Contrast-Enhanced Subtraction Harmonic Sonography for Evaluating Treatment Response in Patients with Hepatocellular Carcinoma
Hong Ding1,2,
Masatoshi Kudo1,
Hirokazu Onda1,
Yoichiro Suetomi1,
Yasunori Minami1 and
Kiyoshi Maekawa3
1
Department of Gastroenterology and Hepatology, Kinki University School of
Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.
2
Present address: Department of Ultrasound, Zhongshan Hospital, Shanghai
Medical University, 180 Fenglin Rd., Shanghai, 200032, China.
3
Section of Abdominal Ultrasound, Kinki University School of Medicine, Osaka
589-8511, Japan.
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Fig. 1. —Diagram of scanning method in intermittent transmission mode.
Arrows indicate scans to obtain one frame, with height of each arrow
representing amplitude of transmission power (H, high acoustic power; L, low
acoustic power), and distance between arrows shows time interval.
High-acoustic-power image with multishot transmission is displayed on
intermittent image display, whereas low-acoustic-power image is displayed on
monitor image in real time during procedure.
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Fig. 2A. —80-year-old man with 3-cm hepatocellular carcinoma
(arrows, A) in liver segment V who underwent one session of
radiofrequency ablation therapy. First-frame image produced by multishot
contrast-enhanced intermittent harmonic B-mode imaging using Levovist
(Schering, Berlin, Germany) with 5-sec interval shows part of nodule enhanced;
however, rest of nodule is not enhanced.
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Fig. 2B. —80-year-old man with 3-cm hepatocellular carcinoma
(arrows, A) in liver segment V who underwent one session of
radiofrequency ablation therapy. Second-frame image produced by multishot
technique with same trigger as A shows destruction of microbubbles.
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Fig. 2C. —80-year-old man with 3-cm hepatocellular carcinoma
(arrows, A) in liver segment V who underwent one session of
radiofrequency ablation therapy. Digital subtraction image (first-frame image
minus third-frame image) clearly shows residual perfusion flow signals
(enhancement) (arrows) in one portion of nodule and tumor perfusion
defect (arrowheads) in other portion, suggesting incomplete tumor
necrosis.
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Fig. 2D. —80-year-old man with 3-cm hepatocellular carcinoma
(arrows, A) in liver segment V who underwent one session of
radiofrequency ablation therapy. Dynamic arterial phase CT scan shows partial
enhancement (arrows) of tumor, which is consistent with subtraction
harmonic image (A).
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Fig. 3A. —65-year-old man with hepatocellular carcinoma who underwent
transcatheter arterial embolization with Lipiodol (Andre Guerbet,
Aulnay-sous-Bois, France) and percutaneous ethanol injection therapy.
Conventional sonogram shows 2.5-cm hyperechoic lesion (arrows) in
liver segment VI.
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Fig. 3B. —65-year-old man with hepatocellular carcinoma who underwent
transcatheter arterial embolization with Lipiodol (Andre Guerbet,
Aulnay-sous-Bois, France) and percutaneous ethanol injection therapy.
First-frame image produced by multishot ultrasound transmission with same
trigger in Levovist -enhanced (Schering, Berlin, Germany) intermittent
harmonic B-mode imaging with 3-sec transmission interval shows somewhat vague
appearance of vascularity in periphery of tumor (arrows).
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Fig. 3C. —65-year-old man with hepatocellular carcinoma who underwent
transcatheter arterial embolization with Lipiodol (Andre Guerbet,
Aulnay-sous-Bois, France) and percutaneous ethanol injection therapy. Digital
subtraction image clearly shows residual flow signal (enhancement)
(arrows) at periphery of lesion, suggesting incomplete tumor
necrosis. This image depicts tumor perfusion flow better than B.
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Fig. 3D. —65-year-old man with hepatocellular carcinoma who underwent
transcatheter arterial embolization with Lipiodol (Andre Guerbet,
Aulnay-sous-Bois, France) and percutaneous ethanol injection therapy. Dynamic
arterial phase CT scan shows peripheral enhancement (arrows) of same
lesion as in A with central necrosis (arrowhead), which is
consistent with finding obtained using digital subtraction.
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Fig. 4A. —63-year-old man with hepatocellular carcinoma
(arrows, A) in liver segment VI who underwent transcatheter
arterial embolization with Lipiodol (Andre Guerbet, Aulnay-sous-Bois, France)
and radiofrequency ablation therapy. First-frame image produced by multishot
ultrasound transmission with same trigger in Levovist-enhanced (Schering,
Berlin, Germany) intermittent harmonic B-mode imaging with 5-sec transmission
interval. It was difficult to evaluate intranodular vascularity because of
hyperechoic change due to posttreatment necrosis and retention of
Lipiodol.
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Fig. 4B. —63-year-old man with hepatocellular carcinoma
(arrows, A) in liver segment VI who underwent transcatheter
arterial embolization with Lipiodol (Andre Guerbet, Aulnay-sous-Bois, France)
and radiofrequency ablation therapy. Second-frame image of same intermittent
harmonic B-mode image as A. Enhancement of surrounding liver parenchyma
apparently disappeared.
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Fig. 4C. —63-year-old man with hepatocellular carcinoma
(arrows, A) in liver segment VI who underwent transcatheter
arterial embolization with Lipiodol (Andre Guerbet, Aulnay-sous-Bois, France)
and radiofrequency ablation therapy. Digital subtraction image obtained by
subtracting last-frame image from first-frame image (which shows only blood
flow) shows tumor perfusion defect (no enhancement), suggesting complete tumor
necrosis.
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Fig. 4D. —63-year-old man with hepatocellular carcinoma
(arrows, A) in liver segment VI who underwent transcatheter
arterial embolization with Lipiodol (Andre Guerbet, Aulnay-sous-Bois, France)
and radiofrequency ablation therapy. Dynamic arterial phase CT scan reveals
complete retention of iodized oil in lesion and necrotic area induced by
radiofrequency ablation (arrows) at periphery. No viable tumor is
visible.
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