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Comparison of Visual and Quantitative Analysis for Characterization of Insonated Liver Tumors After Microbubble Contrast Injection

Emilio Quaia1, Alessandro Palumbo1, Stefania Rossi1, Francesca Degobbis1, Stefano Cernic1, Giuseppe Tona2 and Maria Cova1

1 Department of Radiology, University of Trieste, Cattinara Hospital, Strada di Fiume 447, Trieste 34149, Italy.
2 Department of Radiology, Hospital of Mestre-Venice, Venice, Italy.


Figure 1
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  		Fig. 1A —Criteria for visual diagnosis of solid liver tumors after microbubble contrast agent injection. Higher, similar, or lower in echogenicity compared with adjacent liver was assessed, respectively, as hypervascular (subjective conspicuity = 1 or 2), isovascular (subjective conspicuity = 0), or hypovascular (subjective conspicuity = -2 or -1). Criteria used for visual diagnosis of malignancy: Diffuse indicates that enhancement of whole lesion was homogeneous or heterogeneous; peripheral rimlike, continuous ring of peripheral contrast enhancement; and absent, no difference before and after microbubble injection, with persistent hypovascular appearance.

 

Figure 2
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  		Fig. 1B —Criteria for visual diagnosis of solid liver tumors after microbubble contrast agent injection. Higher, similar, or lower in echogenicity compared with adjacent liver was assessed, respectively, as hypervascular (subjective conspicuity = 1 or 2), isovascular (subjective conspicuity = 0), or hypovascular (subjective conspicuity = -2 or -1). Criteria used for visual diagnosis of benignancy: Diffuse indicates that enhancement of whole lesion was homogeneous or heterogeneous; peripheral nodular, discontinuous or continuous peripheral enhancement with nodular appearance; central spoke-wheel-shaped, enhancing central vessel appeared to branch toward the periphery of the lesion; and absent, no difference before and after microbubble injection, with persistent hypovascular appearance.

 

Figure 3
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  		Fig. 2A —Images show examples of 5-grade system used for visual analysis of conspicuity of liver tumors at late phase. 50-year-old woman with hepatocellular carcinoma (arrow). Score = 2: hypervascular tumor presenting gray-scale intensity at least double that of adjacent liver.

 

Figure 4
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  		Fig. 2B —Images show examples of 5-grade system used for visual analysis of conspicuity of liver tumors at late phase. 30-year-old woman with focal nodular hyperplasia (arrows). Score = 1: hypervascular tumor presenting gray-scale intensity slightly higher (less than double) than that of adjacent liver.

 

Figure 5
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  		Fig. 2C —Images show examples of 5-grade system used for visual analysis of conspicuity of liver tumors at late phase. 45-year-old woman with hepatocellular adenoma (arrows). Score = 0: isovascular tumor with gray-scale intensity equal to that of adjacent liver.

 

Figure 6
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  		Fig. 2D —Images show examples of 5-grade system used for visual analysis of conspicuity of liver tumors at late phase. 50-year-old woman with hepatocellular carcinoma (arrows). Score = -1: hypovascular tumor presenting gray-scale intensity slightly lower (less than half) than that of adjacent liver.

 

Figure 7
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  		Fig. 2E —Images show examples of 5-grade system used for visual analysis of conspicuity of liver tumors at late phase. 57-year-old woman with liver metastasis (arrows) from colon carcinoma. Score = -2: hypovascular tumor presenting gray-scale intensity at least half that of adjacent liver.

 

Figure 8
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  		Fig. 3A —70-year-old woman with macroregenerative nodule (arrow) in cirrhotic liver. Quantitative analysis of sonography videotape intensity in selected frames grabbed from digital cine clips recorded during arterial phase, 30 sec after microbubble contrast agent injection. Regions of interests (ROIs) are positioned in liver tumor, Corresponding histograms (insets) reveal distribution of sonography videotape intensity in gray-scale levels (0-255) in each ROI.

 

Figure 9
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  		Fig. 3B —70-year-old woman with macroregenerative nodule (arrow) in cirrhotic liver. Quantitative analysis of sonography videotape intensity in selected frames grabbed from digital cine clips recorded during arterial phase, 30 sec after microbubble contrast agent injection. adjacent liver parenchyma. Corresponding histograms (insets) reveal distribution of sonography videotape intensity in gray-scale levels (0-255) in each ROI.

 

Figure 10
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  		Fig. 3C —70-year-old woman with macroregenerative nodule (arrow) in cirrhotic liver. Quantitative analysis of sonography videotape intensity in selected frames grabbed from digital cine clips recorded during arterial phase, 30 sec after microbubble contrast agent injection. Another ROI is positioned outside picture to register sonography videotape intensity of background at constant level (35-40 gray-scale levels) in each analyzed frame. Objective conspicuity of tumor was -0.96.

 

Figure 11
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  		Fig. 4A —61-year-old man with hepatocellular carcinoma in cirrhotic liver. Diffuse heterogeneous contrast enhancement is seen in tumor (arrows) 30 sec after microbubble contrast agent injection.

 

Figure 12
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  		Fig. 4B —61-year-old man with hepatocellular carcinoma in cirrhotic liver. Hypovascular appearance of tumor (arrows) 180 sec after contrast injection, which represents typical appearance of malignant tumor at late phase.

 

Figure 13
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  		Fig. 5A —65-year-old man with liver hemangioma. Nodular peripheral enhancement (arrow) appears 25 sec after microbubble contrast agent injection.

 

Figure 14
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  		Fig. 5B —65-year-old man with liver hemangioma. Progressive complete centripetal fill-in with hypervascular appearance (arrow) is revealed 220 sec after contrast injection, which represents typical appearance of benign tumor at late phase.

 

Figure 15
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  		Fig. 6A —Scatterplots of subjective tumor conspicuity at late phase for different reviewers. Horizontal line indicates median values. Difference between malignant and benign liver tumors was found significant at late phase (p= 0.001, nonparametric Mann-Whitney U test). Scatterplots for reviewers 1.

 

Figure 16
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  		Fig. 6B —Scatterplots of subjective tumor conspicuity at late phase for different reviewers. Horizontal line indicates median values. Difference between malignant and benign liver tumors was found significant at late phase (p= 0.001, nonparametric Mann-Whitney U test). Scatterplots for reviewers 2.

 

Figure 17
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  		Fig. 6C —Scatterplots of subjective tumor conspicuity at late phase for different reviewers. Horizontal line indicates median values. Difference between malignant and benign liver tumors was found significant at late phase (p= 0.001, nonparametric Mann-Whitney U test). Scatterplots for reviewers 3.

 

Figure 18
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  		Fig. 7 —Scatterplots of objective tumor conspicuity at late phase. Horizontal lines indicate median values. Difference between malignant and benign liver tumors was found significant at late phase (p= 0.001, nonparametric Mann-Whitney U test). If compared with subjective analysis, quantitative analysis allowed less overlap between conspicuity values of malignant and benign tumors.

 

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