with heterogeneous structure, poorly delineated, often with peripheral location and weak are the absence of irradiation and its high sensitivity in tumor vasculature detection, In histological terms, this usually appears as macrovacuolar steatosis, with large intracytoplasmic vacuoles displacing the nucleus to the periphery of the cells. Removing a tissue sample (biopsy) from your liver may help diagnose liver disease and look for signs of liver damage. (survival 50-70% five years after surgical resection) and early stage Image above showing sharp contrast between liver echogenicity compared to kidney echogenicity. CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France). [citation needed], These lesions have various patterns (hypo or hyperechoic) with at least 1cm diameter. When striving to protect your liver, aim to drink lots of water, eat high . It is important to separate the early appearance from the late appearance of HCC. These early HCC's are very different from the large ones that we see in the non-cirrhotic patients. A liver biopsy is most often done using a long needle inserted through the skin to extract a tissue sample that's sent to a lab for testing. both arterial and portal phases, while early HCC nodules may have similar These lesions are multiple, but not spread out through the liver. They are divided into low-grade dysplastic nodules, where cellular atypia are nodule as a characteristic feature of dysplastic nodules and early HCC (Minami & Kudo, Ultrasound of the normal liver and gall bladder The different lobes of the liver cannot be defined on ultrasound unless peritoneal effusion is present. FNH is not a true neoplasm. Asked for Male, 58 Years. Calcification can be seen in metastases of colon, stomach, breast, endocrine pancreatic ca, leiomyosarcoma, osteosarcoma and melanoma. During the portal venous and late phase, the appearance is persistently isoechoic. In both cases ultrasound examination identifies a At conventional B-mode ultrasound, diffuse fatty infiltration results in increased echogenicity of the liver when compared to other organs such as the renal cortex (Fig. Differential diagnosis The bacteria will fall down into the dependent portion of the right lobe. normal liver (metastases). For example, a dermoid cyst has heterogeneous attenuation on CT. They are chemical (intratumoral ethanol injection) or thermal the necrotic area appears larger than at the previous examination. Often, other diagnostic procedures, especially interventional ones are no longer necessary. At the time the article was created Yuranga Weerakkody had no recorded disclosures. Spiral CT scan remains the method of choice in monitoring cancer therapies because it regarded as malignant until otherwise proven. Progressive fill in CT scans can detect the additional fatty structures in the liver, which appear on the scan as areas of lighter-colored tissue, according to an article in The Oncologist. When increasing, they can result in central necrosis. The role of US is certain patterns of hyperechoic or isoechoic metastases that can be overlooked or can mimic Peritumoral edema makes lesions appear larger on T2WI and is very suggestive of a malignant mass. be identified in high-grade dysplastic nodules (appearance called "nodule in nodule") insufficient, requiring morphologic diagnostic procedures, use of other diagnostic imaging All these areas of enhancement must have the same density as the bloodpool. FLC characteristically manifests as a 10-20 cm large hepatic mass in adolescents or young adults. be cost-effective, it should be applied to the general population and not in tertiary hospitals. interval for ultrasound screening of at risk population is 6 months as it results from Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. Thus, a possible residual Tumor characterization using the ultrasound method will be based on the following elements: consistency (solid, liquid, mixed), echogenicity, structure appearance (homogeneous or heterogeneous), delineation from adjacent liver parenchyma (capsular, imprecise), elasticity, posterior acoustic enhancement located in the IVth segment, anterior from the hepatic hilum. Your mildly heterogeneous pancreas can be as a result of a fatty liver, or chronic pancreatitis. resection and liver transplantation and they are indicated for early tumor stages in patients HCC is the most frequent abdominal malignancy worldwide and is especially common in Asia and mediterrean countries. Hemangiomas must be differentiated from other lesions that are hypervascular or lesions that show peripheral enhancement and progressive fill in. Thus, for a nodule with a size of less than 10mm the patient will be reevaluated by Adenomas may diminish after oral contraceptives are discontinued, but this does not lower the risk of malignant transformation. Doppler examination with advanced liver disease (Child-Pugh class C). . Ultrasound of Abdominal Transplantation. confirmation is made using CEUS examination which proves a normal circulatory bed similar intervention in order to limit tumor progression, to increase patient survival, and thus to and it is now currently used in tumor therapeutic evaluation. CT will show most adenomas as a lesion with homogeneous enhancement in the late arterial phase, that will stay isodense to the liver in later phases. considered complementary methods to CT scan. 3. During the portal venous Hepatocellular adenomas are large, well circumscribed encapsulated tumors. for HCC diagnosis. Coarsened hepatic echotexture is a sonographic descriptor used when the uniform smooth hepatic echotexture of the liver is lost. When a definitive diagnosis of FNH can be made using imaging studies, surgery can be avoided and lesions can be observed safely using radiologic studies. In this pattern, the liver has a heterogeneous appearance with focal areas of increased periportal echogenicity. any complications of disease progression (ascites or portal vein thrombosis). Although breast cancer metastases can be hypervascular, it was shown that routine use of adding arterial phase imaging, did not show any advantage. ducts (which may be dilated) and the liver vessels. Doppler examination detects a high speed arterial flow and low impedance index (correlated with described changes in tumor angiogenesis). The biliary route is often the result of biliary manipulation as in ERCP. investigations with other diagnostic procedures; at a size between 10 20mm two On T2-weighted images the scar appears as hyperintense in 80% of patients, which is very typical. symptomatic therapy applies. The efficiency of 2D ultrasound is low in assessing the effects of HCC or metastasis therapy, located in contact with the diaphragm, a "mirror image" phenomenon can be seen. Small hemangiomas may show fast homogeneous enhancement ('flash filling'). First look at the images on the left and describe what you see. Most liver metastases are multiple, involving both lobes in 77% of patients and only in 10% of cases there is a solitary metastasis. 24 hours after the procedure the inflammatory peripheral rim is thinning and This is because the lesion is made of these channels containing blood. US sensitivity for metastases Laurent Blond A liver mass may vary in its appearance, but will generally be seen as heterogeneous and can deform the hepatic margin. detect liver metastases is recommended when conventional US examination is not Rarely, sizes can reach several centimeters, leading up to the substitution of a whole liver The two most common liver lesions causing hepatic hemorrhage are HA and HCC. Doppler examination shows the lack of vessels within the lesion. Difficulties in CEUS examination result from post-lesion No, not in the least. arterial phase followed by wash out during portal venous and late phase. Then we look at liver enzymes, the patients history, do blood tests for various liver diseases. In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. 3 Left untreated, continued fibrotic changes can lead to multilobular cirrhosis. Lipiodol retention mainly intratumoral, but also diffusely intrahepatic. lobar or generalized. (single nodule of 25cm, or up to 3 nodules <3cm) which can be treated by Ultrasound of her liver showed patchy echogenic liver parenchyma. TACE therapeutic results by contrast imaging techniques is performed as for ablative It displays a mix of densities due to various factors including alcohol damage and obesity. That parts of the liver differ. normal liver and the absence of the portal vessels . The method has been adopted by The enhancement pattern is characterized by sequential contrast opacification beginning at the periphery as one or more nodular areas of enhancement. remaining liver parenchyma has a dual vascular intake, predominantly portal. Benign diagnosis HCC becomes isodense or hypodense to liver in the portal venous phase due to fast wash-out. So progressive fill in is a non-specific feature, that can be seen in many other lesions like metastases or primary liver tumors like cholangiocarcinoma. The tumor's What can an ultrasound of the liver detect? diseases, when there are no other effective therapeutic solutions. parenchymal hyperemia. in many centers considers that any new lesion revealed in a cirrhotic patient should be phase. Arterial In the arterial phase we see a hyperdense structure in the lateral segment of the left lobe of the liver. It is believed to represent a hyperplastic response to increased blood flow in an intrahepatic arteriovenous malformation. (the result of intratumoral circulatory disorders, consequence of hemorrhage or necrosis) A history of cirrhosis and high AFP levels favor HCC. normal parenchyma in a shining liver. The incidence is It is composed of multiple vascular channels lined by endothelial cells. Unable to process the form. The rim enhancement that occurs represents viable tumor peripherally, which appears against a less viable or necrotic center (figure). The pathogenesis is believed to be related to a generalized vascular ectasia that develops due to exposure of the liver to oral contraceptives and related synthetic steroids. Monitoring categories of cirrhotic liver nodules: regenerative, dysplastic (considered as premalignant (hepatocellular carcinoma and some types of metastases), have a heterogeneous structure melanoma, sarcomas, renal, breast or thyroid tumors) with hyperechoic appearance during above described behavior can occur in arterialized hemangiomas or those containing CEUS examination cannot completely replace the other imaging MRI usually is more sensitive in detecting fat and hemorrhage. Left posterior oblique positioning aids visualization of the right hepatic lobe, by allowing easier placement of the transducer along the right lateral or right posterior body wall. Metastases in fatty liver alcoholization (PEI) hyperenhanced septa or vessels can be shown inside the lesion. Next Steps. compare the tumor diameter before therapy with the ablation area. enhancement is slow, during several minutes, depending on the size of hemangioma and mass with irregular shapes, fringed, with fluid or semifluid content, with or without air inside. Radiographics. [citation needed] asymptomatic but also can be associated with pain complaints or cytopenia and/or On non enhanced images a FLC usually presents as a big mass with central calcifications. On CEUS examination both RN and DN may have quite a variable enhancement pattern. [citation needed], They are intravenously administered and are indicated in advanced stages of liver tumor vascularity, metastases can be hypovascular (in gastric, colonic, pancreatic or ovarian . change the therapeutic behavior . Echogenity is variable. slow flow speed. During late phase the appearance is isoechoic or The delayed enhancement in this lesion is due to fibrotic tissue in a cholangiocarcinoma and is a specific feature of these tumors. That is because cholangiocarcinoma has a varied morphology and histology. The nodule's conclusive, when precise information on some injuries (number, location) is necessary in hyperemia, presence of intratumoral air, ultrasound limitations (too deep lesion or the presence of fatty liver) or lack of patient's cooperation (immediately after therapy). Calcifications occur in 30-60% of fibrolamellar tumors. have distinct delineation (hydatid cyst), lack of vascularization or show a characteristic Deviations from the On delayed images the capsule and sometimes septa demonstrate prolonged enhancement. acoustic impedance of the nodules. or the appearance of new lesions. One should always keep in mind the risk of false positive results for HCC in case of staging, particularly when sectional imaging investigations (CT, MRI) provide Fatty liver is a reversible condition that can be brought on by bad diet or high alcohol consumption. arterio-venous shunts. The most common tumor that causes retraction besides cholangiocarcinoma is metastatic breast cancer. to the experience of the examiner. [citation needed], Local recurrence is defined as recurrence of a hyperenhanced area at tumor periphery in the These masses may be benign genetic differences or a result of liver disease. Posterior from the lesion the 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. Hemangioma is the most common benign liver tumor. treatment of hypervascular liver metastases. At Doppler examination, [citation needed], Cirrhotic liver is characterized by the occurrence of nodules with different sizes and detected in cancer patients may be benign . higher in younger women and tumor development is accelerated by oral contraceptives 4 An abdominal aortic . well defined, un-encapsulated area, with echostructure and vasculature similar to those of Several studies have proved similar In this phase the attenuation of the normal liver parenchyma increases, revealing the relatively hypoattenuating metastases, sometimes with peripheral enhancement. First look at the images on the left and try to find good descriptive terms for what you see. On dynamic contrast-enhanced MRi the characteristics of metastases are the same as for CECT. related to US penetration (pronounced fatty liver disease, deep lesion, excessive obesity) and arterial phase, with portal and late wash-out. Radiographics. Color Doppler You see it on the NECT and you could say it is hypodens compared to the liver. This means that in the arterial phase the areas of enhancement must have almost the density of the aorta, while in the portal venous phase the enhancement must be of the same density as the portal vein. conditions) and tumoral (HCC). Secondly, if you have a malignant thrombus in the portal vein, it will increase the diameter of the vessel. So any cystic structure near the biliary tract in a patient, who recently has undergone a biliary procedure, is suspicious of a liver abces. Using CEUS examination to detect metastases a sensitivity of 8095% is obtained, similar to Imaging features of FLC overlap with those of other scar-producing lesions including FNH, HCC, Hemangioma and Cholangiocarcinoma. out at the end of arterial phase. However if you look at the bloodpool, you will notice that on all phases it is as dense as the bloodpool. HCC consists of abnormal hepatocytes arranged in a typical trabecular pattern. In these metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation. The Nowadays we encounter very small HCC's in patients, that we screen for HCC (figure). (long evolution, repeated vascular and parenchymal decompensation, sometimes bleeding due to variceal leakage) in addition to accelerated weight loss in the recent past and lack of efficacy, even superior, of CEUS compared to CE-CT and CE-MRI for the evaluation of post-TACE 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 . (radiofrequency, laser or microwave ablation). Some cholangiocarcinomas have a glandular stroma. In these cases, differentiation from a malignant tumor is difficult Its indications are defined for HCC ablative treatments (pre, intra and Coarse calcifications are seen in only 5% of patients. liver parenchyma of the cirrhotic patient. . {"url":"/signup-modal-props.json?lang=us"}, Weerakkody Y, Jones J, Bell D, et al. create a bridge to liver transplantation. by complete tumor necrosis with a safety margin around the tumor. The key to the diagnosis in the lesion on the left is the fact that it is isoattenuating to normal liver in the portal venous phase and stays that way without a wash out on the delayed phase (not shown). monitoring, CEUS can be used in follow-up protocols, its diagnostic It is usually central in location and then spreads out. Mortel K, Segatto E, Ros P. The Infected Liver: Radiologic-Pathologic Correlation. Sometimes a tumor thrombus may present with neovascularity within the thrombus (figure). validated indications at this time, but with proved efficacy in extensive clinical trials The Echogenic Liver: Steatosis and Beyond Ultrasound is the most common modality used to evaluate the liver. [citation needed], US examination is required to detect liver metastases in patients with oncologic history. late or even very late "wash out" while poorly differentiated HCC has an accelerated wash Fatty liver disease . concordant imaging procedures are necessary, supplemented if necessary by an ultrasound In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. Checking a tissue sample. [citation needed], Given that TACE is indicated only for hyperenhanced lesions during arterial phase, CEUS intake. On the other hand a fatty liver can also obscure metastases. 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 Other elements contributing to lower US While FNH is always very homogeneous, FLC is usually heterogeneous following contrast administration. A low-attenuation pseudocapsule can be seen in as many as 30% of patients. These are two common findings and they can be coincidental. 68F, referred for ultrasound due to recurrent upper abdominal pain. At first glance they look very similar. The cirrhotic liver has a coarse, heterogeneous echotexture with reduced pulsatility of the hepatic venous waveform Ultrasound is approximately 80% sensitive in the detection of HCC. radial vessels network develops from this level with peripheral orientation. appetite and anemia with cancer). Radiology 1996; 201:1-14. At the time the article was last revised Jeremy Jones had no recorded disclosures. Complete fill in is sometimes prevented by central fibrous scarring. Peripheral enhancement or cysts inside is suggestive for parasitic, hydatid nature. treatment which can be complex (chemotherapy, radiofrequency ablation, surgical Thus, highly differentiated HCC illustrates the phenomenon of In patients with cirrhosis or with hepatitis B/C our major concern is HCC, since 85% of HCC occur in these patients. (2002) ISBN: 1588901017. intermediate stages of the disease. In these cases, biopsy may The correlation The risk of significant bleeding from the tumor is as high as 30%. The mean age of the study population was 50.4 years; 199 patients (86.5%) and 170 (74%) presented an ultrasound that was suggestive of heterogeneous liver and liver cirrhosis, respectively. He has been president of the Society of Computed Body Tomography and Magnetic Resonance. In some cases this accumulation can [citation needed], In case of successful treatment, US monitoring using CEUS is performed every three For this Correlation with clinical status and AFP measurements is A history of a primary hypervascular tumor favors metastases. First, if you have a malignant thrombus in the portal vein, it will always enhance and you'll see it best in arterial phase. predominantly arterial vasculature of HCC and hypervascular metastases, while the At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. With color doppler sometimes the vessels can be seen within the scar. On the left a typical FNH with a central scar that is hypodens in the portal venous phase and hyperdens in the equilibrium phase. This looks like an enhancing nodule very suspective of early HCC. the developing context (oncology, septic) are also added. cannot replace CT/MRI examinations which have well established indications in oncology. This is the fibrous component of the tumor. When These masses may be benign genetic differences or a result of liver disease. They are detected as hypodense lesions in the late portal venous phase. [citation needed], However, it is able to detect the appearance of new lesions and to assess the occurrence of months. Large hemangiomas can have an atypical appearance. It captures live images of your organs using high frequency sound waves. Diffuse heterogeneous enlargement of the liver can be seen as a specific pattern in . An ultrasound, CT scan and MRI can show liver damage. What does heterogeneous mean in ultrasound? The size varies from a few millimeters to more than 10 cm (giant hemangiomas). Syed Babar (Contributor), Richard C. Beese (Contributor), Richard Edwards (Contributor) et al. inflammation. palpating the liver with the transducer the hemangioma is compressible sending A similar appearance has been described with liver abscesses.Calcified metastases may shadow when they are densely echogenic (figure). active bleeding). It is generally Typically adenomas have well-defined borders and do not have lobulated contours. During venous and sinusoidal phase the pattern is hypoechoic, and The lesion can have different forms, most cases being oval and characterization of liver nodules. without any established signs of malignancy. Finally most hemangiomas show complete fill in with contrast. malignancy. It is very important to make the diagnosis of liver absces because it is a benign disease that kills and the radiologist may be the first to raise the suspicion. conditions, using the available procedures discussed above for each of them. During the portal venous phase there is a specific "wash out" of ultrasound contrast agent (UCA) and the tumor appears hypoechoic during the late phase. It can also be because you have calcifications on your pancreas. 2D ultrasound shows a well-defined, un-encapsulated, solid mass. The patient has a good general hypoechoic, due to lack of Kupffer cells. [citation needed], 2D ultrasound, Doppler ultrasound and especially CEUS can play an important role in pretherapeutic Hepatocellular adenoma - Hepatocellular adenoma (HCA) (also termed hepatic adenoma) is an uncommon solid, benign liver lesion that develops in an otherwise normal-appearing liver. In otherwise healthy young women using oral contraceptives, adenoma is favored. nodule, with distinct pattern, developed on cirrhotic liver. Most authors accept the carcinogenesis process as a progressive [citation needed], In the first days after RFA both CEUS and spiral CT have low sensitivity in assessing You'll need to see a gastroenterologist, who hopefully specialises in the pancreas, who can . When palpating the liver with the transducer the hemangioma is compressible sending shows no circulatory signal. If it wasn't clustered than any cystic tumor could look like this. Spectral Doppler examination detects central arterial vessels and CFM circulation are vascular density, presence of vessels with irregular paths and size, some of They tend to be very large with a mozaic pattern, a capsule, hemorrhage, necrosis and fat evolution. A heterogeneous liver appears to have different masses or structures inside it when imaged via ultrasound. Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. An ultrasound scan of a liver with hyperechoic parenchyma that is also hyperattenuating (reduced echogenicity in the deep field). This capsule will only show enhancement on delayed scans. Now do not just concentrate on the images, where you see the lesions best. prognostic value; therefore the patient should be periodically examined at short intervals. In 65% there are satellite nodules and in some cases punctate calcifications are seen. characteristic of moderate/poorly differentiated HCC, with low or absent fatty changes. curative or palliative therapies have been considered. Generally, both nodules enhances identically with the surrounding liver parenchyma after 30% of cases. G. Scott Gazelle (Editor), Sanjay Saini (Editor), Peter R. Mueller (Editor). compared PC-LB and EUS-LB methods in terms of diagnostic outcomes including accuracy and safety for both focal and parenchymal liver diseases . It can be a constricting or an expanding lesion, because it can have a fibrous or a glandular stroma. Some advocate surgical resection only when tumors are larger than 5 cm or when AFP levels are elevated, since these two findings are associated with higher risk of malignancy. reasons contrast imaging (CT or CEUS) control should be performed one month after associating "wash out" during portal and late CEUS phases. [citation needed], Spectral Doppler characteristics of early HCC overlap those of the dysplastic nodule, as they By looking at the other phases to see if the enhancing areas match the bloodpool, it is usually possible to differentiate these lesions. Also they are This is the hallmark of fatty liver. [citation needed], It is the most common liver tumor with a prevalence of 0.4 7.4%. The lesion is hypodens in the arterial and portal venous phase with some peripheral enhancement. Abstract Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs . 4. [citation needed], B-mode ultrasonography is unable to distinguish between regenerative nodules and This is consistent with fatty liver. Cystic liver metastases are seen in mucinous ovarian ca, colon ca, sarcoma, melanoma, lung ca and carcinoid tumor. efficiency is currently made by indirect assessing Lipiodol binding to the tumor using nonenhanced when changes occur in arterial vasculature, being able to have an early therapeutic