Sonografische Leberdiagnostik bei Tumorpatienten ohne und mit Kontrastmittel

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.

microbubbles - metastases - ultrasound

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