An Algorithm for the Diagnosis of Focal Liver Masses Using Microbubble Contrast-Enhanced Pulse-Inversion Sonography
Stephanie R. Wilson1,2 and
Peter N. Burns1,3
1 Department of Medical Imaging, University of Toronto, Toronto, ON,
Canada.
2 The Toronto General Hospital, University Health Network, 585 University Ave.,
Toronto, ON M5G 2N2, Canada.
3 Department of Medical Biophysics, University of Toronto Imaging Research, and
Sunnybrook and Women's College Health Sciences Centre, Toronto, ON,
Canada.
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Fig. 1 —Algorithmic procedure developed based on analysis of responses. HCC
= hepatocellular carcinoma.
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Fig. 2A —Hemangioma in asymptomatic 38-year-old woman. (See also Fig. S2,
cine loop, in supplemental data online.) Sagittal baseline sonogram shows
focal echogenic mass in right lobe of liver.
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Fig. 2B —Hemangioma in asymptomatic 38-year-old woman. (See also Fig. S2,
cine loop, in supplemental data online.) Sequential low-mechanical-index early
arterial phase images show peripheral puddles of contrast enhanced more than
adjacent liver parenchyma.
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Fig. 2C —Hemangioma in asymptomatic 38-year-old woman. (See also Fig. S2,
cine loop, in supplemental data online.) Sequential low-mechanical-index early
arterial phase images show peripheral puddles of contrast enhanced more than
adjacent liver parenchyma.
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Fig. 2D —Hemangioma in asymptomatic 38-year-old woman. (See also Fig. S2,
cine loop, in supplemental data online.) Portal venous phase image shows liver
is more enhanced. There has been centripetal progression of enhancement such
that lesion is virtually filled in with contrast agent and is enhanced at
least equal to adjacent parenchyma. Sustained enhancement correctly suggests
benign diagnosis.
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Fig. 3A —Focal nodular hyperplasia in asymptomatic 30-year-old woman. (See
also Fig. S3, cine loop, in supplemental data online.) Baseline sagittal
sonogram shows subtle focal hypoechoic mass in tip of right lobe of liver.
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Fig. 3B —Focal nodular hyperplasia in asymptomatic 30-year-old woman. (See
also Fig. S3, cine loop, in supplemental data online.) Arterial phase image
shows tortuous feeding artery and hypervascular mass. Stellate vascularity is
not optimally shown on this frame.
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Fig. 3C —Focal nodular hyperplasia in asymptomatic 30-year-old woman. (See
also Fig. S3, cine loop, in supplemental data online.) Portal venous phase
image shows positive enhancement of mass in excess of enhancement of liver.
Tiny hypoechoic central scar is seen. Sustained enhancement correlates highly
with benign diagnosis.
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Fig. 4A —Hepatocellular carcinoma in 79-year-old man. (See also Fig. S4, cine
loop, in supplemental data online.) Baseline transverse sonogram of right
liver lobe shows hypoechoic lobulated mass with hypoechoic central zone,
suggesting necrosis.
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Fig. 4B —Hepatocellular carcinoma in 79-year-old man. (See also Fig. S4, cine
loop, in supplemental data online.) Low-mechanical-index arterial phase image
shows dysmorphic lesional vascularity.
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Fig. 4C —Hepatocellular carcinoma in 79-year-old man. (See also Fig. S4, cine
loop, in supplemental data online.) At peak of arterial phase enhancement,
mass is positively enhanced relative to liver.
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Fig. 4D —Hepatocellular carcinoma in 79-year-old man. (See also Fig. S4, cine
loop, in supplemental data online.) In portal venous phase, lesion is
inhomogeneous and again slightly hypoechoic relative to enhanced liver.
Washout is consistent with a malignant diagnosis. Nonenhancing central area on
all images is related to tumor necrosis.
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Fig. 5A —Metastatic colon cancer in 65-year-old man showing peripheral rim
enhancement with rapid washout in portal venous phase. (See also Fig. S5, cine
loop, in supplemental data online.) Baseline transverse sonogram of liver
shows heterogeneity of echotexture of liver and pressure effect on portal vein
but no discrete mass.
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Fig. 5B —Metastatic colon cancer in 65-year-old man showing peripheral rim
enhancement with rapid washout in portal venous phase. (See also Fig. S5, cine
loop, in supplemental data online.) Early arterial phase image shows dominant
mass with marginal vascularity.
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Fig. 5C —Metastatic colon cancer in 65-year-old man showing peripheral rim
enhancement with rapid washout in portal venous phase. (See also Fig. S5, cine
loop, in supplemental data online.) Portal venous phase image shows, in
addition to dominant mass, many other small nonenhancing tumor deposits. This
shows value in detection and characterization of liver masses.
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Fig. 6A —Misdiagnosis with algorithm of focal nodular hyperplasia as
malignant lesion in 46-year-old asymptomatic woman. Baseline sonography shows
small mass (arrow) in segment V of liver.
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Fig. 6B —Misdiagnosis with algorithm of focal nodular hyperplasia as
malignant lesion in 46-year-old asymptomatic woman. Arterial phase image shows
diffuse uniform positive enhancement of mass (arrow) in excess of
enhancement of background parenchyma.
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Fig. 6C —Misdiagnosis with algorithm of focal nodular hyperplasia as
malignant lesion in 46-year-old asymptomatic woman. Portal venous phase
sonogram shows hypoechoic mass (arrow) relative to enhancement of
background liver. This negative enhancement with washout incorrectly suggests
malignant lesion. In portal venous phase, all reviewers interpreted sonogram
as showing negative enhancement with washout. Algorithm diagnosis is wrong, as
it suggests hepatocellular carcinoma. Biopsy showed focal nodular hyperplasia
(FNH). In our experience, only two FNHs have shown negative portal venous
phase enhancement on contrast-enhanced sonography. We do not have an
explanation for this.
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Fig. 7A —Misdiagnosis with algorithm of hepatocellular carcinoma (HCC) as
benign lesion in 47-year-old man with hepatitis B. Baseline transverse image
of liver shows focal hypoechoic mass (arrow).
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Fig. 7B —Misdiagnosis with algorithm of hepatocellular carcinoma (HCC) as
benign lesion in 47-year-old man with hepatitis B. Arterial phase image taken
with infusion technique shows hypervascular mass (arrow).
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Fig. 7C —Misdiagnosis with algorithm of hepatocellular carcinoma (HCC) as
benign lesion in 47-year-old man with hepatitis B. In portal venous phase,
mass (arrow) continues to show inhomogeneous positive enhancement.
All three reviewers interpreted C as showing sustained enhancement,
incorrectly suggesting benign lesion per first step in algorithm.
Contrast-enhanced images are taken in slightly different projection from
baseline image. Biopsy showed HCC.
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Copyright © 2006 by the American Roentgen Ray Society.
