walls, without circulatory signal at Doppler or CEUS investigation. Nowadays we encounter very small HCC's in patients, that we screen for HCC (figure). This may be improved by the use of contrast agents The conclusion must be, that this lesion does not match bloodpool in all phases, so it cannot be a hemangioma. heterogeneous echo pattern. During the portal venous and late phase, the appearance is persistently isoechoic. 4. conditions) and tumoral (HCC). Then we look at liver enzymes, the patients history, do blood tests for various liver diseases. During this phase the center of the lesion becomes hypoechoic, enhancing the tumor these nodules have no circulatory signal. A similar procedure is The patient's general status correlates with the underlying The lesion is hyperdense in the equilibrium phase indicating dens fibrous tissue. establish a differential diagnosis with hepatocellular carcinoma. A history of cirrhosis and high AFP levels favor HCC. intermediate stages of the disease. phase there is a moderate wash out. active bleeding). radiofrequency ablation (RFA) and liver transplantation. This articleand the rest of the serieswill discuss ultrasound evaluation of specific abdominal organs/systems, including scanning principles, normal sonographic appearance, and identification of common abnormalities seen during ultrasound examination. They are applied in order to obtain a full 3 Left untreated, continued fibrotic changes can lead to multilobular cirrhosis. slow flow speed. Abstract Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs . [1], Tumor detection is based on the performance of the method and should include morphometric information (three axes dimensions, volume) and topographic information (number, location specifying liver segment and lobe/lobes). Large hemangiomas can have an atypical appearance. The method Sometimes, especially for HCC treated by occurs. acoustic enhancement phenomenon is seen, which strengthens the suspicion of fluid inflammation. [citation needed], It is the most common liver tumor with a prevalence of 0.4 7.4%. develop HCC. It Some cholangiocarcinomas have a glandular stroma. Calcifications occur in 30-60% of fibrolamellar tumors. conjunction with contrast CT/MRI and to assess the effectiveness of treatment when using an antiangiogenic therapy for hypervascular metastases . [citation needed], Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in It is a heterogeneous disease encompassing a broad spectrum of histologic states characterized universally by macrovesicular hepatic steatosis. Heterogeneous steatosis MRI Definition Steatosis is defined as the accumulation of fatty acids in the form of triglycerides in the cytoplasm of hepatocytes. Currently, local response to treatment is focused on tumor necrosis diagnosed by contrast Malignant lesions however have a tendency to loose their contrast faster than the surrounding liver, so they may become relatively hypodense in later phases. Dr. Leila Hashemi answered Internal Medicine 22 years experience Liver ultrasound: The size is normal but Heterogeneity could be due to fatty liver. It is unique or paucilocular. [citation needed], Please review the contents of the article and, Pseudotumors and inflammatory masses of the liver, Preneoplastic status. Sensitivity is conditioned by the size and Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. Differential diagnosis Therefore, some authors argue that screening well defined, un-encapsulated area, with echostructure and vasculature similar to those of in many centers considers that any new lesion revealed in a cirrhotic patient should be In most clinical settings, increased liver echogenicity is Image above showing sharp contrast between liver echogenicity compared to kidney echogenicity. . In 60% of cases more than one hemangioma is present. the developing context (oncology, septic) are also added. First, histologic studies may lead to misdiagnosis when differentiating HA from FNH. with good liver function. circulatory pattern, displace normal liver structures and even neighboring organs (in case of differentiation and therefore with slower development. Besides the entities listed above inflammatory masses or even pseudo-masses can occur. Hypervascular metastases have to be differentiated from other hypervascular tumors that can be multifocal like hemangiomas, FNH, adenoma and HCC. In these cases, biopsy may On dynamic contrast-enhanced MRi the characteristics of metastases are the same as for CECT. Its development is induced by intake of anabolic hormones and oral contraceptives. Only on the delayed images at 8-10 minutes after contrast injection a relative hyperdense lesion is seen. CEUS. to the experience of the examiner. The most common cause would be central necrosis in a tumor. Following are the characteristic features of some splenic neoplasias: FLC is an uncommon malignant hepatocellular tumor, but less aggressive than HCC. Coarse calcifications are seen in only 5% of patients. On a contrast enhanced CT hypovascular lesions can be obscured if the liver itself is lower in density due to fat deposition. vascularization is typical for HCC and is the key to imaging diagnosis. This appearance was found in approx. So we have a HCC in the right lobe on the upper images and a hemangioma in the left lobe on the lower images. of progressive CA enhancement of the tumor from the periphery towards the center. 3 Abnormal function of the liver. Sometimes the opposite phenomenon can be seen, that is an "island" of The two most common liver lesions causing hepatic hemorrhage are HA and HCC. In terms of staging related to therapy effectiveness, the Barcelona classification is used which identifies five HCC stages. sensitivity and specificity of ultrasound in detecting liver metastases, but also by assessing A heterogeneous liver appears to have different masses or structures inside it when imaged via ultrasound. There are J Ultrasound Med. both arterial and portal phases, while early HCC nodules may have similar 1cm. The lesion on the left has the folowing characteristics: The finding of an infiltrating mass with capsular retraction and delayed persistent enhancement is very typical for a cholangiocarcinoma. In addition oncologists since 2003 because it involves no irradiation and has no hepatic or renal toxicity, Unable to process the form. Rarely the central scar can be on the presence (or absence) of internal thrombosis. confirmation is made using CEUS examination which proves a normal circulatory bed similar FNH is not a true neoplasm. Heterogenous refers to a structure having a foreign origin. The Echogenic Liver: Steatosis and Beyond Ultrasound is the most common modality used to evaluate the liver. The upper images show a lesion that is isodens to the liver on the NECT. This capsule will only show enhancement on delayed scans. appetite. In this pattern, the liver has a heterogeneous appearance with focal areas of increased periportal echogenicity. Adenomas typically measure 8-15 cm and consist of sheets of well-differentiated hepatocytes. With color doppler sometimes the vessels can be seen within the scar. post-therapy), while monitoring of systemic therapies of HCC and metastases are not Particular attention should be paid A history of a primary hypervascular tumor favors metastases. In the arterial phase we see a hyperdense structure in the lateral segment of the left lobe of the liver. These masses may be benign genetic differences or a result of liver disease. without any established signs of malignancy. However if you look at the bloodpool, you will notice that on all phases it is as dense as the bloodpool. In terms of These therapies are based on the There are three These lesions are multiple, but not spread out through the liver. CT sensitivity 24 hours post-therapy is reported to be even lower than vasculature as a sign of incomplete therapy or intratumoral recurrence. hyperemia, presence of intratumoral air, ultrasound limitations (too deep lesion or the parenchyma reconstruction, as occurs in cirrhosis, steatosis accumulation or in case of acute G. Scott Gazelle (Editor), Sanjay Saini (Editor), Peter R. Mueller (Editor). internal bleeding. Another common aspect is "bright Any imaging test done like ct mri or ULTRASOUND etc and it also depends on what cause lead to present disease. When calcified liver metastases are revealed by CT in a patient with unknown primary tumor, colon cancer will be the most likely cause. Doppler signal does not exclude the presence of viable tumor tissue. therefore CEUS appearance is hypoechoic). [citation needed], It consists of localized accumulation of fat-rich liver cells. be cost-effective, it should be applied to the general population and not in tertiary hospitals. FNH is the second most common tumor of the liver. Finally most hemangiomas show complete fill in with contrast. This raises the importance of the operator and equipment dependent part of the ultrasound Coarsened hepatic echotexture is a sonographic descriptor used when the uniform smooth hepatic echotexture of the liver is lost. assess the effectiveness of therapy and to detect other nodules. The tumor's hepatocellular carcinoma can coexist at some moment during disease progression. examination. transonic suggesting fluid composition. In the arterial phase there is enhancement, but not as dense as the bloodpool. [citation needed], They are intravenously administered and are indicated in advanced stages of liver tumor normal liver parenchyma. Complete response is locally proved HCC is a silent tumor, so if patients do not have cirrhosis or hepatitis C, you will discover them in a late stage. Asked for Male, 58 Years. analysis performed using specific software during post-processing in order to assess HCC consists of abnormal hepatocytes arranged in a typical trabecular pattern. This suggested underlying liver fibrosis, although the liver contour was smooth. Rim enhancement is a feature of malignant lesions, especially metastases. increases with the tumor size. Peritumoral edema makes lesions appear larger on T2WI and is very suggestive of a malignant mass. It captures live images of your organs using high frequency sound waves. In addition, it allows for an accurate measurement of the Cystic liver metastases are seen in mucinous ovarian ca, colon ca, sarcoma, melanoma, lung ca and carcinoid tumor. Radiology 1996; 201:1-14. Adenomas may rupture and bleed, causing right upper quadrant pain. Larger HCC lesions typically have a mosaic appearance due to hemorrhage and fibrosis. Although it is difficult to see, there is also portal venous thrombosis on the left. the necrotic area appears larger than at the previous examination. They are very common and are seen in up to 50% of patients with cirrhosis. and the tumor diameter is unchanged. This pattern is commonly seen in colorectal cancer. Ultrasound examination of the liver is performed with patients in a supine position. response to treatment. 68F, referred for ultrasound due to recurrent upper abdominal pain. plays a very important role in monitoring the dysplastic nodules to identify the moment Fatty liver disease . It can be located anywhere in the intrahepatic bile ducts or common bile duct. Tumors can range from benign liver tumors to cancerous masses and metastases from cancer elsewhere in the body. There are not many tumors that cause retraction of the liver capsule, since most tumors will bulge. located in the IVth segment, anterior from the hepatic hilum. metastases, hepatocellular carcinoma and hemangioma and the confusion between They tend to be very large with a mozaic pattern, a capsule, hemorrhage, necrosis and fat evolution. (hepatocellular carcinoma and some types of metastases), have a heterogeneous structure Calcified liver metastases are uncommon. hepatic artery and injection of chemotherapeutic agents (usually adriamycin, but other This behavior of intratumoral different against the general pattern of restructured liver either by different echogenity or by resection) but welcomed. vasculature completely disappearing. It has an incidence of 0.03%. Chemical-shift imaging showing loss of signal on out-of-phase images can confirm the presence of fat. The lesion causes retraction of the liver capsule. Infiltrative cholangiocarcinoma does not cause mass effect, because when the stroma matures, the fibrous tissue will contract and cause retraction of the liver capsule. All these areas of enhancement must have the same density as the bloodpool. radial vessels network develops from this level with peripheral orientation. In recent years, endoscopic ultrasound (EUS)-guided liver biopsy has been adopted as a good alternative to PC and TJ approaches . Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. The nodule's tumor cell replication or multiplication of neoplastic vasculature (antiangiogenic therapies). Some authors consider that early pronounced 10% of HCC are hypodense compared to liver. are represented by the presence of portal venous signal type or arterial type with normal RI Conventional US appearance of metastases is uncharacteristic, consisting as standard method for the evaluation of TACE and local ablative therapies and CEUS and Liver enhancement is often heterogeneous with a mottled appearance, and delayed enhancement in the periphery of the liver and around the hepatic veins is a typical feature. Mild AST and ALT eleva- Thus, highly differentiated HCC illustrates the phenomenon of [citation needed], Spectral Doppler characteristics of early HCC overlap those of the dysplastic nodule, as they At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. therapeutic efficacy. transarterial embolization but without chemotherapeutic agents injection, used in the The content is paucilocular), have distinct delineation, with increased echogenity (hemangiomas, benign Tumor wash out at the end of the arterial phase allows the Checking a tissue sample. Most authors accept the carcinogenesis process as a progressive [citation needed], It is the most common liver malignancy. (single nodule of 25cm, or up to 3 nodules <3cm) which can be treated by 1).Features include increased echogenicity of the liver parenchyma, poor or non-visualisation of the diaphragm, intrahepatic vessels and posterior part of the right hepatic lobe. HCC is known to contain fat in as many as 40% of lesions, therefore the presence of fat does not help differentiate the lesions. Now it has been proved that the Rarely, sizes can reach several centimeters, leading up to the substitution of a whole liver [citation needed], Local recurrence is defined as recurrence of a hyperenhanced area at tumor periphery in the However in 20% of patients the scar is hypointense. borderline lesions such as dysplastic nodules and even early HCC. guided biopsy; at a size over 20mm one single dynamic imaging technique with Similar observation was made in ultrasound scan earlier this month but doctors told it is fatty liver and nothing to . In case of highgrade You'll need to see a gastroenterologist, who hopefully specialises in the pancreas, who can . avoid oily fatty foods etc including milk and derivatives. When an ultrasound states it is minimally heterogeneous.it means its surface has a different echotexture.this could be that it is developing a more coarse appearance which means possible liver disease that has no known cause. (1997) ISBN: 0865777160, CT NCAP (neck, chest, abdomen and pelvis), left ventricular systolic and diastolic function, ultrasound-guided musculoskeletal interventions, gluteus minimus/medius tendon calcific tendinopathy barbotage, lateral cutaneous femoral nerve of the thigh injection, common peroneal (fibular) nerve injection, metatarsophalangeal joint (MTPJ) injection. On ultrasound? Liver involvement can be segmental, By looking at the other phases to see if the enhancing areas match the bloodpool, it is usually possible to differentiate these lesions. contrast enhancement of a nodule within 12cm developed on a cirrhotic liver is sufficient signal may be absent in both regenerative and dysplastic nodules. Thus, during the arterial totally "filled" with CA, hemangioma appears isoechoic to the liver. Although fatty liver disease may progress, it can also be reversed with diet and lifestyle changes. This can occur due to a number of reasons which include: conditions that cause hepatic fibrosis 1 cirrhosis hemochromatosis various types of hepatitis 3 particularly chronic hepatitis conditions that cause cholestasis Residual tumor has poorly defined edges, irregular shape, High-grade dysplastic nodules are hypovascularized or chronic inflammatory diseases. c. stable disease (is not described by a, b, or d) diagnosis of benign lesion. Fatty liver is a reversible condition that can be brought on by bad diet or high alcohol consumption. metastases). Typically, these tumors are more difficult to see than fatty deposits because the difference between the cells in the tumor and regular liver cells may not be obvious on a CT scan. CEUS exploration, by [citation needed], US examination is required to detect liver metastases in patients with oncologic history. To this adds the particularities of intratumoral ablation to confirm the result of the therapy. [citation needed], Ablative therapies are considered curative treatments for HCC together with surgical the circulatory bed during arterial phase and completely enhancement during portal venous above described behavior can occur in arterialized hemangiomas or those containing You see it on the NECT and you could say it is hypodens compared to the liver. You will only see them in the arterial phase. Always look how they present in the other phases and compare with the bloodpool and remember that rim enhancement is never hemangioma. arterial phase followed by wash out during portal venous and late phase. [citation needed], Ultrasound exploration can be an effective procedure for the assessment of liver tumors The patient has a good general short time intervals. Inconclusive ultrasound results warranted a CT scan of the chest, abdomen and pelvis with contrast, which showed a heterogeneous low-density lesion within the right lobe of the liver that extended to the left lobe (Figure 5). As per ultrasound scan report of today, it has been observed that "heterogeneous echotexture of liver with irregular nodular surface of concern for chronic liver parenchymal disease" and "mild ascites". It can be associated with other as it is unable to differentiate viable tumor tissue from post-therapy tumor necrosis. Echogenity is variable. On delayed images the capsule and sometimes septa demonstrate prolonged enhancement. therapeutic efficacy as early as possible. Removing a tissue sample (biopsy) from your liver may help diagnose liver disease and look for signs of liver damage. The specification of these data is important for staging liver tumors and prognosis. Nevertheless, chronic Budd-Chiari syndrome may be difficult to differentiate from cirrhosis ( 8 ). late or even very late "wash out" while poorly differentiated HCC has an accelerated wash [citation needed], It is a benign tumor made up of normal or atypical hepatocytes. They typically displace normal liver vessels but no vascular or biliary invasion limited in the first few days after the procedure, and refers only to its complications, due to . Within 3 weeks the small lesion in the left liver lobe progressed to this huge abces. nodule as a characteristic feature of dysplastic nodules and early HCC (Minami & Kudo, Some authors indicate the What is a heterogeneous liver? The correlation In some cases this accumulation can It is nodular or globular and discontinuous. to the analysis of the circulatory bed. Arterial It consists of selective angiographic catheterization of the Imaging features of FLC overlap with those of other scar-producing lesions including FNH, HCC, Hemangioma and Cholangiocarcinoma. of circumscribed lesions, with clear, imprecise or "halo" delineation, with homogeneous or This article is based on a presentation given by Richard Baron and adapted for the Radiology Assistant by Robin Smithuis. During venous and sinusoidal phase the pattern is hypoechoic, and Whenever you see a small cyst-like lesion in a patient who recently underwent an ERCP, be very carefull to assume it is just a simple cyst. [citation needed], In case of successful treatment, US monitoring using CEUS is performed every three mass with irregular shapes, fringed, with fluid or semifluid content, with or without air inside. {"url":"/signup-modal-props.json?lang=us"}, Weerakkody Y, Jones J, Bell D, et al. On CEUS examination both RN and DN may have quite a variable enhancement pattern. Thus, a possible residual insufficient, requiring morphologic diagnostic procedures, use of other diagnostic imaging For example, a dermoid cyst has heterogeneous attenuation on CT. When striving to protect your liver, aim to drink lots of water, eat high . considered complementary methods to CT scan. (radiofrequency, laser or microwave ablation). Most liver metastases are multiple, involving both lobes in 77% of patients and only in 10% of cases there is a solitary metastasis. (Claudon et al., 2008). compare the tumor diameter before therapy with the ablation area. They CEUS examination is for deep or small lesions. In Color Doppler However, this pattern is not specific for metastases as it can also be seen in primary malignant liver neoplasms (eg, HCC) and benign liver neoplasms (eg, adenoma in glycogen storage disease). A liver ultrasound is an essential tool that . Early HCC needs to be differentiated from other hypervascular lesions, that will be hyperdense in the arterial phase. On the other hand, CE-CT is also Patients with glycogen storage disease, hemochromatosis, acromegaly, or males on anabolic steroids also are more prone to developing hepatic adenomas. It is generally ultrasound every 3 months, as the growth trend is an indication for completion of scar. techniques, CEUS is the one that brought a significant benefit not only by increasing the Hypoechoic appearance is circulatory bed is rich in microcirculatory and portal venous elements. On a NECT these lesions usually are better depicted (figure). TACE therapeutic results by contrast imaging techniques is performed as for ablative or cysts inside is suggestive for parasitic, hydatid nature. symptomatic therapy applies. hypovascular metastases and small liver cysts is added. asymptomatic but also can be associated with pain complaints or cytopenia and/or HCC becomes isodense or hypodense to liver in the portal venous phase due to fast wash-out. The presence of membranes, abundant sediment <2cm (from <5% in the 90s in Europe to > 30% today in Japan) with curative therapy 20%. This could also be an adenoma, but HCC would be unlikely because they show a fast wash out. compared PC-LB and EUS-LB methods in terms of diagnostic outcomes including accuracy and safety for both focal and parenchymal liver diseases . Their diagnosis is quite difficult and the criteria used for differentiation are often Intraoperative use of [citation needed]. the tumor as an eccentric area behaving as the original tumor at CEUS examination, with The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent. By ultrasound metastases to the liver usually take on one of the following appearances: (1) hypoechoic mass, (2) mixed echogenicity mass, (3) mass with target appearance, (4) uniformly echogenic . Although CE-CT and/or MRI are considered the method of choice in post-therapy First look at the images on the left and look at the enhancement patterns. alcoholization (PEI) hyperenhanced septa or vessels can be shown inside the lesion. Neoformation vessels occur with increasing degree of dysplasia. While FNH is always very homogeneous, FLC is usually heterogeneous following contrast administration. In contrast to FNH the central scar in FLC will usually be hypointense on T2WI and will less often show delayed enhancement. Other elements contributing to lower US Characteristic 2D ultrasound appearance is that of a very adenocarcinomas) with hypoechoic pattern during arterial phase, and similar during portal 2 A distended or enlarged organ. First look at the images on the left and try to find good descriptive terms for what you see. investigations with other diagnostic procedures; at a size between 10 20mm two Ultrasound revealed a hypertrophic, heterogeneous liver and a large shunt between a patent umbilical vein and the left branch of the portal vein. The enhancement pattern is characterized by sequential contrast opacification beginning at the periphery as one or more nodular areas of enhancement. The biliary route is often the result of biliary manipulation as in ERCP. Small hemangiomas may show fast homogeneous enhancement ('flash filling'). A mild and high-grade dysplastic nodules with moderate or severe cellular atypia, but Microcirculation investigation allows for discrimination between benign and malignant tumors. Adenomas may diminish after oral contraceptives are discontinued, but this does not lower the risk of malignant transformation. The most common tumor that causes retraction besides cholangiocarcinoma is metastatic breast cancer. Liver ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI) are the primary imaging modalities to diagnose liver lesions. The bacteria enter through the slow flow portal system and they are layered within the vessel. Doppler circulation signal. and avoids intratumoral necrotic areas. normal liver (metastases). molecules are currently the subject of clinical trials), followed by embolization of hepatic Diagnosis and characterization of liver tumors require a distinct approach for each group of These lesions need to be differentiated from other lesions with a scar like FLC, FNH and Cholangiocarcinoma. In the portal venous phase however, the enhancement is not as bright as the enhancement of the portal vein. Computed tomography angiography revealed that this large vessel was a spontaneous extrahepatic portocaval shunt draining portal flow to the iliac veins through the inferior epigastric veins ( Fig. lemon juice etc. Using CEUS examination to detect metastases a sensitivity of 8095% is obtained, similar to methods or patient reevaluation from time to time. Hepatocellular adenomas are large, well circumscribed encapsulated tumors. Rim enhancement is continuous peripheral enhancement and is never hemangioma. Complete fill in is sometimes prevented by central fibrous scarring. is therefore mandatory to analyze all these three phases of CEUS examination for a proper shows no circulatory signal. resection and liver transplantation and they are indicated for early tumor stages in patients anemia when it is very bulky. therapeutic efficacy. useful to exclude an active lesion at the moment of exploration but does not have absolute Often, other diagnostic procedures, especially interventional ones are no longer necessary. If you would describe the image on the left, you would use terms as: So these findings suggest liverabscesses especially because it's clustered. Biliary abscesses start small but can progress rapidly. As a result of the risk of intraperitoneal hemorrhage and the rare occurrence of malignant transformation to HCC, surgical resection has been advocated in most patients with presumed HA. CEUS examination cannot completely replace the other imaging them intercommunicating, some others blocked in the end with "glove finger" appearance, CEUS examination is useful because it confirms the parenchymal hyperemia. It can be a constricting or an expanding lesion, because it can have a fibrous or a glandular stroma. The ultrasonographic appearance of splenic neoplasia is variable and can include splenomegaly or focal mass lesions, which are commonly poorly defined, anechoic, hypoechoic, targetlike, 22 or complex, similar to those of the liver. Metastases in fatty liver after the procedure, including CEUS, can show apart from the character of the lesion any Doppler and requires other imaging procedures, follow up and measurements of the tumor at During the portal venous The risk of significant bleeding from the tumor is as high as 30%.