase is centrifugal contrast enhancement of the lesions [1]. In the portal venous and late phases, FNH is characterized by homogeneous, usually pronounced enhancement (lack of parenchymal washout phenomenon) [1]. In the late phase, central hypoenhancement or a lack of central enhancement of the central scar can be observed. Together with the centrifugal contrast enhancement in the arterial phase (if visible), this is an important characteristic in the differentiation of high flow hemangiomas [1].
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In the case of an atypical CEUS pattern, supplementary MRI can be helpful. MRI has high specificity of 98 % in the diagnosis of FNH [25]. “High flow” metastases [3] must be considered in the differential diagnosis, particularly when washout is observed in the late parenchymal phase (5–7 minutes), which is always an indication for histological diagnostic confirmation.
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2.5 Hepatocellular adenoma
Hepatocellular adenomas (HCAs) are rare, usually incidental findings, occur at a ratio of 1:5 compared to FNH, and have a nonspecific pattern on B-mode US [3] [13] [21]. Since an HCA does not have any portal vein branches and bile ducts on histopathology and is supplied solely by the hepatic artery, the tumor is comprised of non-liver tissue [21]. On CEUS, an HCA is typically perfused by numerous small peripheral vessels (angiogenesis pattern) and achieves hyperenhancement more slowly compared to an FNH ([Fig. 7A]). During the portal venous phase, a liver adenoma has homogeneous, usually isoechogenic enhancement with typically low parenchymal hypoenhancement ([Fig. 7B]) [1].
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HCAs can be classified as inflammatory adenomas (40–50 % of all adenomas), fatty nuclear factor-positive adenomas (30–40 %), and β-catenin-mutated adenomas (approx. 10 %) [21]. In the case of β-catenin-mutated adenomas, there is a risk (4–8 %) of a malignant transformation to a hepatocellular carcinoma [26]. Reliable differentiation between the different types of adenoma can only be achieved by immunohistochemical examination [21] [27]. Therefore, in the case of every incidental liver lesion with an arterial “angiogenesis pattern” and/or more or less parenchymal hypoenhancement, the presence of non-liver tissue (e. g., adenoma) must be suspected with an indication for supplementary MRI followed by histological confirmation if the finding is still unclear [3] [28]. MRI has high diagnostic accuracy with a sensitivity of 87 % and a specificity of 100 % particularly for steatotic adenomas [28].
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2.6 Regenerative nodules
Lesions in a cirrhotic liver are a diagnostic challenge. While a hepatocellular carcinoma (HCC) can be seen in approximately 60 % of all focal lesions in cirrhotic livers, a regenerative nodule can be diagnosed in 11 % of sonographically detected lesions in a cirrhotic liver [29]. Regenerative nodules are bordered by strands of fibrosis and are comprised of hepatocytes, bile ducts, and Kupffer cells [30]. On B-mode US, regenerative nodules have a nonspecific echo pattern (40 % hypoechoic, 30 % hyperechoic, 30 % echo complex) [31]. A regenerative nodule is characterized by isoechogenic enhancement in all phases compared to the surrounding liver tissue on CEUS ([Fig. 8A]) [32].
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The hepatocytes within the regenerative nodule can transform into an HCC [33]. The transformation to an HCC is a dynamic and slow process associated with a decrease in portal venous perfusion and an increase in arterial perfusion due to tumor neoangiogenesis through the hepatic artery ([Fig. 8B]) [3].
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2.7 Hepatocellular carcinoma (HCC)
In patients with liver cirrhosis or chronic liver diseases like hepatitis B, hepatitis C, non-alcoholic and alcoholic steatohepatitis (NASH, ASH), autoimmune hepatitis, hereditary hemochromatosis, or Wilson's disease must be suspected or ruled out in the case of every solid liver lesion. However, it must be taken into consideration that approximately 20 percent of HCCs occur in patients with a non-cirrhotic liver [34]. HCCs typically show hyperenhancement with an angiogenesis pattern in the arterial phase of CEUS [35]. In the portal venous phase and late phase, HCCs have isoechogenic enhancement lasting up to 6 minutes (lack of washout phenomenon, [Fig. 8C]) due to the pronounced tumor angiogenesis and invasion of the portal venous fields with consecutive shunt formation in 13 % of cases [35]. In 10 % of HCCs, a mild washout phenomenon can occur in the late parenchymal phase (4–6 minutes) ([Fig. 8D]) [35]. According to the current S3 guidelines of the Association of the Scientific Medical Societies in Germany, contrast-enhanced MRI should be used primarily to diagnose an HCC in liver cirrhosis. The use of CEUS or contrast-enhanced CT is only indicated in the case of an unclear MRI finding [36]. A biopsy is recommended in a palliative situation, primarily in the case of suspicion of an HCC in a non-cirrhotic liver, and in the case of unclear contrast behavior in 2 independent imaging methods in a curative treatment approach [36].
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2.8 Liver metastasis
In patients with a malignant primary disease and synchronous or metachronous evidence of a liver lesion, a malignancy should be ruled out. CEUS significantly increases the diagnostic sensitivity and specificity of B-mode US in this case ([Fig. 9]).
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In the arterial phase, these lesions show variable contrast enhancement in terms of chaotic perfusion (angiogenesis pattern) [16]. In the portal venous phase, a washout phenomenon is typically seen in the lesions as an indication of non-liver tissue ([Fig. 10]) [1]. In the case of metastases with arterial hyperenhancement, washout can also occur first in the late parenchymal phase (5–7 minutes). Primary malignant carcinomatous liver lesions ([Fig. 10A]) or also focal lesions in other malignant hematological diseases including infiltrates in malignant lymphoma, Hodgkin lymphoma ([Fig. 10B]), and stem cell diseases (chloroma), have an arterial angiogenesis pattern with parenchymal washout on CEUS like metastases [37].
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In this connection it must be mentioned that benign granulomatous lesions (e. g., sarcoidosis) and also localized chronic inflammation have parenchymal washout ([Fig. 10C]) [3]. In the case of the latter pathology, the parenchymal washout phenomenon on CEUS may be due to localized inflammatory pylephlebitis of the smallest portal veins [38].
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3 Limitations
In general, CEUS as an examiner-dependent method compared to CT and MRI. Therefore, the diagnostic value depends on the experience and expertise of the examiner [39]. Moreover, ultrasound is characterized by a lack of overview compared to other cross-sectional imaging methods. As in B-mode US, deep regions sometimes cannot be visualized on CEUS due to significant sound absorption and regions of the liver and diaphragm cannot be imaged due to overlying gas in patients that are difficult to examine [40]. A further challenge when using CEUS is the fact that multiple lesions in the liver cannot be evaluated at the same time if the lesions do not appear in the same acoustic window [39].
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4 Conclusion
CEUS is an established method for evaluating the status of focal liver lesions and should be used in the case of unclear lesions under consideration of the clinical background and the B-mode US and FDS findings. Under consideration of the limitations of ultrasound, CEUS is an equivalent alternative to imaging methods like CT and MRI in the evaluation of focal liver lesions and should be used as the primary imaging method given the lack of radiation and availability. The examiner must have sufficient competence to perform and interpret CEUS and be familiar with the indications, limitations, contraindications, artifacts, and emergency treatment in the case of complications.
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Conflict of Interest
Christian Görg received funding from Bracco Imaging. Bracco Imaging supported CEUS workshops at the University Hospital Marburg.
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References
- 1 Dietrich CF, Nolsøe CP, Barr RG. et al. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver – Update 2020 – WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultraschall in Med 2020; 41: 562-585 DOI: 10.1055/a-1177-0530.
- 2 Safai ZadehE, Baumgarten MA, Dietrich CF. et al. Frequency of synchronous malignant liver lesions initially detected by ultrasound in patients with newly diagnosed underlying non-hematologic malignant disease: a retrospective study in 434 patients. Z Gastroenterol 2021; DOI: 10.1055/a-1649-8857.
- 3 Schmidt G, Görg C. Kursbuch Ultraschall. 2015. DOI: 10.1055/b-003-124669
- 4 Greis C. Grundlagen. In: Teichgräber U, Fischer T, Clevert DA. Hrsg. Praxisbuch Kontrastmittelsonografie: Kursbuch des CEUS-Kurs-Zertifikats der DRG. Berlin, Heidelberg: Springer Berlin Heidelberg; 2022: 1-20 DOI: 10.1007/978-3-662-61686-4_1
- 5 Michels G, Horn R, Helfen A. et al. [Standardized contrast-enhanced ultrasound (CEUS) in clinical acute and emergency medicine and critical care (CEUS Acute): Consensus statement of DGIIN, DIVI, DGINA, DGAI, DGK, ÖGUM, SGUM and DEGUM]. Med Klin Intensivmed Notfmed 2022; 117: 1-23 DOI: 10.1007/s00063-021-00891-4.
- 6 Sidhu PS, Cantisani V, Deganello A. et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall in Med 2017; 38: 33-43 DOI: 10.1055/s-0042-110394.
- 7 Sidhu PS, Huang DY, Fang C. Contrast enhanced ultrasound (CEUS) in Pregnancy: Is this the last frontier for microbubbles?. Ultraschall in Med 2020; 41: 8-11 DOI: 10.1055/a-0964-9827.
- 8 Dietrich CF, Averkiou M, Nielsen MB. et al. How to perform Contrast-Enhanced Ultrasound (CEUS). Ultrasound Int Open 2018; 4: e2-e15 DOI: 10.1055/s-0043-123931.
- 9 Friedrich-Rust M. Kontrastmittelsonografie der Leber: Literatur-Update und systematische Befundung. https://www.pkd-am-staedel.de/Fortbildung_PKD/fortbildung/2009_06_23_Sonografie.pdf
- 10 Lim AKP, Patel N, Eckersley RJ. et al. Evidence for Spleen-specific Uptake of a Microbubble Contrast Agent: A Quantitative Study in Healthy Volunteers. Radiology 2004; 231: 785-788 DOI: 10.1148/radiol.2313030544.
- 11 Yamaguchi A, Taniguchi H, Kunishima S. et al. Correlation between angiographically assessed vascularity and blood flow in hepatic metastases in patients with colorectal carcinoma. Cancer 2000; 89: 1236-1244 DOI: 10.1002/1097-0142(20000915)89:6<1236::aid-cncr7>3.0.co;2-k.
- 12 Nagy JA, Chang SH, Dvorak AM. et al. Why are tumour blood vessels abnormal and why is it important to know?. British Journal of Cancer 2009; 100: 865-869 DOI: 10.1038/sj.bjc.6604929.
- 13 Kaltenbach TE-M, Engler P, Kratzer W. et al. Prevalence of benign focal liver lesions: ultrasound investigation of 45,319 hospital patients. Abdominal Radiology 2016; 41: 25-32 DOI: 10.1007/s00261-015-0605-7.
- 14 Lantinga MA. Evaluation of hepatic cystic lesions. World Journal of Gastroenterology 2013; 19: 3543 DOI: 10.3748/wjg.v19.i23.3543.
- 15 Larsen LP. Role of contrast enhanced ultrasonography in the assessment of hepatic metastases: A review. World J Hepatol 2010; 2: 8-15 DOI: 10.4254/wjh.v2.i1.8.
- 16 Dietrich CF, Douira-Khomsi W, Gharbi H. et al. Cystic and alveolar echinococcosis of the hepatobiliary tract – the role of new imaging techniques for improved diagnosis. Med Ultrason 2020; 22: 75-84 DOI: 10.11152/mu-2421.
- 17 Brunetti E, Tamarozzi F, Macpherson C. et al. Ultrasound and Cystic Echinococcosis. Ultrasound Int Open 2018; 4: e70-e78 DOI: 10.1055/a-0650-3807.
- 18 [Anonym]. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop 2003; 85: 253-261 DOI: 10.1016/s0001-706x(02)00223-1.
- 19 Kratzer W, Weimer H, Schmidberger J. Echinococcosis: a Challenge for Liver Sonography. Ultraschall in Med 2022; 43: 120-145 DOI: 10.1055/a-1694-5552.
- 20 Chung JJ, Kim MJ, Kim JH. et al. Fat sparing of surrounding liver from metastasis in patients with fatty liver: MR imaging with histopathologic correlation. Am J Roentgenol 2003; 180: 1347-1350 DOI: 10.2214/ajr.180.5.1801347.
- 21 Fröhlich E, Jenssen C, Schuler A. et al. [Contrast-enhanced ultrasound for characterisation of focal liver lesions, practical advice]. Z Gastroenterol 2015; 53: 1099-1107 DOI: 10.1055/s-0035-1553491.
- 22 Tamada T, Ito K, Ueki A. et al. Peripheral low intensity sign in hepatic hemangioma: diagnostic pitfall in hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI of the liver. J Magn Reson Imaging 2012; 35: 852-858 DOI: 10.1002/jmri.23514.
- 23 Bauditz JFK, Wermke W. Sonomorphologie und Kontrastverhalten von Fokal Nodulären Hyperplasien der Leber im Langzeitverlauf. Ultraschall in Med 2006; DOI: 10.1055/s-2006-953916.
- 24 Vidili G, Piscaglia F, Ainora ME. et al. Focal nodular hyperplasia: new findings at Doppler ultrasonography. Eur Rev Med Pharmacol Sci 2020; 24: 12288-12295 DOI: 10.26355/eurrev_202012_24020.
- 25 Hussain SM, Terkivatan T, Zondervan PE. et al. Focal nodular hyperplasia: findings at state-of-the-art MR imaging, US, CT, and pathologic analysis. Radiographics 2004; 24: 3-17 DOI: 10.1148/rg.241035050.
- 26 Chandler CM, Labadie KP, Park JO. et al. Hepatocellular carcinoma arising within a β-catenin mutated inflammatory hepatic adenoma. Human Pathology: Case Reports 2021; 24: 200501 DOI: 10.1016/j.ehpc.2021.200501.
- 27 Goltz D, Fischer HP. Hepatozelluläre Tumoren im nichtzirrhotischen Lebergewebe. Der Pathologe 2015; 36: 597-608 DOI: 10.1007/s00292-015-0113-0.
- 28 Laumonier H, Bioulac-Sage P, Laurent C. et al. Hepatocellular adenomas: magnetic resonance imaging features as a function of molecular pathological classification. Hepatology 2008; 48: 808-818 DOI: 10.1002/hep.22417.
- 29 Alhyari A, Görg C, Alakhras R. et al. HCC or Something Else? Frequency of Various Benign and Malignant Etiologies in Cirrhotic Patients with Newly Detected Focal Liver Lesions in Relation to Different Clinical and Sonographic Parameters. Diagnostics (Basel) 2022; 12 DOI: 10.3390/diagnostics12092079.
- 30 Laniado M. Bildgebung der Leberzirrhose und ihrer Komplikationen. In: Vogl TJ, Mack MG, Balzer JO. Hrsg. LeberMetastasen: Diagnose – Intervention – Therapie. Berlin, Heidelberg: Springer Berlin Heidelberg; 2002: 175-179 DOI: 10.1007/978-3-642-59385-7_14
- 31 Rickes S, Ocran K, Schulze S. et al. [Evaluation of Doppler sonographic criteria for the differentiation of hepatocellular carcinomas and regenerative nodules in patients with liver cirrhosis]. Ultraschall in Med 2002; 23: 83-90 DOI: 10.1055/s-2002-25197.
- 32 Dănilă M, Sporea I, Sirli R. et al. The role of contrast enhanced ultrasound (CEUS) in the assessment of liver nodules in patients with cirrhosis. Med Ultrason 2010; 12: 145-149
- 33 Jeong YY, Yim NY, Kang HK. Hepatocellular carcinoma in the cirrhotic liver with helical CT and MRI: imaging spectrum and pitfalls of cirrhosis-related nodules. Am J Roentgenol 2005; 185: 1024-1032 DOI: 10.2214/ajr.04.1096.
- 34 Lee DH, Lee JM. Primary malignant tumours in the non-cirrhotic liver. Eur J Radiol 2017; 95: 349-361 DOI: 10.1016/j.ejrad.2017.08.030.
- 35 Meitner-Schellhaas B, Jesper D, Goertz RS. et al. Washout appearance of hepatocellular carcinomas using standardized contrast-enhanced ultrasound (CEUS) including an extended late phase observation – Real-world data from the prospective multicentre DEGUM study. Clin Hemorheol Microcirc 2023; DOI: 10.3233/ch-231740.
- 36 Sabrina V, Michael B, Jörg A. et al. [Not Available]. Z Gastroenterol 2022; 60: e56-e130 DOI: 10.1055/a-1589-7568.
- 37 Trenker C, Görg C, Burchert A. et al. Presentation of Chloromas in B-Mode Ultrasound and Contrast-Enhanced Ultrasound. Ultrasound in Medicine & Biology 2022; DOI: 10.1016/j.ultrasmedbio.2022.05.024.
- 38 Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol 2000; 32: 865-871 DOI: 10.1016/s0168-8278(00)80259-7.
- 39 Fang C, Anupindi SA, Back SJ. et al. Contrast-enhanced ultrasound of benign and malignant liver lesions in children. Pediatric Radiology 2021; 51: 2181-2197 DOI: 10.1007/s00247-021-04976-2.
- 40 Claudon M, Dietrich CF, Choi BI. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall in Med 2013; 34: 11-29 DOI: 10.1055/s-0032-1325499.
Correspondence
Publikationsverlauf
Eingereicht: 15. August 2023
Angenommen: 24. Oktober 2023
Artikel online veröffentlicht:
04. Januar 2024
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References
- 1 Dietrich CF, Nolsøe CP, Barr RG. et al. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver – Update 2020 – WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultraschall in Med 2020; 41: 562-585 DOI: 10.1055/a-1177-0530.
- 2 Safai ZadehE, Baumgarten MA, Dietrich CF. et al. Frequency of synchronous malignant liver lesions initially detected by ultrasound in patients with newly diagnosed underlying non-hematologic malignant disease: a retrospective study in 434 patients. Z Gastroenterol 2021; DOI: 10.1055/a-1649-8857.
- 3 Schmidt G, Görg C. Kursbuch Ultraschall. 2015. DOI: 10.1055/b-003-124669
- 4 Greis C. Grundlagen. In: Teichgräber U, Fischer T, Clevert DA. Hrsg. Praxisbuch Kontrastmittelsonografie: Kursbuch des CEUS-Kurs-Zertifikats der DRG. Berlin, Heidelberg: Springer Berlin Heidelberg; 2022: 1-20 DOI: 10.1007/978-3-662-61686-4_1
- 5 Michels G, Horn R, Helfen A. et al. [Standardized contrast-enhanced ultrasound (CEUS) in clinical acute and emergency medicine and critical care (CEUS Acute): Consensus statement of DGIIN, DIVI, DGINA, DGAI, DGK, ÖGUM, SGUM and DEGUM]. Med Klin Intensivmed Notfmed 2022; 117: 1-23 DOI: 10.1007/s00063-021-00891-4.
- 6 Sidhu PS, Cantisani V, Deganello A. et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall in Med 2017; 38: 33-43 DOI: 10.1055/s-0042-110394.
- 7 Sidhu PS, Huang DY, Fang C. Contrast enhanced ultrasound (CEUS) in Pregnancy: Is this the last frontier for microbubbles?. Ultraschall in Med 2020; 41: 8-11 DOI: 10.1055/a-0964-9827.
- 8 Dietrich CF, Averkiou M, Nielsen MB. et al. How to perform Contrast-Enhanced Ultrasound (CEUS). Ultrasound Int Open 2018; 4: e2-e15 DOI: 10.1055/s-0043-123931.
- 9 Friedrich-Rust M. Kontrastmittelsonografie der Leber: Literatur-Update und systematische Befundung. https://www.pkd-am-staedel.de/Fortbildung_PKD/fortbildung/2009_06_23_Sonografie.pdf
- 10 Lim AKP, Patel N, Eckersley RJ. et al. Evidence for Spleen-specific Uptake of a Microbubble Contrast Agent: A Quantitative Study in Healthy Volunteers. Radiology 2004; 231: 785-788 DOI: 10.1148/radiol.2313030544.
- 11 Yamaguchi A, Taniguchi H, Kunishima S. et al. Correlation between angiographically assessed vascularity and blood flow in hepatic metastases in patients with colorectal carcinoma. Cancer 2000; 89: 1236-1244 DOI: 10.1002/1097-0142(20000915)89:6<1236::aid-cncr7>3.0.co;2-k.
- 12 Nagy JA, Chang SH, Dvorak AM. et al. Why are tumour blood vessels abnormal and why is it important to know?. British Journal of Cancer 2009; 100: 865-869 DOI: 10.1038/sj.bjc.6604929.
- 13 Kaltenbach TE-M, Engler P, Kratzer W. et al. Prevalence of benign focal liver lesions: ultrasound investigation of 45,319 hospital patients. Abdominal Radiology 2016; 41: 25-32 DOI: 10.1007/s00261-015-0605-7.
- 14 Lantinga MA. Evaluation of hepatic cystic lesions. World Journal of Gastroenterology 2013; 19: 3543 DOI: 10.3748/wjg.v19.i23.3543.
- 15 Larsen LP. Role of contrast enhanced ultrasonography in the assessment of hepatic metastases: A review. World J Hepatol 2010; 2: 8-15 DOI: 10.4254/wjh.v2.i1.8.
- 16 Dietrich CF, Douira-Khomsi W, Gharbi H. et al. Cystic and alveolar echinococcosis of the hepatobiliary tract – the role of new imaging techniques for improved diagnosis. Med Ultrason 2020; 22: 75-84 DOI: 10.11152/mu-2421.
- 17 Brunetti E, Tamarozzi F, Macpherson C. et al. Ultrasound and Cystic Echinococcosis. Ultrasound Int Open 2018; 4: e70-e78 DOI: 10.1055/a-0650-3807.
- 18 [Anonym]. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop 2003; 85: 253-261 DOI: 10.1016/s0001-706x(02)00223-1.
- 19 Kratzer W, Weimer H, Schmidberger J. Echinococcosis: a Challenge for Liver Sonography. Ultraschall in Med 2022; 43: 120-145 DOI: 10.1055/a-1694-5552.
- 20 Chung JJ, Kim MJ, Kim JH. et al. Fat sparing of surrounding liver from metastasis in patients with fatty liver: MR imaging with histopathologic correlation. Am J Roentgenol 2003; 180: 1347-1350 DOI: 10.2214/ajr.180.5.1801347.
- 21 Fröhlich E, Jenssen C, Schuler A. et al. [Contrast-enhanced ultrasound for characterisation of focal liver lesions, practical advice]. Z Gastroenterol 2015; 53: 1099-1107 DOI: 10.1055/s-0035-1553491.
- 22 Tamada T, Ito K, Ueki A. et al. Peripheral low intensity sign in hepatic hemangioma: diagnostic pitfall in hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI of the liver. J Magn Reson Imaging 2012; 35: 852-858 DOI: 10.1002/jmri.23514.
- 23 Bauditz JFK, Wermke W. Sonomorphologie und Kontrastverhalten von Fokal Nodulären Hyperplasien der Leber im Langzeitverlauf. Ultraschall in Med 2006; DOI: 10.1055/s-2006-953916.
- 24 Vidili G, Piscaglia F, Ainora ME. et al. Focal nodular hyperplasia: new findings at Doppler ultrasonography. Eur Rev Med Pharmacol Sci 2020; 24: 12288-12295 DOI: 10.26355/eurrev_202012_24020.
- 25 Hussain SM, Terkivatan T, Zondervan PE. et al. Focal nodular hyperplasia: findings at state-of-the-art MR imaging, US, CT, and pathologic analysis. Radiographics 2004; 24: 3-17 DOI: 10.1148/rg.241035050.
- 26 Chandler CM, Labadie KP, Park JO. et al. Hepatocellular carcinoma arising within a β-catenin mutated inflammatory hepatic adenoma. Human Pathology: Case Reports 2021; 24: 200501 DOI: 10.1016/j.ehpc.2021.200501.
- 27 Goltz D, Fischer HP. Hepatozelluläre Tumoren im nichtzirrhotischen Lebergewebe. Der Pathologe 2015; 36: 597-608 DOI: 10.1007/s00292-015-0113-0.
- 28 Laumonier H, Bioulac-Sage P, Laurent C. et al. Hepatocellular adenomas: magnetic resonance imaging features as a function of molecular pathological classification. Hepatology 2008; 48: 808-818 DOI: 10.1002/hep.22417.
- 29 Alhyari A, Görg C, Alakhras R. et al. HCC or Something Else? Frequency of Various Benign and Malignant Etiologies in Cirrhotic Patients with Newly Detected Focal Liver Lesions in Relation to Different Clinical and Sonographic Parameters. Diagnostics (Basel) 2022; 12 DOI: 10.3390/diagnostics12092079.
- 30 Laniado M. Bildgebung der Leberzirrhose und ihrer Komplikationen. In: Vogl TJ, Mack MG, Balzer JO. Hrsg. LeberMetastasen: Diagnose – Intervention – Therapie. Berlin, Heidelberg: Springer Berlin Heidelberg; 2002: 175-179 DOI: 10.1007/978-3-642-59385-7_14
- 31 Rickes S, Ocran K, Schulze S. et al. [Evaluation of Doppler sonographic criteria for the differentiation of hepatocellular carcinomas and regenerative nodules in patients with liver cirrhosis]. Ultraschall in Med 2002; 23: 83-90 DOI: 10.1055/s-2002-25197.
- 32 Dănilă M, Sporea I, Sirli R. et al. The role of contrast enhanced ultrasound (CEUS) in the assessment of liver nodules in patients with cirrhosis. Med Ultrason 2010; 12: 145-149
- 33 Jeong YY, Yim NY, Kang HK. Hepatocellular carcinoma in the cirrhotic liver with helical CT and MRI: imaging spectrum and pitfalls of cirrhosis-related nodules. Am J Roentgenol 2005; 185: 1024-1032 DOI: 10.2214/ajr.04.1096.
- 34 Lee DH, Lee JM. Primary malignant tumours in the non-cirrhotic liver. Eur J Radiol 2017; 95: 349-361 DOI: 10.1016/j.ejrad.2017.08.030.
- 35 Meitner-Schellhaas B, Jesper D, Goertz RS. et al. Washout appearance of hepatocellular carcinomas using standardized contrast-enhanced ultrasound (CEUS) including an extended late phase observation – Real-world data from the prospective multicentre DEGUM study. Clin Hemorheol Microcirc 2023; DOI: 10.3233/ch-231740.
- 36 Sabrina V, Michael B, Jörg A. et al. [Not Available]. Z Gastroenterol 2022; 60: e56-e130 DOI: 10.1055/a-1589-7568.
- 37 Trenker C, Görg C, Burchert A. et al. Presentation of Chloromas in B-Mode Ultrasound and Contrast-Enhanced Ultrasound. Ultrasound in Medicine & Biology 2022; DOI: 10.1016/j.ultrasmedbio.2022.05.024.
- 38 Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol 2000; 32: 865-871 DOI: 10.1016/s0168-8278(00)80259-7.
- 39 Fang C, Anupindi SA, Back SJ. et al. Contrast-enhanced ultrasound of benign and malignant liver lesions in children. Pediatric Radiology 2021; 51: 2181-2197 DOI: 10.1007/s00247-021-04976-2.
- 40 Claudon M, Dietrich CF, Choi BI. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall in Med 2013; 34: 11-29 DOI: 10.1055/s-0032-1325499.
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