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Diagnostic Value of Hepatocellular Nodule Vascularity After Microbubble Injection for Characterizing Malignancy in Patients with Cirrhosis

¹ Department of Radiology, Cattinara Hospital, University of Trieste, Strada di Fiume 447, Trieste, Italy 34149.
² Department of Radiology, Hospital G. B. Rossi, University of Verona, Verona, Italy.
³ Department of Radiology, Spedali Civili di Brescia, University of Brescia, Brescia, Italy.
⁴ Biostatistics/Epidemiology/Research Design, Center for Clinical and Translational Science, The Rockefeller University Hospital, New York, NY.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —53-year-old man with liver cirrhosis related to hepatitis C virus infection and with poorly differentiated hepatocellular carcinoma. Unenhanced longitudinal sonogram shows heterogeneous nodule (arrow) with diameter of 2.5 cm.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —53-year-old man with liver cirrhosis related to hepatitis C virus infection and with poorly differentiated hepatocellular carcinoma. Contrast-enhanced Cadence Contrast Pulse Sequencing (CPS; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) is homogeneously hypervascular 25 seconds after microbubble injection during arterial phase (B) and hypovascular in comparison with adjacent liver parenchyma during portal venous phase (C).

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —53-year-old man with liver cirrhosis related to hepatitis C virus infection and with poorly differentiated hepatocellular carcinoma. Contrast-enhanced Cadence Contrast Pulse Sequencing (CPS; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) is homogeneously hypervascular 25 seconds after microbubble injection during arterial phase (B) and hypovascular in comparison with adjacent liver parenchyma during portal venous phase (C).

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —46-year-old woman with liver cirrhosis related to hepatitis C virus infection and with well-differentiated hepatocellular carcinoma. Unenhanced transverse color Doppler sonogram shows nodule (arrow) has diameter of 3 cm and contains intranodular vessels.

View larger version (176K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —46-year-old woman with liver cirrhosis related to hepatitis C virus infection and with well-differentiated hepatocellular carcinoma. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) transverse sonograms show nodule (arrow) appears homogeneously hypervascular 35 seconds after microbubble injection during arterial phase (B) and isovascular to adjacent liver during portal venous phase (C) 160 seconds after microbubble injection because of persistent microbubble uptake in nodule.

View larger version (205K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —46-year-old woman with liver cirrhosis related to hepatitis C virus infection and with well-differentiated hepatocellular carcinoma. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) transverse sonograms show nodule (arrow) appears homogeneously hypervascular 35 seconds after microbubble injection during arterial phase (B) and isovascular to adjacent liver during portal venous phase (C) 160 seconds after microbubble injection because of persistent microbubble uptake in nodule.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —42-year-old man with liver cirrhosis related to hepatitis B virus infection and with poorly differentiated hepatocellular carcinoma. Unenhanced longitudinal sonogram shows nodule (arrow) has diameter of 3 cm and appears hyperechoic.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —42-year-old man with liver cirrhosis related to hepatitis B virus infection and with poorly differentiated hepatocellular carcinoma. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) appears persistently hypovascular during arterial phase (B) 35 seconds after microbubble injection and during portal venous phase (C) 130 seconds after microbubble injection, also with evidence of peripheral rimlike enhancement.

View larger version (186K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —42-year-old man with liver cirrhosis related to hepatitis B virus infection and with poorly differentiated hepatocellular carcinoma. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) appears persistently hypovascular during arterial phase (B) 35 seconds after microbubble injection and during portal venous phase (C) 130 seconds after microbubble injection, also with evidence of peripheral rimlike enhancement.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —75-year-old man with liver cirrhosis related to hepatitis B virus infection and with high-grade dysplastic nodule. Unenhanced oblique color Doppler sonogram shows nodule (arrow) has diameter of 2.3 cm and contains intranodular vessel.

View larger version (189K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —75-year-old man with liver cirrhosis related to hepatitis B virus infection and with high-grade dysplastic nodule. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) oblique sonograms show nodule (arrow) has homogeneous hypervascular appearance during arterial phase (B) and appears isovascular during portal venous phase (C) 130 seconds after microbubble injection.

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —75-year-old man with liver cirrhosis related to hepatitis B virus infection and with high-grade dysplastic nodule. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) oblique sonograms show nodule (arrow) has homogeneous hypervascular appearance during arterial phase (B) and appears isovascular during portal venous phase (C) 130 seconds after microbubble injection.

View larger version (191K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —75-year-old man with liver cirrhosis related to hepatitis B virus infection and with regenerative nodule. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) is 2.5 cm in diameter and appears hypovascular during arterial phase (A) 25 seconds after microbubble injection. Lesion became isovascular in portal venous phase (B) 140 seconds after microbubble injection and is isovascular in portal venous phase 150 seconds after injection.

View larger version (186K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —75-year-old man with liver cirrhosis related to hepatitis B virus infection and with regenerative nodule. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) longitudinal sonograms show nodule (arrow) is 2.5 cm in diameter and appears hypovascular during arterial phase (A) 25 seconds after microbubble injection. Lesion became isovascular in portal venous phase (B) 140 seconds after microbubble injection and is isovascular in portal venous phase 150 seconds after injection.

View larger version (179K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —41-year-old woman with liver cirrhosis and intrahepatic arterioportal shunt. Unenhanced oblique sonogram shows one nodule (arrow) with diameter of 1.5 cm.

View larger version (182K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —41-year-old woman with liver cirrhosis and intrahepatic arterioportal shunt. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) oblique sonograms after microbubble show injection nodule (arrow) is encompassed by diffuse hypervascular appearance persisting during arterial (B) and portal venous (C) phases.

View larger version (177K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —41-year-old woman with liver cirrhosis and intrahepatic arterioportal shunt. Contrast-enhanced Coherent Contrast Imaging (CCI; Acuson Sequoia, Siemens Medical Solutions) oblique sonograms after microbubble show injection nodule (arrow) is encompassed by diffuse hypervascular appearance persisting during arterial (B) and portal venous (C) phases.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —41-year-old woman with liver cirrhosis and intrahepatic arterioportal shunt. Contrast-enhanced CT scan of nodule (arrow) shows clear hypervascularity in arterial phase. Because it appeared solid on unenhanced sonography, nodule was biopsied and later surgically resected.

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Results of receiver operating characteristic analysis show diagnostic confidence in diagnosis of malignancy for unenhanced (solid curve) and contrast-enhanced (dashed curve) sonography. Diagonal line from 0 to 1 represents hypothetical technique with which malignant nodules cannot be differentiated from benign nodules. Graph shows results for reviewer 1.

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Results of receiver operating characteristic analysis show diagnostic confidence in diagnosis of malignancy for unenhanced (solid curve) and contrast-enhanced (dashed curve) sonography. Diagonal line from 0 to 1 represents hypothetical technique with which malignant nodules cannot be differentiated from benign nodules. Graph shows results for reviewer 2.

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