Prospective evaluation of liver shearwave elastography measurements with 3 different technologies and same day liver biopsy in patients with chronic liver disease.

BACKGROUND: Most ultrasound-based methods for assessing liver fibrosis still need further validation with liver biopsy used as gold standard to assess their accuracy. AIMS: To assess accuracy of three shear wave elastography (SWE) methods: 1) Philips Elast Point Quantification (ElastPQTM), 2) Siemens Virtual TouchTM Quantification (VTQ) acoustic radiation force impulse (ARFI), and 3) transient elastography (TE) measured by Echosens FibroscanTM. METHODS: 160 patients underwent liver stiffness measurements (LSM) with three SWE methods immediately prior to liver biopsy. RESULTS: The number of LSM required for reliable studies could be reduced to 6 for ElastPQ and to 7 for VTQ from standard recommendations of 10. Significant fibrosis and interquartile range/median (IQR/M)> 30 were independent predictors for lower reliability for detection of liver fibrosis. Ordinal logistic regression corrected for age showed that there was a significant interaction between steatosis (p = 0.008) and lobular inflammation (p = 0.04) and VTQ (ARFI) and between lobular inflammation and TE (p = 0.006). CONCLUSIONS: We showed variations in SWE measurements using different ARFI technologies. TE and ElastPQ achieved good diagnostic performance, whereas VTQ showed lower diagnostic accuracy. The number of measurements required for reliable studies can be reduced to 6 for ElastPQ and to 7 for VTQ, which have important clinical implications.

The Accuracy of Ultrasound Controlled Attenuation Parameter in Diagnosing Hepatic Fat Content.

Purpose: The Controlled Attenuation Parameter (CAP score) is based on ultrasonic properties of retropropagated radiofrequency signals acquired by FibroscanTM (Echosens, Paris, France). Since ultrasound propagation is influenced by the presence of fat, CAP score was developed to quantify steatosis. The aim of this study was to delineate the accuracy of CAP in diagnosing hepatic steatosis, compared to the gold standard of liver biopsy. Patients and Methods: A total of 150 patients underwent same-day liver biopsy and measurement of hepatic steatosis with Fibroscan. Only examinations with 10 satisfactory measurements, and an inter-quartile range of less than 30% of the median liver stiffness values were included for data analysis. Histological staging was then correlated with median values and Spearman correlation calculated. P values of <0.05 were considered statistically significant. Results: For diagnosis of hepatic steatosis (HS), CAP could predict the steatosis S2 with AUROC 0.815 (95% CI 0.741-0.889), sensitivity (0.81) and specificity (0.73) when the optimal cut-off value was set at 288 dB/m. CAP detected histological grade S3 with AUROC 0.735 (95% CI 0.618-0.851), sensitivity (0.71) and specificity (0.74), with a cut-off value of 330 dB/m. The AUROC for steatosis grade S1 was 0.741 (95% CI 0.650-0.824), with a cut-off value of 263 dB/m with sensitivity 0.75 and specificity 0.70. Univariate analysis showed a correlation between CAP and diabetes (p 0.048). Conclusion: The performance of CAP to diagnose steatosis severity decreases as steatosis progresses. CAP is associated with diabetes but not other clinical factors and parameters of the metabolic syndrome.

Radiological assessment of the breast following enhancement with Macrolane: Managing the challenges.

Macrolane VRF®, a biodegradable, stabilized hyaluronic acid gel, was used for breast enhancement 2008-2012. Similar to permanent implants, the presence of Macrolane gel may interfere with interpretation of mammography. This short communication aims to provide a guide to the appearance of Macrolane on radiology examination (including mammography, ultrasound and magnetic resonance imaging) and aid selection of the most appropriate imaging modality to facilitate breast examination in women who have undergone Macrolane breast enhancement.

A comparison of the diagnostic accuracy of MARS MRI and ultrasound of the painful metal-on-metal hip arthroplasty.

BACKGROUND AND PURPOSE: Metal artifact reduction sequence (MARS) MRI and ultrasound scanning (USS) can both be used to detect pseudotumors, abductor muscle atrophy, and tendinous pathology in patients with painful metal-on-metal (MOM) hip arthroplasty. We wanted to determine the diagnostic test characteristics of USS using MARS MRI as a reference for detection of pseudotumors and muscle atrophy. PatienTS AND METHODS: We performed a prospective cohort study to compare MARS MRI and USS findings in 19 consecutive patients with unilateral MOM hips. Protocolized USS was performed by consultant musculoskeletal radiologists who were blinded regarding clinical details. Reports were independently compared with MARS MRI, the imaging gold standard, to calculate predictive values. RESULTS: The prevalence of pseudotumors on MARS MRI was 68% (95% CI: 43-87) and on USS it was 53% (CI: 29-76). The sensitivity of USS in detecting pseudotumors was 69% (CI 39-91) and the specificity was 83% (CI: 36-97). The sensitivity of detection of abductor muscle atrophy was 47% (CI: 24-71). In addition, joint effusion was detected in 10 cases by USS and none were seen by MARS MRI. INTERPRETATION: We found a poor agreement between USS and MARS MRI. USS was inferior to MARS MRI for detection of pseudotumors and muscle atrophy, but it was superior for detection of joint effusion and tendinous pathologies. MARS MRI is more advantageous than USS for practical reasons, including preoperative planning and longitudinal comparison.

Can contrast-enhanced ultrasound distinguish malignant from reactive lymph nodes in patients with head and neck cancers?

The purpose of this study was to investigate the utility of contrast-enhanced ultrasound in differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. A consecutive series of 17 patients with known head and neck malignancy scheduled for neck surgery and lymph node clearance were recruited for contrast-enhanced ultrasound evaluation. Sonographic signal intensity as a function of time, comparing features of time to peak, time to arrival and time to wash-out, was quantified. The selected node was removed surgically and submitted for histology. Contrast-enhanced ultrasound examination had 100% sensitivity and 85.7% specificity for lymph node involvement. Functional analysis revealed contrast peaks significantly earlier in the malignant nodes (mean ± standard deviation) of 24.14 ± 2.7 s compared with 29.33 ± 3.4 s (p = 0.0128). Contrast-enhanced ultrasound holds promise in the detection and characterization of metastatic nodes that would not be diagnosed as abnormal on the basis of conventional ultrasound criteria.

The efficacy of axillary ultrasound in the detection of nodal metastasis in breast cancer.

OBJECTIVE: Recent reports indicate a lack of survival benefit for axillary lymph node dissection (ALND) versus sentinel lymph node biopsy in early breast cancer. To study this issue further, we assessed the accuracy and effectiveness of ultrasound examination in detecting axillary nodal involvement in breast cancer patients with the aim of refining our current clinical pathways. MATERIALS AND METHODS: Ultrasound data were collected from breast cancer cases over 3 years. Images were reviewed by experienced radiologists and the following characteristics were assessed: size, morphology, hyperechoic hilum, and cortical thickness of the ipsilateral axillary nodes. The findings were correlated with histologic outcomes after ALND. RESULTS: Two hundred twenty-four cases were included in the analysis, 113 (50.4%) of which had evidence of metastatic nodal involvement at final histology. Of these 113 cases, ultrasound findings for 59 (52.2%) were positive. The overall positive predictive value of ultrasound for detecting metastatic nodal involvement measured 0.81. The negative predictive value was 0.60. The sensitivity was 53.7%; specificity, 85.1%; and accuracy, 67.9%. The ultrasound morphologic lymph node features with the greatest correlation with malignancy were the absence of a hyperechoic hilum (p = 0.003) and increased cortical thickness (p = 0.03). Patients with a metastatic nodal burden density of at least 20% were more likely to have abnormal findings on axillary ultrasound examination (p = 0.009). CONCLUSION: Axillary ultrasound has a low negative predictive value and negative ultrasound results do not exclude axillary node metastases with sufficient sensitivity to justify its routine clinical use. Clinical pathways need to consider an evidence-based approach, focusing on the criteria by which we select breast cancer patients for ALND.

Embolization of uterine arteriovenous malformations in patients with gestational trophoblastic tumors: a review of patients at Charing Cross Hospital, 2000-2009.

OBJECTIVE: To review the indications, efficacy and follow-up for gestational trophoblastic tumor (GTT) patients treated for uterine arteriovenous vascular malformations (AVMs) and bleeding vaginal metastases with modern polyvinyl alcohol particle (PVA)-based radiological embolization. STUDY DESIGN: GTT patients undergoing embolization were identified from the Charing Cross Hospital database. The patients' records were assessed for indication, technique used, primary and overall success in controlling bleeding, complications and subsequent pregnancy outcome. RESULTS: During the period 2000-2009, 19 patients were treated for persistent or life-threatening bleeding by PVA-based uterine artery embolization performed via the femoral artery approach. Embolization resulted in control of hemorrhage in 18 of the 19 patients; 15 achieved control after the first procedure, with only 4 patients requiring a second procedure. In 1 case surgical intervention was required to control bleeding. The most frequent morbidity from the procedure was pelvic pain, requiring opiate administration; there were no other regular complications. The fertility outcome for these 19 patients indicates that 9 women have gone on to deliver a total of 12 healthy infants postembolization. CONCLUSION: For GTT patients with heavy bleeding from AVMs, uterine artery embolization is a safe and effective treatment with low short-term toxicity and no obvious detrimental effect on future fertility.

CT angiography of inferior epigastric and gluteal perforating arteries before free flap breast reconstruction.

Muscle-sparing perforator free flap breast reconstruction with the use of an inferior epigastric or gluteal perforating artery to create a vascular pedicle is increasingly popular because it obviates breast implants and results in lower donor site morbidity than breast reconstruction with myocutaneous flaps. The tissue harvesting procedure for a perforator free flap involves dissecting the subcutaneous fat of the anterior abdominal wall or the buttock to locate and visually evaluate the perforating arteries so as to decide which one is most suitable for the vascular pedicle. The vessel selected depends on multiple anatomic and surgical considerations, and the decision-making process can be exceptionally time-consuming, in part because of the wide variation that occurs in vascular anatomy. Preoperative imaging can greatly improve the efficiency of the selection process. Doppler ultrasonography (US) is the most frequently used modality for vascular mapping, but the results are mixed because most perforating arteries have a diameter of less than 15 mm, the threshold for reliable visualization with US. A computed tomographic (CT) angiographic evaluation performed with the use of specific postprocessing and display techniques may be more accurate for identifying the most suitable vessel. CT angiography provides valuable information that can help optimize surgical planning, decrease time spent in the operating room, and improve the outcome of breast reconstruction surgery.

Recent advances in imaging hepatic fibrosis and steatosis.

Liver disease is an increasing cause of morbidity and mortality worldwide. Currently, the gold standard for diagnosis and assessment of parenchymal disease is histopathological assessment of a percutaneous or transjugular liver biopsy. The risks and limitations of this technique are well recognized and as a result, significant effort has gone into the development of novel noninvasive methods of diagnosis and longitudinal assessment. Imaging techniques have improved significantly over the past decade and new technologies are beginning to enter clinical practice. Ultrasound, computed tomography and MRI are the main modalities currently used, but novel MRI-based techniques will have an increasing role. While there has been extensive research into the imaging of focal liver disease, the evidence base for imaging in diffuse disease has also undergone recent rapid development, particularly in the assessment of fibrosis and steatosis. Both of these abnormalities of the parenchyma can lead to cirrhosis and/or hepatocellular carcinoma and represent an important opportunity for detection of early liver disease. We discuss the recent advances in liver imaging techniques and their role in the diagnosis and monitoring of diffuse liver disease, with a focus on their current and potential clinical relevance and whether they may replace or augment liver biopsy. We also discuss techniques currently under development and their potential clinical applications in the future.

Perihepatic lymph nodes as markers of disease response in patients with hepatitis C-related liver disease: a prospective clinical evaluation.

AIM: To assess the clinical feasibility of utilizing the presence of perihepatic lymphadenopathy, seen on ultrasound, as a marker of response to antiviral treatment in patients with hepatitis C virus (HCV)-related liver disease. METHODS: Eighty-five patients with HCV-related liver disease [51 men and 34 women; mean age 47 years (range 26-67)] underwent liver biopsy and baseline ultrasound scans. Twenty-two of these patients were followed up longitudinally with 6-monthly ultrasound scans, whereas they were receiving anti-HCV eradication therapy with interferon and ribavirin. Perihepatic lymph nodes detected in the coeliac axis and peripancreatic region were noted, with the largest node size on maximal diameter recorded. The patients were subsequently assessed in the light of long-term virological response to treatment. RESULTS: Perihepatic lymph nodes were detected in 26 of the 85 patients. Of the 22 patients followed up longitudinally, 11 responded to antiviral treatment, nine failed to respond and two did not complete a course of treatment. No significant difference was found between patients with detectable lymphadenopathy and those without according to age, sex, disease severity and genotype. There was a general reduction in size of lymph nodes in both responders and nonresponders to treatment, although this reduction was only significant in the responder group (P=0.003). CONCLUSION: The presence of perihepatic lymphadenopathy when detected in patients with viral hepatitis can potentially serve as an indicator of response to treatment. However, as only 30-40% of patients have detectable lymphadenopathy, its clinical utility is limited.

Imaging of liver cancer.

Improvements in imaging technology allow exploitation of the dual blood supply of the liver to aid in the identification and characterisation of both malignant and benign liver lesions. Imaging techniques available include contrast enhanced ultrasound, computed tomography and magnetic resonance imaging. This review discusses the application of several imaging techniques in the diagnosis and staging of both hepatocellular carcinoma and cholangiocarcinoma and outlines certain characteristics of benign liver lesions. The advantages of each imaging technique are highlighted, while underscoring the potential pitfalls and limitations of each imaging modality.

Pelvic imaging in gestational trophoblastic neoplasia.

OBJECTIVE: To assess the accuracy of Doppler ultrasound (DU) compared with magnetic resonance imaging (MRI) in high-risk patients with gestational trophoblastic neoplasia (GTN). STUDY DESIGN: From January 2005 to October 2007, patients with proven high-risk GTN or suspicion of relapse who had both DU and MRI of the pelvis were reviewed retrospectively for tumor detection and tumor extent and vascularity. RESULTS: There were a total of 54 patients who had both DU and MRI performed; of these, 40 were first-time presentation and 14 had either residual disease not responding to chemotherapy or suspicion of recurrent GTN based on rising human chorionic gonadotropin (hCG). Extrauterine extension and extent of endometrial encroachment were better assessed on MRI than on DU in 10 of 46 patients with visible uterine lesion. CONCLUSION: MRI and DU are complementary investigations of the pelvis in patients with GTN. Tumor vascularity is better assessed on DU, tumor extension and detection are better with MRI.

31P MR spectroscopy in assessment of response to antiviral therapy for hepatitis C virus-related liver disease.

OBJECTIVE: An increase in the ratio of phosphomonoester (PME) to phosphodiester (PDE) during 31P MR spectroscopy of the liver has been observed with increasing severity of hepatitis C-related liver disease. The purpose of this study was to investigate the utility of 31P MR spectroscopy as a biomarker of response to interferon and ribavirin treatment. SUBJECTS AND METHODS: Forty-seven patients with biopsy-proven hepatitis C undergoing viral eradication treatment with interferon and ribavirin underwent hepatic 31P MR spectroscopy at 1.5 T (voxel size, 70 x 70 x 70 mm; TR, 10,000; number of signals averaged, 48). All underwent baseline imaging before treatment and repeated imaging at 6-month intervals after the start of treatment. RESULTS: All patients underwent follow-up imaging 6 months after the start of treatment; 25 patients, 12 months; and 10 patients, 18 months after the start of treatment. According to the Ishak histologic scoring system, nine patients had mild hepatitis; 30 patients, moderate to severe hepatitis; and eight patients, cirrhosis. Thirty-two patients responded to antiviral treatment. Among these patients, 25 had a decrease in PME/PDE ratio on follow-up imaging. Among responders the mean baseline PME/PDE ratio decreased from 0.27 +/- 0.02 (standard error) to 0.16 +/- 0.01 after treatment (paired Student's t test, p < 0.001). Among the 15 virologic nonresponders, the ratios were similar in six patients; six other patients had an increase on follow-up imaging. In the latter nonresponder group, the mean baseline PME/PDE ratio was 0.21 +/- 0.03 compared with 0.31 +/- 0.08 after treatment (paired Student's t test, p =0.24). CONCLUSION: The in vivo hepatic PME/PDE ratio decreased in patients with hepatitis C who responded to antiviral treatment and remained similar or increased in patients without a virologic response. These results suggest that PME and PDE can be used as biomarkers in a noninvasive test of response to treatment.

Role of microbubble ultrasound contrast agents in the non-invasive assessment of chronic hepatitis C-related liver disease.

Patients who are chronically infected with the hepatitis C virus often develop chronic liver disease and assessment of the severity of liver injury is required prior to considering viral eradication therapy. This article examines the various assessment methods currently available from gold standard liver biopsy to serological markers and imaging. Ultrasound is one of the most widely used imaging modalities in clinical practice and is already a first-line diagnostic tool for liver disease. Microbubble ultrasound contrast agents allow higher resolution images to be obtained and functional assessments of microvascular change to be carried out. The role of these agents in quantifying the state of hepatic injury is discussed as a viable method of determining the stage and grade of liver disease in patients with hepatitis C. Although currently confined to specialist centres, the availability of microbubble contrast-enhanced ultrasound will inevitably increase in the clinical setting.

Hepatic vein transit time of SonoVue: a comparative study with Levovist.

PURPOSE: To prospectively compare transit times of Levovist and SonoVue in healthy volunteers and patients with biopsy-proved hepatitis C-related liver disease. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Forty patients and 25 healthy volunteers were examined. Subjects fasted, a bolus of SonoVue (0.6 mL) was injected into a cubital fossa vein, and hepatic venous time-intensity profiles were measured with spectral Doppler tracing. This was repeated with two injections of Levovist (2 g) and another injection of SonoVue. Time-intensity curves of spectral Doppler signals of right and middle hepatic veins were analyzed. A sustained signal intensity increase of 10% above baseline levels indicated hepatic vein transit time (HVTT). Carotid artery audio intensity was measured in volunteers. Analysis of variance and t tests were used for statistical analysis. RESULTS: Twelve patients had mild hepatitis; 18, moderate or severe hepatitis; and 10, cirrhosis. Mean HVTTs in control, mild hepatitis, moderate or severe hepatitis, and cirrhosis groups were 38.3 seconds +/- 2.4 (standard error), 47.5 seconds +/- 6.5, 29.5 seconds +/- 10.8, and 17.6 seconds +/- 5.0, respectively, with Levovist (P < .001) and 29.4 seconds +/- 6.9, 27.4 seconds +/- 9.3, 22.9 seconds +/- 4.7, and 16.4 seconds +/- 4.9, respectively, with SonoVue (P < .001). HVTT decreased as severity increased at imaging with both contrast agents. There was no significant difference in HVTT between mild and moderate hepatitis groups with SonoVue; however, there were significant differences in HVTT between all patient groups with Levovist. HVTT of SonoVue was shorter than that of Levovist in all groups (P < .001) except the cirrhosis group; in this group, HVTT of the two contrast agents was similar (P = .05). No difference was observed in mean cardiopulmonary transit time for SonoVue or Levovist (9.1 seconds +/- 2.4 [standard error] and 8.4 seconds +/- 2.5, respectively, P = .18). CONCLUSION: HVTT was significantly shorter with SonoVue than with Levovist; there was no significant difference in cardiopulmonary transit time.

Can Doppler sonography grade the severity of hepatitis C-related liver disease?

OBJECTIVE: Many authors have claimed that Doppler sonography indexes are of value in grading and assessing diffuse liver disease. However, there is much controversy regarding the reliability and reproducibility of these techniques. We performed a prospective study to evaluate whether these methods can grade disease in a well-stratified cohort of patients with hepatitis C virus (HCV)-related liver disease. SUBJECTS AND METHODS: Sixty-five patients with biopsy-proven HCV-related liver disease were recruited, and Doppler sonography was performed by one operator. The patients were classified into one of the following three groups on the basis of the Ishak-modified histologic activity index (HAI) fibrosis (F) and necroinflammatory (NI) scores: mild hepatitis (F < or = 2 and NI < or = 3), moderate or severe hepatitis (3 < or = F < 6 or NI > or = 4), or cirrhosis (F = 6/6). We measured the following Doppler indexes: main hepatic artery peak velocity (Vmax) and resistive index, main portal vein peak velocity (Vmax), and maximal portal vein diameter and circumference that allowed calculation of the portal vein congestive index (portal vein area and portal vein velocity). The ratio of the hepatic artery velocity (Vmax) to the portal vein velocity (Vmax) was also calculated, and the phasicity (triphasic, biphasic, or monophasic) of the hepatic veins of each patient was recorded. We also measured the maximal spleen length longitudinally. RESULTS: A total of 65 patients with liver disease (mild hepatitis, n = 20; moderate or severe hepatitis, n = 25; cirrhosis, n = 20) with biopsy-proven HCV-related liver disease were studied. Optimal hepatic arterial traces were obtained in only 30 patients and portal vein circumference in 18 patients. No significant differences were observed in the Doppler indexes with increasing severity of liver disease. Five (29%) of 17 patients with mild hepatitis had an abnormal hepatic vein trace (i.e., biphasic or monophasic) compared with 11 (55%) of 20 patients with moderate or severe hepatitis and 12 (60%) of 20 patients with cirrhosis. The only index to show a significant intergroup difference was splenic length (analysis of variance, p < 0.001), but there was still overlap between the groups. CONCLUSION: Doppler-derived indexes, which have previously been recommended for the assessment of severity in chronic liver disease, are difficult to reproduce reliably and therefore have a limited clinical role in the noninvasive assessment of hepatic fibrosis or inflammation.

The relationship of in vivo 31P MR spectroscopy to histology in chronic hepatitis C.

Liver biopsy remains the gold standard for characterizing diffuse liver disease and is associated with significant morbidity and, rarely, mortality. Our aim was to investigate whether a noninvasive technique, in vivo phosphorus 31 ((31)P)-magnetic resonance spectroscopy (MRS), could be used to assess the severity of hepatitis C virus (HCV)-related liver disease. Fifteen healthy controls and 48 patients with biopsy-proven HCV-related liver disease were studied prospectively. Based on their histologic fibrosis (F) and necroinflammatory (NI) scores, patients were divided into mild hepatitis (F or= 4/18), and cirrhosis (F = 6/6). Hepatic (31)P MR spectra were obtained using a 1.5-T spectroscopy system. Quantitation of the (31)P signals was performed in the time domain using the Advanced MAgnetic RESonance algorithm. There was a monotonic increase in the mean +/- 1 standard error phosphomonoester (PME) to phosphodiester (PDE) ratios for the control, mild disease, moderate disease, and cirrhosis groups: 0.15 +/- 0.01, 0.18 +/- 0.02, 0.25 +/- 0.02, 0.38 +/- 0.04, respectively (ANOVA, P <.001). An 80% sensitivity and specificity was achieved when using a PME/PDE ratio less than or equal to 0.2 to denote mild hepatitis and a corresponding ratio greater than or equal to 0.3 to denote cirrhosis. No other significant spectral changes were observed. In conclusion, (31)P MRS can separate mild from moderate disease and these 2 groups from cirrhosis. The ability to differentiate these populations of patients has therapeutic implications and (31)P MRS, in some situations, would not only complement a liver biopsy but could replace it and be of particular value in assessing disease progression.

Embolization of bleeding residual uterine vascular malformations in patients with treated gestational trophoblastic tumors.

PURPOSE: To retrospectively evaluate embolotherapy of bleeding residual uterine vascular malformations in patients with gestational trophoblastic tumors. MATERIALS AND METHODS: Fourteen patients were treated over the past 20 years. Embolizations were performed with a common femoral artery approach. Duplex ultrasonography was performed before and after embolization to document the uterine vascularity. The technique and materials used for each embolization, control of hemorrhage, need for repeat embolization, complications, and outcome of subsequent pregnancies were assessed. RESULTS: Hemorrhage was controlled in 11 of the 14 patients; two patients required hysterectomy and one required uterine artery ligation for failure to control hemorrhage after initial embolization. Six patients required repeat embolization for recurrence of bleeding. Therapeutic benefit and success were associated with the ability to selectively embolize the uterine artery and to achieve a greater than 80% reduction in vascular malformation size. Pulsatility indexes of the uterine arteries and endometrial encroachment were not predictive of recurrent hemorrhage. Two patients delivered a total of three full-term infants, one patient experienced a miscarriage, and another experienced a termination of pregnancy following embolotherapy. Pain requiring opiate analgesia was a frequent complication of treatment. CONCLUSION: Selective uterine artery embolization is a safe and effective treatment for severe bleeding from residual uterine vascular malformations in patients with treated gestational trophoblastic tumors.

Detection of an occult hepatocellular carcinoma using ultrasound with liver-specific microbubbles.

The radiological surveillance of cirrhosis to detect the development of hepatocellular carcinoma (HCC) is problematic because no highly sensitive and specific imaging investigation is available. Ultrasound is typically the first modality used but is less accurate than other imaging modalities. We report the first case of a patient with cirrhosis in whom US imaging with liver-specific microbubbles detected an HCC prior to its detection by MR. The use of liver-specific microbubble US contrast agents is an exciting development in the detection of HCC in chronic liver disease and may help to rectify some of the shortcomings of US.