Contrast-enhanced ultrasonography of the liver using SonoVue

Abstract

This review focuses on the use of contrast-enhanced ultrasonography (CEUS) with SonoVue (Bracco Imaging) for the diagnosis of focal liver lesions (FLLs), guidance during ablative treatment, and follow-up of liver tumors. Multicenter trials have shown that the performance of CEUS for the characterization of FLLs is similar to that of contrast-enhanced computed tomography or contrast-enhanced magnetic resonance imaging. CEUS with SonoVue has been effectively used for guiding the percutaneous treatment of malignant liver tumors that are invisible or poorly visualized in traditional gray-scale ultrasonography. Postprocedural CEUS may be used to detect and retreat residual viable tissue in the same ablative session. The use of CEUS for the assessment of diffuse liver disease is also discussed.

Keywords: Carcinoma, hepatocellular; Contrast-enhanced ultrasound; Liver; Liver metastasis; Liver tumors.

Fig. 1.. Focal nodular hyperplasia in a 36-year-old woman without a history of liver disease.

A. A 4.8×5.1-cm incidental focal liver lesion in segment 5 shows a spoke-wheel appearance (arrow) after SonoVue injection. In the early arterial phase, there was centrifugal enhancement. B. In the late phase, the lesion exhibits sustained enhancement except a central scar (arrow).

Fig. 2.. Hepatocellular carcinoma in a 69-year-old cirrhotic man with alcohol addiction and chronic hepatitis B.

A. During surveillance, a 2.5-cm nodule was detected in segment 5. In the early arterial phase, the lesion becomes hyper-enhancing (arrow) with respect to the surrounding liver. B. The nodule is iso-enhancing (arrow) in the portal venous phase. C. The nodule showed a slow and mild washout and becomes hypoechoic (arrow) in the late phase.

Fig. 3.. A 68-year-old woman with liver cirrhosis and a hyperechoic nodule in segment 7.

A. In contrast-enhanced ultrasonography, the nodule shows a globular enhancement (arrow) in the arterial phase. This feature was typical of hemangioma. B. In the late phase, the entire nodule is hyper-enhancing (arrow) with respect to the adjacent liver. It was categorized as LR-1 (a definitely benign lesion).

Fig. 4.. A 64-year-old man with chronic hepatitis C.

A. A 9-mm hypoechoic nodule (arrow) is seen in segment 5 liver. B. In the arterial phase, the nodule shows enhancement similar to the surrounding liver parenchyma. C. In the portal venous phase, there is no washout of the contrast material distinguished from background parenchyma. D. In the late phase, the nodule looks still iso-enhancing. It was classified as LR-2 (probably benign).

Fig. 5.. A 62-year-old man with alcoholic liver cirrhosis.

A. During surveillance, a 19-mm nodular lesion (arrow) is seen in segment 7. B. The nodule is iso-enhancing with respect to the surrounding liver parenchyma in the arterial phase. C. In the late phase, 3 minutes 45 seconds after the administration of the ultrasound contrast, the nodule looks still iso-enhancing. D. Later, at 4 minutes 28 seconds, mild washout (arrows) is detected. The nodule was classified as LR-3 (an intermediate probability of hepatocellular carcinoma). Ultrasonography-guided biopsy of the nodule confirmed a high-grade dysplastic nodule.

Fig. 6.. A 68-year-old man with alcoholic liver cirrhosis.

A. A 7-mm subcapsular nodule (arrow) is seen during a surveillance ultrasonography. B. The whole nodule is hyper-enhancing (arrow) in the arterial phase. C. The nodule shows mild and late washout (arrow) in the late phase, 2 minutes 30 seconds after the injection of the contrast. Due to a size smaller than 10 mm, it was classified as LR-4 (a nodule with high probability for hepatocellular carcinoma). Ultrasound-guided biopsy of the nodule confirmed a well-differentiated hepatocellular carcinoma.

Fig. 7.. A nodule 3 cm in size in a 72-year-old woman with liver cirrhosis.

A. The nodule is hyper-enhancing (arrow) in the arterial phase. B. The nodule shows mild and late washout (arrow), which is typical for hepatocellular carcinoma. It was classified as LR-5 (definitely hepatocellular carcinoma).

Fig. 8.. A 75-year-old man with liver cirrhosis and hepatocellular carcinoma.

A. Unenhanced ultrasound shows a thrombus (arrow) in the left branch of the portal vein. B. The thrombus shows enhancement (arrow) in the arterial phase. C. In the late phase, there is washout of the contrast (arrow), allowing the diagnosis of a neoplastic thrombus (i.e., a tumor in the vein) following the contrast-enhanced ultrasonography Liver Imaging Reporting and Data System classification (LR-5V).

Fig. 9.. A 45-year-old woman with colon cancer and a synchronous metastasis.

A. It shows early enhancement (arrow) in the arterial phase, 20 seconds after the contrast injection. B. There is a very rapid washout (arrow) in the arterial phase, 36 seconds after the contrast injection. C. In the late phase, the contrast looks completely washed out (arrow).

Fig. 10.. Hepatocellular carcinoma in a 72-year-old man with chronic hepatitis C and Child A liver cirrhosis.

A. The figure shows hyper-enhancement (arrow) of the mass in the arterial phase. B. Percutaneous microwave ablation of the hepatocellular carcinoma performed at a power of 100 W delivered by the antenna for 10 minutes. The figure shows the microwave antenna correctly positioned in the mass. C. Twenty-four hours after treatment, contrast-enhanced ultrasonography shows no enhancement (arrow) of the mass, indicating that the lesion had been effectively ablated.