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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. In 60% of cases more than one hemangioma is present. If you only had the portal venous phase you surely would miss this lesion. On dynamic contrast-enhanced MRi the characteristics of metastases are the same as for CECT. The specification of these data is important for staging liver tumors and prognosis. after the procedure, including CEUS, can show apart from the character of the lesion any Only when you have a population with livertransplants, bilomas in an infarcted area would look the same. Intermediate stage (polinodular, 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). A heterogeneous liver appears to have different masses or structures inside it when imaged via ultrasound. These are two common findings and they can be coincidental. conjunction with contrast CT/MRI and to assess the effectiveness of treatment when using an antiangiogenic therapy for hypervascular metastases . concordant imaging procedures are necessary, supplemented if necessary by an ultrasound clinical trials that investigated the tumor size doubling time (Bruix, 2005; Maruyama et al., Tumor wash out at the end of the arterial phase allows the It is believed to represent a hyperplastic response to increased blood flow in an intrahepatic arteriovenous malformation. Their diagnosis is quite difficult and the criteria used for differentiation are often He has been president of the Society of Computed Body Tomography and Magnetic Resonance. This appearance was found in approx. Echogenity is variable. This could also be an adenoma, but HCC would be unlikely because they show a fast wash out. The examination has an acceptable sensitivity which or the appearance of new lesions. palliative therapies (TACE and sorafenib systemic therapy) and in the end stage only [citation needed], It develops on non cirrhotic liver. Then we look at liver enzymes, the patients history, do blood tests for various liver diseases. performance are: excessive obesity, fatty liver disease, hypomobility of the diaphragm, and . Some authors consider that early pronounced Given the CEUS limitations, currently some authors consider CT <2cm (from <5% in the 90s in Europe to > 30% today in Japan) with curative therapy : this is a common ultrasound finding, echogenic or heterogenous liver - meaning not all of liver tissue looks exactly the same. oncologists since 2003 because it involves no irradiation and has no hepatic or renal toxicity, tissue must be higher than the initial tumor volume. conclusive, when precise information on some injuries (number, location) is necessary in phase. confirmation is made using CEUS examination which proves a normal circulatory bed similar Fatty liver is a reversible condition that can be brought on by bad diet or high alcohol consumption. Ultrasound on admission followed by abdominal computed tomography (CT) scan revealed hepatomegaly, trace ascites without any other features of chronic liver disease, and multiple small. sensitivity and specificity of ultrasound in detecting liver metastases, but also by assessing This capsule will only show enhancement on delayed scans. So this is fibrotic tissue and the diagnosis is FNH. However, continued high alcohol consumption can result in fatty liver disease, which can cause cirrhosis of the liver, an irreversible condition. They are high in numbers and have a more or less uniform distribution, involving all liver segments. late or even very late "wash out" while poorly differentiated HCC has an accelerated wash You will only see them in the arterial phase. shows no circulatory signal. A high content of fat in the liver is indicative of fatty liver disease. Ultrasound This is because the lesion is made of these channels containing blood. During the portal venous and late phase, the appearance is persistently isoechoic. The volume of damaged In some cases this accumulation can 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. Hepatocellular adenomas are large, well circumscribed encapsulated tumors. Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study Marilyn J. Siegel MD 1 , A. Jay Freeman MD 2 , Wen Ye PhD 3 , Joseph J. Palermo MD 4 , Jean P. Molleston MD 5 , Shruti M. Paranjape MD 6 , Janis Stoll MD 7 , currently used in large clinical trials aimed at determining the efficacy of different types of 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. Similar observation was made in ultrasound scan earlier this month but doctors told it is fatty liver and nothing to . In these cases, differentiation from a malignant tumor is difficult single, solid consistency with inhomogeneous structure. ultrasound every 3 months, as the growth trend is an indication for completion of Thus, for a nodule with a size of less than 10mm the patient will be reevaluated by Therefore, current practice The figure on the left shows such a case. inflammation. The most common tumor that causes retraction besides cholangiocarcinoma is metastatic breast cancer. showing that the wash out process is directly correlated with the size and features of 30 seconds after injection. The conclusion must be, that this lesion does not match bloodpool in all phases, so it cannot be a hemangioma. CE-MRI as complementary methods. Hypervascular metastases are less common and are seen in renal cell carcinoma, insulinomas, carcinoid, sarcomas, melanoma and breast cancer. In Part II the imaging features of the most common hepatic tumors are presented. with heterogeneous structure, poorly delineated, often with peripheral location and weak Mild AST and ALT eleva- There are three Currently, local response to treatment is focused on tumor necrosis diagnosed by contrast Their efficacy required. However if you look at the delayed phase, you will notice that this area enhances. large sizes), are quite elastic and do not invade liver vessels. CEUS examination cannot completely replace the other imaging It is a heterogeneous disease encompassing a broad spectrum of histologic states characterized universally by macrovesicular hepatic steatosis. On the left a typical FNH with a central scar that is hypodens in the portal venous phase and hyperdens in the equilibrium phase. [citation needed], Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in These are small lesions that transiently enhance homogeneously. Coarsened hepatic echotexture is a sonographic descriptor used when the uniform smooth hepatic echotexture of the liver is lost. When increased, they can compress the bile (captures CA in Kuppfer cells) against tumor parenchyma (does not contain Kuppfer cells, Secondly, if you have a malignant thrombus in the portal vein, it will increase the diameter of the vessel. To this the risk of confusion between hypervascular During late (sinusoidal) phase, if Gubernick J, Rosenberg H, Ilaslan H, Kessler A. Another common aspect is "bright Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. HCC is the most frequent abdominal malignancy worldwide and is especially common in Asia and mediterrean countries. Now it has been proved that the It is composed of multiple vascular channels lined by endothelial cells. paucilocular), have distinct delineation, with increased echogenity (hemangiomas, benign They are best seen in the late arterial phase at 35 sec after contrast injection. walls, without circulatory signal at Doppler or CEUS investigation. Finally most hemangiomas show complete fill in with contrast. associating "wash out" during portal and late CEUS phases. ablation to confirm the result of the therapy. hypoechoic, due to lack of Kupffer cells. collection size and an indication regarding its topography inside the liver (lobe, segment). [citation needed], It is a benign tumor made up of normal or atypical hepatocytes. In patients with cirrhosis or with hepatitis B/C our major concern is HCC, since 85% of HCC occur in these patients. What do you mean by heterogeneity? . Nowadays we encounter very small HCC's in patients, that we screen for HCC (figure). vascularization is typical for HCC and is the key to imaging diagnosis. In a further 2 patients both increased echogenicity and heterogeneous parenchyma were found. The described changes have diagnostic value in liver nodules larger than 2cm. This suggested underlying liver fibrosis, although the liver contour was smooth. tool in the evaluation of liver enzyme abnormalities is abdominal ultrasound (US), with more in-depth evalua-tion by computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatog-raphy (MRCP), or cholescintigraphy as detailed later. On the other hand a fatty liver can also obscure metastases. metastases have non-characteristic Doppler vascular pattern, with few exceptions (carcinoid The role of US is 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 Ultrasound of the normal liver and gall bladder The different lobes of the liver cannot be defined on ultrasound unless peritoneal effusion is present. tumor is asymptomatic but may be associated with right upper quadrant pain in case of is high only for lesions who are hyperenhanced during arterial phase. Generally, therapeutic efficacy. In the arterial phase we see two hypervascular lesions. analysis performed using specific software during post-processing in order to assess They may be associated with renal cysts; in this case the disease [citation needed], These lesions have various patterns (hypo or hyperechoic) with at least 1cm diameter. Other authors noticed the presence of an arterial flow with small frequency variations Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. For example, a dermoid cyst has heterogeneous attenuation on CT. 4 An abdominal aortic . Conventional US appearance of metastases is uncharacteristic, consisting Doppler examination detects a high speed arterial flow and low impedance index (correlated with described changes in tumor angiogenesis). Laurent Blond A liver mass may vary in its appearance, but will generally be seen as heterogeneous and can deform the hepatic margin. The enhancement of a hemangioma starts peripheral . [citation needed], The substrate on which the tumor condition develops (if the liver is normal or if there is evidence of diffuse liver disease) and FNH is the second most common tumor of the liver. measurement of the tumor diameter (RECIST criteria) is not enough for therapy assessment. Intraoperative use of neoplasm) or multiple. addition, the method can incidentally detect metastases in asymptomatic patients. potential post-intervention complications (e.g. Then continue. The content is alcoholization (PEI) hyperenhanced septa or vessels can be shown inside the lesion. A heterogeneous liver appears to have different masses or structures inside it when imaged via ultrasound. staging, particularly when sectional imaging investigations (CT, MRI) provide the procedure increases its performance even if it does not have a decisive contribution to At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. The lower images show a lesion that is visible on all images. This is however also a feature of HCC and large hemangiomas. appetite and anemia with cancer). The 2004;24(4):937-55. Coarsened hepatic echotexture. With color doppler sometimes the vessels can be seen within the scar. What do these results mean?ULTRASOUND LIVER ** HISTORY **: 42 years old, abnormal liver function tests. It can be located anywhere in the intrahepatic bile ducts or common bile duct. In case of highgrade is therefore mandatory to analyze all these three phases of CEUS examination for a proper Thus, during the arterial [citation needed] of circumscribed lesions, with clear, imprecise or "halo" delineation, with homogeneous or When striving to protect your liver, aim to drink lots of water, eat high . Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-17361, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":17361,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/coarsened-hepatic-echotexture/questions/2403?lang=us"}, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, doi:10.1148/radiographics.20.1.g00ja25173, shoulder (modified transthoracic supine lateral), acromioclavicular joint (AP weight-bearing view), sternoclavicular joint (anterior oblique views), sternoclavicular joint (serendipity view), foot (weight-bearing medial oblique view), paranasal sinus and facial bone radiography, paranasal sinuses and facial bones (lateral view), transoral parietocanthal view (open mouth Waters view), temporomandibular joint (axiolateral oblique view), cervical spine (flexion and extension views), lumbar spine (flexion and extension views), systematic radiographic technical evaluation (mnemonic), foreign body ingestion series (pediatric), foreign body inhalation series (pediatric), pediatric chest (horizontal beam lateral view), neonatal abdominal radiograph (supine view), pediatric abdomen (lateral decubitus view), pediatric abdomen (supine cross-table lateral view), pediatric abdomen (prone cross-table lateral view), pediatric elbow (horizontal beam AP view), pediatric elbow (horizontal beam lateral view), pediatric forearm (horizontal beam lateral view), pediatric hip (abduction-internal rotation view), iodinated contrast-induced thyrotoxicosis, saline flush during contrast administration, CT angiography of the cerebral arteries (protocol), CT angiography of the circle of Willis (protocol), cardiac CT (prospective high-pitch acquisition), CT transcatheter aortic valve implantation planning (protocol), CT colonography reporting and data system, CT kidneys, ureters and bladder (protocol), CT angiography of the splanchnic vessels (protocol), esophageal/gastro-esophageal junction protocol, absent umbilical arterial end diastolic flow, reversal of umbilical arterial end diastolic flow, monochorionic monoamniotic twin pregnancy, benign and malignant characteristics of breast lesions at ultrasound, differential diagnosis of dilated ducts on breast imaging, musculoskeletal manifestations of rheumatoid arthritis, sonographic features of malignant lymph nodes, ultrasound classification of developmental dysplasia of the hip, ultrasound appearances of liver metastases, generalized increase in hepatic echogenicity, dynamic left ventricular outflow tract obstruction, focus assessed transthoracic echocardiography, arrhythmogenic right ventricular cardiomyopathy, ultrasound-guided biopsy of a peripheral soft tissue mass, ultrasound-guided intravenous cannulation, intensity-modulated radiation therapy (IMRT), stereotactic ablative radiotherapy (SBRT or SABR), sealed source radiation therapy (brachytherapy), selective internal radiation therapy (SIRT), preoperative pulmonary nodule localization, transjugular intrahepatic portosystemic shunt, percutaneous transhepatic cholangiography (PTC), transhepatic biliary drainage - percutaneous, percutaneous endoscopic gastrostomy (PEG), percutaneous nephrostomy salvage and tube exchange, transurethral resection of the prostate (TURP), long head of biceps tendon sheath injection, rotator cuff calcific tendinitis barbotage, subacromial (subdeltoid) bursal injection, spinal interventional procedures (general), transforaminal epidural steroid injection, intravenous cannulation (ultrasound-guided), inferomedial superolateral oblique projection, breast ultrasound features: benign vs malignant, certain bile duct tumors: will also usually show of accompanying biliary duct dilatation, diffusely infiltrating hepatic metastases, 1. immediately post-procedure (with the possibility of reintervention in case of partial response) HCC is a silent tumor, so if patients do not have cirrhosis or hepatitis C, you will discover them in a late stage. active bleeding). Heterogeneous refers to a structure with dissimilar components or elements, appearing irregular or variegated. be cost-effective, it should be applied to the general population and not in tertiary hospitals. be identified in high-grade dysplastic nodules (appearance called "nodule in nodule") loop" or "nodule-in-nodule" appearance, hypoechoic nodules in a hyperechoic tumor. US Approach to Jaundice in Infants and Children. Brancatelli G., Baron RL, Peterson MS, Marsh W. Helical CT screening for HCC in patients with Cirrhosis: Frequency and causes of False-Positive interpretation. The lesion is hypodens in the arterial and portal venous phase with some peripheral enhancement. ADVERTISEMENT: Supporters see fewer/no ads. Dr. Leila Hashemi answered Internal Medicine 22 years experience Liver ultrasound: The size is normal but Heterogeneity could be due to fatty liver. They are very common and are seen in up to 50% of patients with cirrhosis. Tumors can range from benign liver tumors to cancerous masses and metastases from cancer elsewhere in the body. CEUS examination is Chemical-shift imaging showing loss of signal on out-of-phase images can confirm the presence of fat. conditions, using the available procedures discussed above for each of them. with advanced liver disease (Child-Pugh class C). The main problem of ultrasound screening is that, in order to radial vessels network develops from this level with peripheral orientation. It is generally [citation needed], Benign liver tumors generally develop on normal or fatty liver, are single or multiple (generally Malignant lesions however have a tendency to loose their contrast faster than the surrounding liver, so they may become relatively hypodense in later phases. totally "filled" with CA, hemangioma appears isoechoic to the liver. [citation needed], The suggestive appearance of early HCC on 2D ultrasound examination is that of hypoechoic Posterior from the lesion the The imaging findings will be non-specific. On CEUS examination both RN and DN may have quite a variable enhancement pattern. The bacteria enter through the slow flow portal system and they are layered within the vessel. acoustic impedance of the nodules. investigations with other diagnostic procedures; at a size between 10 20mm two and requires other imaging procedures, follow up and measurements of the tumor at When calcified liver metastases are revealed by CT in a patient with unknown primary tumor, colon cancer will be the most likely cause. [citation needed], HCC appearance on 2D ultrasound is that of a solid tumor, with imprecise delineation, with heterogeneous structure, uni- or multilocular (encephaloid form). and hypoechoic appearance during late phase. tumor periphery during arterial phase followed by wash-out during portal venous phase portal vasculature continues to decline. 30% of cases. Nevertheless, chronic Budd-Chiari syndrome may be difficult to differentiate from cirrhosis ( 8 ). of hemangioma, ultimately prove to be hepatocellular carcinoma. arterial hyperenhancement and portal and late wash-out. characteristic of moderate/poorly differentiated HCC, with low or absent fatty changes. For a recently developed nodule the dimensional criteria will be taken into account. Neoformation vessels occur with increasing degree of dysplasia. It can also be because you have calcifications on your pancreas. compared PC-LB and EUS-LB methods in terms of diagnostic outcomes including accuracy and safety for both focal and parenchymal liver diseases . ducts (which may be dilated) and the liver vessels. Routine use of CEUS examination to cannot replace CT/MRI examinations which have well established indications in oncology. Lipiodol appears intensely hyperechoic inside the tumor, with significant posterior the efficacy of systemic therapy for HCC and metastases. Limitations of the method are those Adenomas are prone to central necrosis and hemorrhage because the vascular supply is limited to the surface of the tumor. therapeutic efficacy as early as possible. In terms of presence of venous type Doppler flow which reflects the portal venous nutrition of the What is the cause of course liver and so high BILIRUBIN. Although it is difficult to see, there is also portal venous thrombosis on the left. During the portal venous reasons contrast imaging (CT or CEUS) control should be performed one month after The incidence is [citation needed], On CEUS examination, early HCC has an iso- or hypervascular appearance during the It is unique or paucilocular. In the portal venous phase the lesion is again isodense to the surrounding liver parenchyma and you can't see it. cholangiocarcinomas so complementary diagnostic procedures should be considered. 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. HCC may be solitary, multifocal or diffusely infiltrating. methods or patient reevaluation from time to time. CEUS examination reveals a moderate enhancement of the At the time the article was created Yuranga Weerakkody had no recorded disclosures. [citation needed], Cirrhotic liver is characterized by the occurrence of nodules with different sizes and borderline lesions such as dysplastic nodules and even early HCC. Among ultrasound Several studies have proved similar clinical suspicion of abscess. The diagnosis of FNH is based on the demonstration of a central scar and a homogeneous enhancement. So any cystic structure near the biliary tract in a patient, who recently has undergone a biliary procedure, is suspicious of a liver abces. A Most liver metastases are multiple, involving both lobes in 77% of patients and only in 10% of cases there is a solitary metastasis. [citation needed], Given that TACE is indicated only for hyperenhanced lesions during arterial phase, CEUS In the portal venous phase however, the enhancement is not as bright as the enhancement of the portal vein. NAFLD is now recognized as the hepatic manifestation of the metabolic syndrome and is a major cause of liver-related morbidity and mortality. circulatory pattern, displace normal liver structures and even neighboring organs (in case of Ultrasound of Abdominal Transplantation. [citation needed], After curative therapies (surgical resection, local ablative therapies) continuing ultrasound Typically HCC invades liver vessels, primarily the portal veins but also the hepatic veins . Complete fill in is sometimes prevented by central fibrous scarring. Local response to treatment is defined as:[citation needed] It is the antonym for homogeneous, meaning a structure with similar components. slow flow speed. J Ultrasound Med. During the arterial phase, the signal is weak or The spatial distribution of the vessels is irregular, disordered. ranges between 4080% . Abstract Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs . degree of tumor necrosis is not correlated with tumor diameter, therefore simple phase there is a moderate wash out. arterial phase, with portal and late wash-out. Poorly differentiated tumors may have a stronger wash out leading to an isoechoic appearance to the liver parenchyma during portal venous phase. neovascularization is enhanced in a chaotic and explosive way, while normal, arterial and [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). 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. On the other hand, CE-CT is also Hypovascular metastases are the most common and occur in GI tract, lung, breast and head/neck tumors. Now do not just concentrate on the images, where you see the lesions best. You see it on the NECT and you could say it is hypodens compared to the liver. [citation needed], Increased performance is based on identifying specific vascular patterns during the arterial First look at the images on the left and describe what you see. [3], They can be single or multiple, with variable size, generally less than 20mm (congenital). When circulation represented by a reduced arterial bed compared to that of the surrounding Occasionally, well-differentiated HCC foci can This looks like an enhancing nodule very suspective of early HCC. 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. A similar procedure is Peritumoral edema makes lesions appear larger on T2WI and is very suggestive of a malignant mass. asymptomatic but also can be associated with pain complaints or cytopenia and/or Hepatocellular Injury Mild AST and ALT Elevations. Image above showing sharp contrast between liver echogenicity compared to kidney echogenicity. The importance of a non enhanced scan is demonstrated in the case on the left. provides an overview of tumor extension and it is not limited by bloating or steatosis. AJR 2003; ISO: 1007-1014. diseases, when there are no other effective therapeutic solutions. For a lesion diameter below 10mm US accuracy is [citation needed], US examination is required to detect liver metastases in patients with oncologic history. CEUS exploration is quite ambiguous and cannot always In recent years, endoscopic ultrasound (EUS)-guided liver biopsy has been adopted as a good alternative to PC and TJ approaches . well defined, un-encapsulated area, with echostructure and vasculature similar to those of If you take a cohort of patients with hepatitis C and you follow them for 10 years, 50% of them will have end stage liver disease and 25% will have HCC. detection varies depending on the examiner's experience and the equipment used and Hemangioma is the most common benign liver tumor. Although breast cancer metastases can be hypervascular, it was shown that routine use of adding arterial phase imaging, did not show any advantage. Following are the characteristic features of some splenic neoplasias: mass. In otherwise healthy young women using oral contraceptives, adenoma is favored. In these cases, biopsy may coconut water. anti-angiogenic molecules by quantifying intratumoral perfusion based on the statistical To accurately assess the effectiveness of treatment it is mandatory to