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Real-Time Harmonic Contrast Material–specific US of Focal Liver Lesions¹

¹ From the Department of Radiology, S. Maria delle Grazie Hospital, Via Domitiana Località La Schiana, Pozzuoli, Italy (O.C., R.L., A.S.); and the Diagnostic Imaging Area, PSI Napoli Est, Naples, Italy (A.N.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received April 7, 2004; revision requested June 30; final revision received November 3; accepted November 3. All authors have no financial relationships to disclose.

View larger version (29K): [in a new window]   Figure 1.  Graph illustrates the hemodynamic behavior of liver lesions. Lesion conspicuity depends on the lesion-to-parenchyma echogenicity gradient; in this case, HCC has greater conspicuity during the arterial phase and appears hyperechoic. During the portal and sinusoidal phases, the lesion is first slightly and then clearly hypoechoic relative to the surrounding parenchyma.

 

View larger version (42K): [in a new window]   Figure 2.  Drawings illustrate the most typical patterns of liver lesion enhancement. Enhancement may be absent (eg, cyst, small hemangioma, dysplastic nodule, or early HCC) or may be diffuse homogeneous or diffuse heterogeneous (eg, hypervascular metastasis or atypical CCC, lymphoma, FNH). Rim pattern manifests as peripheral, irregular but continuous arterial phase enhancement (eg, metastasis, CCC). The globular pattern consists of discontinuous peripheral arterial phase enhancement with discrete echoic globules (eg, cavernous hemangioma). The spokelike pattern seen during the arterial phase is due to discrete arteries radiating to the periphery (eg, FNH). The stippled pattern seen during this phase consists of discrete arteries with a chaotic distribution (eg, HCC). The arterial phase "basket" pattern, usually seen in combination with a stippled appearance, consists of a feeding artery branching around and then within a nodule (eg, HCC).

 

View larger version (122K): [in a new window]   Figure 3a.  Small hemangiomas discovered incidentally in a 45-year-old woman. (a) Baseline US image shows two homogeneously hyperechoic lesions (arrowheads) contiguous with a portal branch (arrow). (b) Early portal phase US image obtained 35 seconds after contrast material injection demonstrates lesion isoechogenicity. Arrow indicates an enhanced vein. (c) Parenchymal phase US image obtained 121 seconds after injection demonstrates persistent lesion isoechogenicity.

 

View larger version (142K): [in a new window]   Figure 3b.  Small hemangiomas discovered incidentally in a 45-year-old woman. (a) Baseline US image shows two homogeneously hyperechoic lesions (arrowheads) contiguous with a portal branch (arrow). (b) Early portal phase US image obtained 35 seconds after contrast material injection demonstrates lesion isoechogenicity. Arrow indicates an enhanced vein. (c) Parenchymal phase US image obtained 121 seconds after injection demonstrates persistent lesion isoechogenicity.

 

View larger version (152K): [in a new window]   Figure 3c.  Small hemangiomas discovered incidentally in a 45-year-old woman. (a) Baseline US image shows two homogeneously hyperechoic lesions (arrowheads) contiguous with a portal branch (arrow). (b) Early portal phase US image obtained 35 seconds after contrast material injection demonstrates lesion isoechogenicity. Arrow indicates an enhanced vein. (c) Parenchymal phase US image obtained 121 seconds after injection demonstrates persistent lesion isoechogenicity.

 

View larger version (110K): [in a new window]   Figure 4a.  Large hemangioma in a 56-year-old woman with rectal cancer. (a) Baseline US image shows a heterogeneously hypoechoic lesion (arrow). (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates peripheral globular enhancement (large arrow) and a perilesional vessel (small arrow). (c) Portal phase US image obtained 93 seconds after injection demonstrates centripetal (albeit incomplete) lesion enhancement (large arrow), which is clearly hyperechoic relative to the surrounding parenchyma. Small arrow indicates the perilesional vessel. (d) Portal phase computed tomographic (CT) scan shows a hyperattenuating lesion with small central areas of poor enhancement (arrow).

 

View larger version (113K): [in a new window]   Figure 4b.  Large hemangioma in a 56-year-old woman with rectal cancer. (a) Baseline US image shows a heterogeneously hypoechoic lesion (arrow). (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates peripheral globular enhancement (large arrow) and a perilesional vessel (small arrow). (c) Portal phase US image obtained 93 seconds after injection demonstrates centripetal (albeit incomplete) lesion enhancement (large arrow), which is clearly hyperechoic relative to the surrounding parenchyma. Small arrow indicates the perilesional vessel. (d) Portal phase computed tomographic (CT) scan shows a hyperattenuating lesion with small central areas of poor enhancement (arrow).

 

View larger version (114K): [in a new window]   Figure 4c.  Large hemangioma in a 56-year-old woman with rectal cancer. (a) Baseline US image shows a heterogeneously hypoechoic lesion (arrow). (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates peripheral globular enhancement (large arrow) and a perilesional vessel (small arrow). (c) Portal phase US image obtained 93 seconds after injection demonstrates centripetal (albeit incomplete) lesion enhancement (large arrow), which is clearly hyperechoic relative to the surrounding parenchyma. Small arrow indicates the perilesional vessel. (d) Portal phase computed tomographic (CT) scan shows a hyperattenuating lesion with small central areas of poor enhancement (arrow).

 

View larger version (122K): [in a new window]   Figure 4d.  Large hemangioma in a 56-year-old woman with rectal cancer. (a) Baseline US image shows a heterogeneously hypoechoic lesion (arrow). (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates peripheral globular enhancement (large arrow) and a perilesional vessel (small arrow). (c) Portal phase US image obtained 93 seconds after injection demonstrates centripetal (albeit incomplete) lesion enhancement (large arrow), which is clearly hyperechoic relative to the surrounding parenchyma. Small arrow indicates the perilesional vessel. (d) Portal phase computed tomographic (CT) scan shows a hyperattenuating lesion with small central areas of poor enhancement (arrow).

 

View larger version (107K): [in a new window]   Figure 5.  Large, atypical hemangioma discovered incidentally in a 33-year-old woman. Early portal phase US image obtained 43 seconds after contrast material injection shows multiple peripheral enhancing globules (large arrows) and thin enhancing septa centrally (small arrows). Although most of the lesion is hypoechoic, and was even on delayed images (not shown), the globular pattern allowed characterization.

 

View larger version (119K): [in a new window]   Figure 6a.  Hepatocellular adenoma in a 40-year-old woman with a history of oral contraception who was being evaluated for blunt abdominal trauma. (a) Baseline US image shows a subtle hyperechoic area (arrow). Contrast-enhanced US was performed to rule out liver injury. (b) Arterial phase US image obtained 21 seconds after contrast material injection demonstrates early, marked lesion enhancement (arrow). K = kidney. (c) Portal phase US image obtained 55 seconds after injection demonstrates subtle but persistent enhancement (arrow). K = kidney.

 

View larger version (102K): [in a new window]   Figure 6b.  Hepatocellular adenoma in a 40-year-old woman with a history of oral contraception who was being evaluated for blunt abdominal trauma. (a) Baseline US image shows a subtle hyperechoic area (arrow). Contrast-enhanced US was performed to rule out liver injury. (b) Arterial phase US image obtained 21 seconds after contrast material injection demonstrates early, marked lesion enhancement (arrow). K = kidney. (c) Portal phase US image obtained 55 seconds after injection demonstrates subtle but persistent enhancement (arrow). K = kidney.

 

View larger version (81K): [in a new window]   Figure 6c.  Hepatocellular adenoma in a 40-year-old woman with a history of oral contraception who was being evaluated for blunt abdominal trauma. (a) Baseline US image shows a subtle hyperechoic area (arrow). Contrast-enhanced US was performed to rule out liver injury. (b) Arterial phase US image obtained 21 seconds after contrast material injection demonstrates early, marked lesion enhancement (arrow). K = kidney. (c) Portal phase US image obtained 55 seconds after injection demonstrates subtle but persistent enhancement (arrow). K = kidney.

 

View larger version (107K): [in a new window]   Figure 7a.  FNH discovered incidentally in a 29-year-old woman with a history of oral contraception. (a) Baseline US image shows a slightly hypoechoic lesion (arrows). (b) Very early arterial phase US image obtained 15 seconds after contrast material injection demonstrates rapid lesion enhancement (arrows) with discrete intralesional and perilesional arteries. (c) Later arterial phase US image obtained 29 seconds after injection demonstrates marked homogeneous lesion enhancement (arrows). (d) Portal phase US image obtained 49 seconds after injection demonstrates lesion isoechogenicity (arrows). (e) Arterial phase CT scan show a homogeneously hyperattenuating lesion (arrow) (cf c).

 

View larger version (68K): [in a new window]   Figure 7b.  FNH discovered incidentally in a 29-year-old woman with a history of oral contraception. (a) Baseline US image shows a slightly hypoechoic lesion (arrows). (b) Very early arterial phase US image obtained 15 seconds after contrast material injection demonstrates rapid lesion enhancement (arrows) with discrete intralesional and perilesional arteries. (c) Later arterial phase US image obtained 29 seconds after injection demonstrates marked homogeneous lesion enhancement (arrows). (d) Portal phase US image obtained 49 seconds after injection demonstrates lesion isoechogenicity (arrows). (e) Arterial phase CT scan show a homogeneously hyperattenuating lesion (arrow) (cf c).

 

View larger version (112K): [in a new window]   Figure 7c.  FNH discovered incidentally in a 29-year-old woman with a history of oral contraception. (a) Baseline US image shows a slightly hypoechoic lesion (arrows). (b) Very early arterial phase US image obtained 15 seconds after contrast material injection demonstrates rapid lesion enhancement (arrows) with discrete intralesional and perilesional arteries. (c) Later arterial phase US image obtained 29 seconds after injection demonstrates marked homogeneous lesion enhancement (arrows). (d) Portal phase US image obtained 49 seconds after injection demonstrates lesion isoechogenicity (arrows). (e) Arterial phase CT scan show a homogeneously hyperattenuating lesion (arrow) (cf c).

 

View larger version (113K): [in a new window]   Figure 7d.  FNH discovered incidentally in a 29-year-old woman with a history of oral contraception. (a) Baseline US image shows a slightly hypoechoic lesion (arrows). (b) Very early arterial phase US image obtained 15 seconds after contrast material injection demonstrates rapid lesion enhancement (arrows) with discrete intralesional and perilesional arteries. (c) Later arterial phase US image obtained 29 seconds after injection demonstrates marked homogeneous lesion enhancement (arrows). (d) Portal phase US image obtained 49 seconds after injection demonstrates lesion isoechogenicity (arrows). (e) Arterial phase CT scan show a homogeneously hyperattenuating lesion (arrow) (cf c).

 

View larger version (105K): [in a new window]   Figure 7e.  FNH discovered incidentally in a 29-year-old woman with a history of oral contraception. (a) Baseline US image shows a slightly hypoechoic lesion (arrows). (b) Very early arterial phase US image obtained 15 seconds after contrast material injection demonstrates rapid lesion enhancement (arrows) with discrete intralesional and perilesional arteries. (c) Later arterial phase US image obtained 29 seconds after injection demonstrates marked homogeneous lesion enhancement (arrows). (d) Portal phase US image obtained 49 seconds after injection demonstrates lesion isoechogenicity (arrows). (e) Arterial phase CT scan show a homogeneously hyperattenuating lesion (arrow) (cf c).

 

View larger version (111K): [in a new window]   Figure 8a.  Large, pedunculated FNH in a 38-year-old woman with a palpable mass. The patient had no history of oral contraception. (a) Baseline US image shows a homogeneous, well-defined mass (arrows) depending from the right hepatic lobe. (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates multiple radiating arteries within the mass (arrows). (c) Portal phase US image obtained 56 seconds after injection demonstrates marked enhancement of the mass (white arrows), with a hypoechoic central scar (black arrow). (d) Late arterial phase CT scan shows a markedly enhancing mass (white arrows) with central scarring (black arrow) (cf c).

 

View larger version (109K): [in a new window]   Figure 8b.  Large, pedunculated FNH in a 38-year-old woman with a palpable mass. The patient had no history of oral contraception. (a) Baseline US image shows a homogeneous, well-defined mass (arrows) depending from the right hepatic lobe. (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates multiple radiating arteries within the mass (arrows). (c) Portal phase US image obtained 56 seconds after injection demonstrates marked enhancement of the mass (white arrows), with a hypoechoic central scar (black arrow). (d) Late arterial phase CT scan shows a markedly enhancing mass (white arrows) with central scarring (black arrow) (cf c).

 

View larger version (110K): [in a new window]   Figure 8c.  Large, pedunculated FNH in a 38-year-old woman with a palpable mass. The patient had no history of oral contraception. (a) Baseline US image shows a homogeneous, well-defined mass (arrows) depending from the right hepatic lobe. (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates multiple radiating arteries within the mass (arrows). (c) Portal phase US image obtained 56 seconds after injection demonstrates marked enhancement of the mass (white arrows), with a hypoechoic central scar (black arrow). (d) Late arterial phase CT scan shows a markedly enhancing mass (white arrows) with central scarring (black arrow) (cf c).

 

View larger version (93K): [in a new window]   Figure 8d.  Large, pedunculated FNH in a 38-year-old woman with a palpable mass. The patient had no history of oral contraception. (a) Baseline US image shows a homogeneous, well-defined mass (arrows) depending from the right hepatic lobe. (b) Arterial phase US image obtained 22 seconds after contrast material injection demonstrates multiple radiating arteries within the mass (arrows). (c) Portal phase US image obtained 56 seconds after injection demonstrates marked enhancement of the mass (white arrows), with a hypoechoic central scar (black arrow). (d) Late arterial phase CT scan shows a markedly enhancing mass (white arrows) with central scarring (black arrow) (cf c).

 

View larger version (138K): [in a new window]   Figure 9a.  Dysplastic nodule in a 61-year-old man with chronic liver disease. (a) Baseline US image shows a small, hypoechoic nodule (arrow). (b) Arterial phase US image obtained 25 seconds after contrast material injection fails to depict any lesion.

 

View larger version (151K): [in a new window]   Figure 9b.  Dysplastic nodule in a 61-year-old man with chronic liver disease. (a) Baseline US image shows a small, hypoechoic nodule (arrow). (b) Arterial phase US image obtained 25 seconds after contrast material injection fails to depict any lesion.

 

View larger version (113K): [in a new window]   Figure 10a.  Small HCC in a 54-year-old man with chronic liver disease. (a) Baseline US image shows a small, hypoechoic nodule (arrows) (cf Fig 9a). (b) Arterial phase US image obtained 26 seconds after contrast material injection demonstrates diffuse homogeneous enhancement of the nodule (arrows). (c) Portal phase US image obtained 41 seconds after injection shows isoechogenicity of the nodule (arrow).

 

View larger version (136K): [in a new window]   Figure 10b.  Small HCC in a 54-year-old man with chronic liver disease. (a) Baseline US image shows a small, hypoechoic nodule (arrows) (cf Fig 9a). (b) Arterial phase US image obtained 26 seconds after contrast material injection demonstrates diffuse homogeneous enhancement of the nodule (arrows). (c) Portal phase US image obtained 41 seconds after injection shows isoechogenicity of the nodule (arrow).

 

View larger version (143K): [in a new window]   Figure 10c.  Small HCC in a 54-year-old man with chronic liver disease. (a) Baseline US image shows a small, hypoechoic nodule (arrows) (cf Fig 9a). (b) Arterial phase US image obtained 26 seconds after contrast material injection demonstrates diffuse homogeneous enhancement of the nodule (arrows). (c) Portal phase US image obtained 41 seconds after injection shows isoechogenicity of the nodule (arrow).

 

View larger version (102K): [in a new window]   Figure 11a.  HCC in a 78-year-old man with chronic liver disease and an elevated serum -fetoprotein level. (a) Very early arterial phase US image obtained 21 seconds after contrast material injection shows an enhancing mass, with a feeding artery (large arrow) and perinodular arteries (small arrows) nearby. (b) Delayed arterial phase US image obtained 31 seconds after injection shows a homogeneously enhancing mass (arrows).

 

View larger version (105K): [in a new window]   Figure 11b.  HCC in a 78-year-old man with chronic liver disease and an elevated serum -fetoprotein level. (a) Very early arterial phase US image obtained 21 seconds after contrast material injection shows an enhancing mass, with a feeding artery (large arrow) and perinodular arteries (small arrows) nearby. (b) Delayed arterial phase US image obtained 31 seconds after injection shows a homogeneously enhancing mass (arrows).

 

View larger version (127K): [in a new window]   Figure 12a.  Large liver dome HCC in an 81-year-old man with uncompensated liver cirrhosis. (a) Arterial phase US image obtained 27 seconds after contrast material injection shows a peripherally enhancing mass (large arrows) with discrete arteries (small arrows) and a necrotic center. (b) Arterial phase CT scan demonstrates a peripherally enhancing mass (arrows) with small internal arteries, findings that correlate well with those seen at US. F = peritoneal fluid.

 

View larger version (86K): [in a new window]   Figure 12b.  Large liver dome HCC in an 81-year-old man with uncompensated liver cirrhosis. (a) Arterial phase US image obtained 27 seconds after contrast material injection shows a peripherally enhancing mass (large arrows) with discrete arteries (small arrows) and a necrotic center. (b) Arterial phase CT scan demonstrates a peripherally enhancing mass (arrows) with small internal arteries, findings that correlate well with those seen at US. F = peritoneal fluid.

 

View larger version (127K): [in a new window]   Figure 13a.  Liver metastasis in a 59-year-old man with pancreatic cancer. (a) Arterial phase US image obtained 24 seconds after contrast material injection shows a thick, continuous collar of enhancement (arrows). (b) Portal phase US image obtained 114 seconds after injection shows a heterogeneously hypoechoic lesion (arrows).

 

View larger version (129K): [in a new window]   Figure 13b.  Liver metastasis in a 59-year-old man with pancreatic cancer. (a) Arterial phase US image obtained 24 seconds after contrast material injection shows a thick, continuous collar of enhancement (arrows). (b) Portal phase US image obtained 114 seconds after injection shows a heterogeneously hypoechoic lesion (arrows).

 

View larger version (128K): [in a new window]   Figure 14a.  Hypervascular liver metastases in a 60-year-old man with previously resected retroperitoneal sarcoma. (a) Early arterial phase US image obtained 20 seconds after contrast material injection shows a large lesion with heterogeneous and mostly peripheral (nonglobular) enhancement (large arrows). Two small lesions remain hypoechoic (small arrows). (b) Delayed arterial phase US image obtained 34 seconds after injection shows homogeneous enhancement of the large lesion and one of the small lesions (large arrows) and rim enhancement of the other small lesion (small arrow). Note that, in this case, lesion enhancement is variable and asynchronous.

 

View larger version (126K): [in a new window]   Figure 14b.  Hypervascular liver metastases in a 60-year-old man with previously resected retroperitoneal sarcoma. (a) Early arterial phase US image obtained 20 seconds after contrast material injection shows a large lesion with heterogeneous and mostly peripheral (nonglobular) enhancement (large arrows). Two small lesions remain hypoechoic (small arrows). (b) Delayed arterial phase US image obtained 34 seconds after injection shows homogeneous enhancement of the large lesion and one of the small lesions (large arrows) and rim enhancement of the other small lesion (small arrow). Note that, in this case, lesion enhancement is variable and asynchronous.

 

View larger version (125K): [in a new window]   Figure 15a.  Liver metastasis in a 48-year-old woman with colon cancer. (a) Baseline US image shows a barely appreciable hypoechoic lesion (arrow). (b) Portal phase US image obtained 54 seconds after contrast material injection demonstrates an enhancement defect (arrow) with parenchymal enhancement. Small intralesional echoic dots appear on real-time images as fine internal echo pollution (microcirculation).

 

View larger version (153K): [in a new window]   Figure 15b.  Liver metastasis in a 48-year-old woman with colon cancer. (a) Baseline US image shows a barely appreciable hypoechoic lesion (arrow). (b) Portal phase US image obtained 54 seconds after contrast material injection demonstrates an enhancement defect (arrow) with parenchymal enhancement. Small intralesional echoic dots appear on real-time images as fine internal echo pollution (microcirculation).

 

View larger version (118K): [in a new window]   Figure 16a.  Focal steatosis in a 62-year-old woman with previous breast cancer. (a) Baseline US image shows a hyperechoic area within the dorsal aspect of liver segment IV (arrows). Although the appearance and location of the lesion were typical for a focal area of steatosis, the referring clinician requested contrast-enhanced US. (b) Arterial phase US image obtained 40 seconds after contrast material injection demonstrates lesion isoechogenicity.

 

View larger version (131K): [in a new window]   Figure 16b.  Focal steatosis in a 62-year-old woman with previous breast cancer. (a) Baseline US image shows a hyperechoic area within the dorsal aspect of liver segment IV (arrows). Although the appearance and location of the lesion were typical for a focal area of steatosis, the referring clinician requested contrast-enhanced US. (b) Arterial phase US image obtained 40 seconds after contrast material injection demonstrates lesion isoechogenicity.

 

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