CT-based radiomics for preoperative prediction of early recurrent hepatocellular carcinoma: technical reproducibility of acquisition and scanners.

PURPOSE: To test the technical reproducibility of acquisition and scanners of CT image-based radiomics model for early recurrent hepatocellular carcinoma (HCC). METHODS: We included primary HCC patient undergone curative therapies, using early recurrence as endpoint. Four datasets were constructed: 109 images from hospital #1 for training (set 1: 1-mm image slice thickness), 47 images from hospital #1 for internal validation (sets 2 and 3: 1-mm and 10-mm image slice thicknesses, respectively), and 47 images from hospital #2 for external validation (set 4: vastly different from training dataset). A radiomics model was constructed. Radiomics technical reproducibility was measured by overfitting and calibration deviation in external validation dataset. The influence of slice thickness on reproducibility was evaluated in two internal validation datasets. RESULTS: Compared with set 1, the model in set 2 indicated favorable prediction efficiency (the area under the curve 0.79 vs. 0.80, P = 0.47) and good calibration (unreliability statistic U: P = 0.33). However, in set 4, significant overfitting (0.63 vs. 0.80, P < 0.01) and calibration deviation (U: P < 0.01) were observed. Similar poor performance was also observed in set 3 (0.56 vs. 0.80, P = 0.02; U: P < 0.01). CONCLUSIONS: CT-based radiomics has poor reproducibility between centers. Image heterogeneity, such as slice thickness, can be a significant influencing factor.

Intraprocedural computed tomography/magnetic resonance-contrast-enhanced ultrasound fusion imaging improved thermal ablation effect of hepatocellular carcinoma: Comparison with conventional ultrasound.

AIM: To retrospectively compare the treatment effect of intraprocedural computed tomography/magnetic resonance-contrast-enhanced ultrasound (CT/MR-CEUS) fusion imaging (FI) with that of conventional ultrasound (US) in the guidance and assessment of thermal ablation of hepatocellular carcinoma (HCC). METHODS: The FI group (112 patients with 129 HCC) was treated between April 2010 and December 2012, whereas the US group (83 patients with 90 HCC) was treated between January 2008 and March 2010. Either CT/MR-CEUS FI or US was used to guide puncture, provide immediate assessment, and guide supplementary ablation. Technical efficacy, cumulative local tumor progression rate (LTP), recurrence-free survival (RFS), and overall survival (OS) were evaluated and compared during follow-up. Technical success rate of CT/MR-CEUS FI was also recorded. RESULTS: Technical efficacy was significantly higher in the FI group than in the US group (100% vs. 86.7%, P < 0.001). The 1-, 2-, 3-, 4-, 5-, and 6-year cumulative LTP rates in the FI group were significantly lower than in the US group (3.8%, 4.9%, 6.0%, 6.0%, 7.2%, and 7.2% vs. 16.9%, 20.1%, 25%, 25%, 25%, and 25%, respectively; P < 0.001); RFS and OS were significantly higher in the FI group than in the US group (P = 0.027 and P = 0.049, respectively). The technical success rate of FI was 85.3%. CONCLUSIONS: Intraprocedural CT/MR-CEUS FI improved the treatment effect of thermal ablation of HCC by immediately assessing treatment response and guiding supplementary ablation relative to those resulting from the use of conventional US.

Intraprocedural contrast-enhanced ultrasound-CT/MR fusion imaging assessment in HCC thermal ablation to reduce local tumor progression: compared with routine contrast-enhanced ultrasound.

Purpose: To evaluate whether local tumor progression (LTP) would be further reduced when contrast-enhanced ultrasound (CEUS)-CT/MR fusion imaging was used as intraprocedural assessment method in hepatocellular carcinoma (HCC) thermal ablation compared with routine CEUS. Materials and methods: This prospective non-randomized study was conducted from December 2010 to July 2012. CEUS-CT/MR fusion imaging and routine CEUS were used for treatment response assessment in the ablation procedure of 146 HCCs and 122 HCCs, respectively. Supplementary ablations were performed immediately if necessary. The primary technique efficacy rate, LTP rate and overall survival (OS) rate were calculated. Results: For CEUS-CT/MR fusion imaging and routine CEUS, the technical success rate, technique efficacy rate and supplementary ablation rate were 86.3% (126/146) and 98.4% (120/122) (p = .000), 99.2% (125/126) and 94.2% (113/120) (p = .032), and 14.3% (18/126) and 4.2% (5/120) (p = .006), respectively. The cumulative LTP rate and OS rate were not significantly different between fusion imaging group and routine CEUS group. However, for lesions that were larger than 3 cm or close to major vessels (41 lesions in fusion imaging group and 44 lesions in routine CEUS group, who received transcatheter arterial chemoembolization before ablation), the cumulative LTP rate was significantly lower in fusion imaging group than in routine CEUS group (p = .032). Conclusion: Although intraprocedural CEUS-CT/MR fusion imaging has certain limitations in application, it might provide a potential more efficient method compared with routine CEUS in reducing LTP in HCC thermal ablation, especially for difficult ablation lesions.

Immediate evaluation and guidance of liver cancer thermal ablation by three-dimensional ultrasound/contrast-enhanced ultrasound fusion imaging.

PURPOSE: To investigate the feasibility and value of three-dimensional ultrasound/contrast-enhanced ultrasound (3D US-CEUS) fusion imaging for the immediate evaluation of technical success and the guidance of supplementary ablation during the liver cancer thermal ablation procedure. MATERIALS AND METHODS: Patients diagnosed with malignant liver cancer intending to receive thermal ablation including radiofrequency ablation (RFA) or microwave ablation (MWA) were enrolled. 3D US-CEUS fusion imaging was used to immediately assess the technical success and guide supplementary ablation. Contrast-enhanced computed tomography/magnetic resonance imaging (CECT/CEMRI) was performed one month after ablation to assess the technique effectiveness of the ablation. The registration success rate, duration time of 3D US-CEUS fusion imaging, technique effectiveness rate and major complications were recorded. RESULTS: In total, 76 patients with 95 tumours who underwent RFA or MWA and assessed by 3D US-CEUS fusion imaging were enrolled. The registration success rate of 3D US-CEUS fusion imaging was 93.7% (89/95), and the duration time was 4.0 ± 1.1 min. Thirty lesions received supplementary ablation immediately during the procedure. The technique effectiveness rate of the ablation was 98.8% (81/82). There were no major complications related to ablation. CONCLUSIONS: 3D US-CEUS fusion imaging is a feasible and valuable technique for the immediate evaluation and guidance of supplementary ablation during the liver cancer thermal ablation procedure.

Potential application of ultrasound-guided thermal ablation in rare liver tumors.

BACKGROUND: With the advances of imaging techniques, the detection rate of rare liver tumor is increased. However, the therapeutic strategies of the rare liver tumors remain limited. METHODS: We analyzed twelve pathologically confirmed rare liver tumors in 8 patients. All of the patients underwent ultrasound (US) guided biopsy and subsequent thermal ablation. The tumors were ablated according to the preoperative plans and monitored by real-time US. CT/MRI fused with contrast enhanced US (CEUS) or three-dimensional (3D) US-CEUS images were used to guide and assess the ablation zone more accurately during thermal ablation. The rate of technical efficacy was assessed based on the contrast-enhance CT/MRI (CECT/MRI) results one month after ablation. Local tumor progression (LTP), recurrence and complications were followed up and recorded. RESULTS: Among these twelve nodules, nine were subject to US-guided thermal ablation, whereas the other three inconspicuous nodules were subject to CEUS-guided thermal ablation. Intra-procedure CT/MRI-CEUS or 3D US-CEUS fusion imaging assessments demonstrated that the ablation zone sufficiently covered the original tumor, and no immediate supplementary ablation was required. Additionally, no major complications were observed during the follow-up period. The postoperative CECT/MRI confirmed that the technique success rate was 100%. Within the surveillance period of 13 months, no LTP or recurrence was noted. CONCLUSIONS: US-guided thermal ablation was feasible and safe for rare liver tumors. The use of fusion imaging technique might make US-guided thermal ablation as effective as surgical resection, and this technique might serve as a potential therapeutic modality for rare liver tumors in the future.

Improvement of ablative margins by the intraoperative use of CEUS-CT/MR image fusion in hepatocellular carcinoma.

BACKGROUND: To assess whether intraoperative use of contrast-enhanced ultrasound (CEUS)-CT/MR image fusion can accurately evaluate ablative margin (AM) and guide supplementary ablation to improve AM after hepatocellular carcinoma (HCC) ablation. METHODS: Ninety-eight patients with 126 HCCs designated to undergo thermal ablation treatment were enrolled in this prospective study. CEUS-CT/MR image fusion was performed intraoperatively to evaluate whether 5-mm AM was covered by the ablative area. If possible, supplementary ablation was applied at the site of inadequate AM. The CEUS image quality, the time used for CEUS-CT/MR image fusion and the success rate of image fusion were recorded. Local tumor progression (LTP) was observed during follow-up. Clinical factors including AM were examined to identify risk factors for LTP. RESULTS: The success rate of image fusion was 96.2% (126/131), and the duration required for image fusion was 4.9 ± 2.0 (3-13) min. The CEUS image quality was good in 36.1% (53/147) and medium in 63.9% (94/147) of the cases. By supplementary ablation, 21.8% (12/55) of lesions with inadequate AMs became adequate AMs. During follow-up, there were 5 LTPs in lesions with inadequate AMs and 1 LTP in lesions with adequate AMs. Multivariate analysis showed that AM was the only independent risk factor for LTP (hazard ratio, 9.167; 95% confidence interval, 1.070-78.571; p = 0.043). CONCLUSION: CEUS-CT/MR image fusion is feasible for intraoperative use and can serve as an accurate method to evaluate AMs and guide supplementary ablation to lower inadequate AMs.

Value of contrast-enhanced ultrasonography in microwave ablation treatment of symptomatic focal uterine adenomyosis.

PURPOSE: This study evaluated the value of contrast-enhanced ultrasonography (CEUS) in the ultrasound-guided microwave ablation (MWA) treatment of symptomatic focal uterine adenomyosis. METHODS: This retrospective study was conducted between March 2020 and January 2023, enrolling 52 patients with symptomatic focal uterine adenomyosis who had undergone MWA. All patients were examined with CEUS before and after MWA. The non-perfused volume (NPV) was compared between CEUS and dynamic contrast-enhanced magnetic resonance imaging (DCEMRI) following ablation. Therapeutic efficacy and safety were evaluated at 3-, 6-, and 12-month follow-ups. Additionally, this study explored the correlations between pre-treatment CEUS features and a volume reduction ratio indicating sufficient ablation, defined as 50% or more at the 3-month follow-up. RESULTS: No significant differences in NPV were noted between CEUS and DCE-MRI immediately after MWA and during follow-up (all P>0.05). At the 3-month follow-up, the median VRRs for the uterus and adenomyosis were 33.2% and 63.9%, respectively. Sufficient ablation was achieved in 69.2% (36/52) of adenomyosis cases, while partial ablation was observed in the remaining 30.8% (16/52). The identification of non-enhancing areas on pre-treatment CEUS was associated with sufficient ablation (P=0.016). At the 12-month follow-up, significant decreases were observed in both the uterine and adenomyosis volumes (all P<0.001). Dysmenorrhea and menorrhagia were significantly alleviated at 12 months, and no major complications were encountered. CONCLUSION: CEUS can be used to evaluate the ablation zone of focal adenomyosis that has been treated with MWA, similarly to DCE-MRI. The identification of non-enhancing areas on pretreatment CEUS indicates satisfactory treatment outcomes.

Dynamic Contrast-Enhanced Ultrasound Radiomics for Hepatocellular Carcinoma Recurrence Prediction After Thermal Ablation.

PURPOSE: To develop a radiomics model based on dynamic contrast-enhanced ultrasound (CEUS) to predict early and late recurrence in patients with a single HCC lesion ≤ 5 cm in diameter after thermal ablation. PROCEDURES: We enrolled patients who underwent thermal ablation for HCC in our hospital from April 2004 to April 2017. Radiomics based on two branch convolution recurrent network was utilized to analyze preoperative dynamic CEUS image of HCC lesions to establish CEUS model, in comparison to the conventional ultrasound (US), clinical, and combined models. Clinical follow-up of HCC recurrence after ablation were taken as reference standard to evaluate the predicted performance of CEUS model and other models. RESULTS: We finally analyzed 318 patients (training cohort: test cohort = 255:63). The combined model showed better performance for early recurrence than CUES (in training cohort, AUC, 0.89 vs. 0.84, P < 0.001; in test cohort, AUC, 0.84 vs. 0.83, P = 0.272), US (P < 0.001), or clinical model (P < 0.001). For late recurrence prediction, the combined model showed the best performance than the CEUS (C-index, in training cohort, 0.77 vs. 0.76, P = 0.009; in test cohort, 0.77 vs. 0.68, P < 0.001), US (P < 0.001), or clinical model (P < 0.001). CONCLUSIONS: The CEUS model based on dynamic CEUS radiomics performed well in predicting early HCC recurrence after ablation. The combined model combining CEUS, US radiomics, and clinical factors could stratify the high risk of late recurrence.

Contrast-enhanced ultrasound for the evaluation of hepatic artery stenosis after liver transplantation: potential role in changing the clinical algorithm.

Hepatic artery stenosis (HAS) is a common complication in liver transplant patients. Conventional angiography remains the gold standard for diagnosis. Recently, contrast-enhanced ultrasound (CEUS) has begun providing real-time angiographic-like images of vessels and allowing the accurate diagnosis of arterial diseases such as hepatic artery thrombosis. The purpose of this study was to evaluate the efficacy of CEUS in depicting HAS after liver transplantation. Forty-seven liver transplant recipients underwent CEUS examinations with the intravenous injection of microbubble contrast agents. The reference standard was conventional angiography for 15 patients and computed tomographic angiography for 32 patients. The presence, degree, location, and type of HAS were evaluated. For the detection of HAS by CEUS, the following was found: an accuracy of 91.5% (43/47), a sensitivity of 92.3% (36/39), a specificity of 87.5% (7/8), a positive predictive value of 97.3% (36/37), and a negative predictive value of 70% (7/10). CEUS corrected false-positive findings on color Doppler ultrasound in 7 of 47 cases (14.9%). The accuracy of CEUS in identifying the location and type of HAS was 92.3% (36/39) and 84.6% (33/39), respectively. CEUS is a useful noninvasive technique for the detection of HAS in liver transplant patients because it provides comprehensive information, including the presence, location, degree, and type. A positive CEUS finding suggests angiography as the next step rather than a computed tomography scan and may thereby alter the clinical imaging algorithm.

Usefulness of contrast-enhanced ultrasound in the diagnosis of biliary leakage following T-tube removal.

Biliary leakage is a serious complication related to T-tube removal. Identifying the location of the leak is important for accurate diagnosis and prompt treatment. We report a case of biliary leakage in the common bile duct (CBD) following a T-tube removal that was successfully diagnosed with contrast-enhanced ultrasound (CEUS). The micro-bubble contrast medium was administrated into the bile ducts through the percutaneous transhepatic biliary drainage catheter. The real-time delineation of contrast agent leaking from the CBD was confirmed by percutaneous transhepatic cholangiography. CEUS can be used to detect biliary leakage after T-tube removal.

[Role of contrast-enhanced ultrasound in the differentiation of solid focal lesions of pancreas].

OBJECTIVE: To investigate the value of contrast-enhanced ultrasound in the differential diagnosis of solid focal lesions of pancreas (s-FLPs). METHODS: We retrospectively analyzed the clinical data of 56 s-FLPs examined with contrast agent combined with low mechanical indicators contrast-enhanced ultrasound. RESULTS: The surrounding pancreas parenchyma enhancement time, lesion enhancement time, and peak enhancement time between different groups of s-FLPs had no significant differences (P > 0.05), while the beginning to peak enhancement time showed significant difference (P < 0.05). When using the enhancement speed as a diagnostic indicator to differentiate pancreatic carcinoma from tumor-like pancreatitis, the sensitivity, specificity, and accuracy were 90.5%, 71.4%, and 85.7% for pancreatic carcinoma and 75.0%, 91.7%, and 89.3% for tumor-like pancreatitis. When using the enhancement pattern as a diagnosis indicator to differentiate pancreatic carcinoma from tumor-like pancreatitis, the sensitivity, specificity, and accuracy were 85.7%, 78.6%, and 83.9% for pancreatic carcinoma and 75.0%, 100%, and 94.6% for tumor-like pancreatitis. When different indicators were combined, enhancement pattern and enhancement speed showed the best diagnostic results; however, the Youden index was not improved. CONCLUSIONS: Different s-FLPs show different enhancement findings on contrast-enhanced ultrasound. The enhancement pattern and enhancement speed are the most useful diagnostic indicators.

[The clinical value of high frequency ultrasound in diagnosis of peripheral nerve diseases].

OBJECTIVE: To evaluate the clinical value of high frequency ultrasound in diagnosing peripheral nerve diseases (PNDs). METHODS: From January 2003 to December 2006, 64 cases of PNDs were analyzed retrospectively. The ultrasound diagnosis was compared with the operative and pathological diagnosis. RESULTS: Based on the operative and histopathological results, in 38 patients with trauma or entrapment, 38 among 45 traumatic nerves were rightly diagnosed by ultrasound. The coincidence rate was 84.4%. In 26 patients with original peripheral nerve tumors (PNTs), including 20 neurilemmomas, 4 neurofibromas and 2 malignant neurilemmomas, 16 cases were diagnosed by ultrasound with a coincidence rate of 61.5%. The coincidence rates in limbs and trunk were 86.7% (13/15) and 27.3% (3/11) respectively. CONCLUSIONS: The study suggests that high frequency ultrasound can locate peripheral nerve trauma precisely, assess the impair degree correctly and provide useful information for clinic diagnosis. The high frequency ultrasound brings better diagnosis outcome in limbs nerve tumors than in trunk.

Intracavitary Contrast-Enhanced Ultrasound in the Management of Post-Surgical Gastrointestinal Fistulas.

The goal of this study was to investigate intracavitary contrast-enhanced ultrasound (IC-CEUS) measures in the management of post-surgical gastrointestinal (GI) fistula throughout detection, treatment and follow-up. From June 2010 to August 2016, patients who were administered ultrasound contrast agent (UCA) via a drainage tube for IC-CEUS were enrolled and retrospectively analyzed. They were suspected of having GI anastomotic fistulas or had been found to have fluid collections with ultrasound that were accompanied by abdominal pain or fever after surgical procedures. Forty-two patients met the inclusion criteria and were enrolled into this study. Twenty-two were confirmed to have GI fistulas confirmed by standard references. None were detected by conventional ultrasound. Although IC-CEUS successfully detected GI fistulas in 16 patients, it missed GI fistulas in 6 patients. One patient was misdiagnosed with a GI fistula. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the diagnosis of GI fistulas by IC-CEUS were 72.7% (16/22), 95.0% (19/20), 94.1% (16/17), 76.0% (19/25) and 83.3% (35/42), respectively. Twenty peritoneal fluid collections in 14 patients were related to fistulas by IC-CEUS based on the distribution of ultrasound contrast agents. Additional drainage was performed in 14 fistula-related fluid collections. Eight GI fistulas were judged to be cured after IC-CEUS re-evaluation, and the drainage tubes were removed from these patients. In conclusion, IC-CEUS can greatly improve the ability to diagnose post-surgical GI fistulas and may also play an important role in interventional treatment and follow-up.

Double contrast-enhanced ultrasonography in the detection of periampullary cancer: Comparison with B-mode ultrasonography and MR imaging.

PURPOSE: To investigate the value of double contrast-enhanced ultrasonography (DCEUS) in the detection of periampullary cancer. MATERIALS AND METHODS: Ninety-nine patients with surgery or biopsy-proven periampullary cancer who underwent both DCEUS and magnetic resonance imaging (MRI) examinations before operation were enrolled in our study. DCEUS in which intravenous microbubbles were used in combination with oral contrast agent and MRI were performed preoperatively to make a detection diagnosis of periampullary cancer. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of DCEUS, B-mode ultrasonography (BUS) and MRI were calculated and compared. Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of BUS, DCEUS and MRI in the detection. Stratified analyses were performed for different pathological types and different sizes of periampullary lesions. The inter- and intra-observer reliability of DCEUS for cancer detection was also investigated. RESULT: There were no significant differences in sensitivity, specificity, PPV, NPV or accuracy between DCEUS and MRI (all P>0.05). ROC analysis showed that the accuracy of DCEUS or MRI was higher than that of BUS (P<0.001), while no significant differences were noted in the accuracy between DCEUS and MR. In the 76 cases of periampullary cancer, DCEUS appeared to be superior to BUS for ampullary carcinoma, duodenum carcinoma and for lesions with an average diameter of less than 3cm. DCEUS appeared equal to BUS in other groups. No significant differences were noted between DCEUS and MRI in the stratified analysis. A considerably well agreement between DCEUS and MRI was obtained using Kappa analysis (k=0.649, P<0.001). The intra- and inter-observer reproducibility were both good for detection of periampullary cancer by DCEUS, with a Kappa values of 0.783 (P<0.01) and 0.732 (P<0.01), respectively. CONCLUSION: DCEUS provides an available and useful imaging modality in the detection of periampullary cancer. This technique can aid in displaying the invisible periampullary region in BUS and may also become an effective supplemental method to MRI.

Hepatocellular adenoma: comparison between real-time contrast-enhanced ultrasound and dynamic computed tomography.

PURPOSE: To investigate and compare the contrast-enhanced ultrasound (CEUS) features of histologically proven HCA with those of contrast-enhanced computed tomography (CECT). METHODS: Eighteen patients with proven hepatic adenoma by pathology were retrospectively selected from the CEUS database. Fourteen of them had undergone liver CECT exams. The basic features on unenhanced imaging and the enhancement level and specific features on contrast-enhanced imaging were retrospectively analyzed, and the differences between CEUS and CECT were compared. RESULTS: All the HCAs showed hyper-enhancement in the arterial phase. During the portal and late phases, 12 HCAs (12/18, 66.7 %) on CEUS and 11 (11/14, 78.6 %) on CT showed washout. On CEUS, 10 (10/18, 55.5 %) showed centripetal filling in the arterial phase and persistent peripheral rim enhancement. Five of them (61.1 %, 11/18) showed delayed central washout in the portal or late phase. However, on CECT, 2 (14.3 %, 2/14) and 4 (28.6 %, 4/14) HCAs showed persistent enhancement of the peripheral rim and central non-enhancing hemorrhage areas, respectively. CONCLUSIONS: Compared with dynamic CT, CEUS was superior at characterizing specific dynamic features. Considering that it is radiation-free, readily availability and easy to use, CEUS is suggested as the first line imaging tool to diagnose HCA.

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: a preliminary study.

OBJECTIVES: The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD). MATERIALS AND METHODS: 80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison. RESULTS: Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P<0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80). CONCLUSION: IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.

Evaluating biliary anatomy and variations in living liver donors by a new technique: three-dimensional contrast-enhanced ultrasonic cholangiography.

Accurate assessment of the biliary anatomy is important for the safety of liver donors in living donor liver transplantation (LDLT). We evaluated the biliary anatomy and variations of 12 living liver donors with 3-D contrast-enhanced ultrasonic cholangiography (3-D CEUSC) by injecting microbubble contrast agents into the common hepatic ducts intraoperatively. Two radiologists assessed the diagnostically adequate, delineation of biliary branch orders, visibility scores (grades 0 to 3) and anatomical patterns of the intrahepatic biliary tree by consensus. The results were compared with findings on intraoperative cholangiography (IOC) and surgery. 3-D CEUSC successfully demonstrated the spatial structure of the intrahepatic biliary tree in all 12 donors. The maximum branching order of intrahepatic bile ducts displayed on 3-D CEUSC was the fifth order in the right lobe and fourth order in the left lobe of the liver, respectively. The visibility scores of the first-order (3.00 +/- 0.00) and second-order (2.67 +/- 0.69) branches were significantly (p < 0.001) higher than that of the third-order (1.98 +/- 1.13) branches, whereas visibility scores of the second-order (2.88 +/- 0.34) and third-order (2.44 +/- 1.01) branches in the right lobe were significantly (p = 0.040 and p < 0.001, respectively) higher than those in the left lobe (2.46 +/- 0.88 and 1.33 +/- 0.99). The 3-D CEUSC images of the 12 donors were diagnostically adequate for evaluating the biliary anatomy. Normal biliary pattern in nine donors and biliary variations in three donors were confirmed by both IOC and surgical findings. 3-D CEUSC may be a potential alternative to IOC in the evaluation of biliary anatomical variation before graft harvesting in LDLT.