Contrast-Enhanced Ultrasound Patterns for the Non-invasive Diagnosis of Hepatocellular Carcinoma: A Prospective Multicenter Study in Histologically Proven Liver Lesions in a Real-Life Setting Demonstrating the Benefit of Extended Late Phase Observation.

The hallmark for the non-invasive diagnosis of hepatocellular carcinoma (HCC) with contrast-enhanced ultrasound (CEUS) in cirrhosis is arterial phase hyperenhancement (APHE), followed by late-onset (>60 s), mild washout. Large retrospective studies report this pattern of washout to occur in the vast majority of HCCs. However, a prospective multicenter validation of these findings is still missing. Thus, we initiated a prospective multicenter validation study assessing CEUS enhancement patterns in focal liver lesions of patients at risk for HCC. We analyzed lesions that were eventually histology proven in a real-life setting. CEUS patterns were assessed for subgroups of HCC, intrahepatic cholangiocellular carcinoma (iCCA) and non-HCC, non-iCCA lesions. The diagnosis was HCC in 316 lesions (median size: 40 mm), iCCA in 26 lesions (median size: 47.5 mm) and non-HCC, non-iCCA in 53 lesions (median size: 27 mm). Overall, 85.8% of HCCs exhibited APHE. APHE followed by washout occurred in 72.8% of HCCs and 50% of iCCAs and non-HCC, non-iCCA malignancies (p < 0.05). Early and marked washout was associated more commonly with iCCA; HCCs exhibited mostly late and mild washout (onset >4-6 min in 10% of cases). Our prospective data confirm that the typical pattern of APHE followed by late-onset, mild washout occurs in the majority of HCCs.

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study.

BACKGROUND: This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients. METHODS: Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System). RESULTS: 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site. CONCLUSION: This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

The importance of pancreatic inflammation in endosonographic diagnostics of solid pancreatic masses.

AIMS: Endosonography (EUS) is one of the main diagnostic tools for the differential diagnosis of pancreatic masses. The aim of our study was to describe the value of this technique in the work-up of solid pancreatic lesions, considering the influence of the morphological evidence of pancreatic inflammation in the diagnostic process. MATERIAL AND METHODS: Retrospective analysis of prospectively collected data in our tertiary University center. From March 2007 to October 2015, 218 patients underwent EUS for a suspected solid pancreatic neoplasm (based on previous cross-sectional imaging results, idiopatic acute pancreatitis, weight loss, pancreatic hyperenzymemia, painless jaundice or elevated Ca 19-9 values). RESULTS: Malignant lesions were diagnosed in 98 (45%) patients. Sensitivity of EUS for malignancy was 91% and specificity 89.2%. Signs of pancreatic inflammation in the surrounding pancreatic parenchyma around the focal lesion were present in 97 patients (44.4%)(more often in men, smokers and drinkers, and the most common etiology was focal chronic pancreatitis) and in these patients the sensitivity and sensibility dropped to 44% and 87.1%, respectively. In patients without signs of pancreatic inflammation, the pancreatic focal lesions were adenocarcinoma, neuroendocrine tumor, ventral/dorsal split, non-pancreatic pathology, pancreatic lipomatosis and autoimmune pancreatitis. CONCLUSION: Pancreatic inflammation (either focal or involving the whole gland) lowers the diagnostic sensibility of EUS in the work- up of pancreatic masses suspected for cancer, requiring further invasive diagnostic methods. Focal autoimmune pancreatitis and paraduodenal pancreatitis are still confused with pancreatic cancer, even in the absence of pancreatic inflammation.

Assessment of Crohn's disease activity by confocal laser endomicroscopy.

BACKGROUND: Confocal laser endomicroscopy (CLE) allows microscopic imaging within the mucosal layer of the gut during ongoing endoscopy. Different studies have addressed the potential of CLE for in vivo diagnosis of ulcerative colitis and microscopic colitis. However, there are no data on the utility of CLE for in vivo diagnosis of Crohn's disease (CD). The aim was to assess the clinical utility of CLE in patients with CD and to determine whether disease activity can be graded using CLE. METHODS: Consecutive patients with and without CD were enrolled. The colonic mucosa was examined by standard white-light endoscopy followed by CLE. The features seen on CLE were compared between CD patients and controls. RESULTS: In all, 76 patients with CD were screened, of whom 54 patients were included in the present study. Eighteen patients without inflammatory bowel disease (IBD) served as controls. A significantly higher proportion of patients with active CD had increased colonic crypt tortuosity, enlarged crypt lumen, microerosions, augmented vascularization, and increased cellular infiltrates within the lamina propria. In quiescent CD, a significant increase in crypt and goblet cell number was detected compared with controls. Based on our findings, we propose a Crohn's Disease Endomicroscopic Activity Score (CDEAS) for assessing CD activity in vivo. CONCLUSIONS: CLE has the potential to significantly improve diagnosis of CD compared with standard endoscopy. These findings should be evaluated in future prospective trials to assess the value of this newly developed CLE score for prediction of disease course and therapeutic responses.

Diagnostics in inflammatory bowel disease: ultrasound.

Diagnosis of chronic inflammatory bowel diseases (IBD) is based on a combination of clinical symptoms, laboratory tests and imaging data. Imaging of the morphological characteristics of IBD includes the assessment of mucosal alterations, transmural involvement and extraintestinal manifestations. No single imaging technique serves as a diagnostic gold standard to encompass all disease manifestations. Ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) allow cross-sectional imaging of the transmural alterations and extraintestinal manifestations. While in the USA the technique of choice is CT, in Europe the focus is more on MRI and ultrasound (US). Most patients with chronic IBD are diagnosed at a young age. After baseline diagnosis many of these young patients have to undergo repetitive imaging procedures during the variable clinical course of the disease, characterized by alternate periods of remission and active disease, and in monitoring the response to treatment. US has the advantage of being noninvasive, less costly, and easily repeatable, and thus can be very useful in following up patients with IBD. In addition, rising concern about radiation exposure in young adults indicates the demand for radiation-sparing techniques like US and MRI. This article focuses on the current clinical practice of US in IBD, describing the current technologies used in transabdominal intestinal US and the characteristic sonographic findings in Crohn´s disease and ulcerative colitis.

Hemodynamic efficacy of sequential hemoclip application using the Olympus HX-110/610 reloadable clipping device in spurting bleedings.

BACKGROUND: Hemoclip application in GI-hemorrhage has proven to be effective. Clinical experience shows that multiple clips are frequently necessary. In 2005, an easily reloadable clip-applicator was introduced. We evaluated the hemodynamic efficacy of this new device. MATERIAL/METHODS: We prospectively compared the new clipping device (Olympus HX 110/610) in a validated experimental setting using the compactEASIE®-simulator for GI bleeding. The artificial blood circulation system in the simulator was connected to a pressure transducer. Four investigators of different endoscopic experience (1000-6000 endoscopies) treated 12 bleeding sources each, with up to 6 clips for each bleeding location. Pressures were recorded to objectify the additive effects of sequential clip application on the reduction in vessel diameter. The intervention was abandoned if a maximum measurable pressure of 300 mmHg was achieved. RESULTS: Hemoclip application led to a significant increase of peak pressure (91±100 mmHg, p<0.001) and mean pressure (95±99 mmHg, p<0.001), representing a significant reduction in vessel diameter. Pooled data showed a significant stepwise increase in mean and maximum system pressure, resulting in reduction of vessel diameter up to the fifth hemoclip. On average, 5 clips (range 1-6) were used. More experienced endoscopists achieved a higher increase in mean pressure (167 and 118 mmHg vs 72 and 23 mmHg, p<0.05). Mean reloading time was 39 seconds (19-49 sec). CONCLUSIONS: Sequential application of multiple hemoclips led to an increasing effect, comparable to the results of previous clinical trials. The number of hemoclips applied correlated inversely, but not significantly, with the endoscopist´s experience. Expensive single-use clips appear dispensable in view of the short reloading time.

[Pulsed radiofrequency ablation using perfused needle applicators in an in vitro trial on bovine liver]. / Getaktete Dreifachapplikation mit perfundierten Nadelapplikatoren bei Radiofrequenzablation: In-vitro-Versuch an der Rinderleber.

Intermittent energy application seems to have positive effects in achieving necrotic zones. We analyzed different pulse periods (PPs) to optimize this method. A radiofrequency alternating current was delivered via a triple-needle applicator (3 cm distance of each needle) introduced into freshly procured bovine liver. The open applicator system was constantly perfused with physiological NaCl solution (3×80 ml/h, power output was constant 90 W). Radiofrequency current was fed to the individual needle in turn of varying PPs (1, 2, 5, and 7 s) over 15 min. Each experimental run comprised a total of 30 applications and temperature was recorded over time. The largest necrotic diameters were found at PP 1 s (relevant: shortest axial diameter/D in the center of the lesion: 9.27 cm, SD±0.97 cm) (PP 2 s D=8.65 cm, SD±0.95 cm, p=0.021; PP 5 s D=8.35 cm, SD±0.95 cm, p=0.001; PP 7 s D=8.18 cm, SD±0.79 cm, p=0.0001). Neither doubling the perfusion rate nor raising the concentration of the perfusion liquid led at PP 1 s to increased necrotic diameters (p=0.82). Our study shows that reducing the PP to 1 s of an open perfused intermittent radiofrequency ablation system produces significantly larger coagulation volumes in explanted liver tissue reaching necrotic diameters over 9 cm. Neither doubling perfusion rates nor higher concentrated perfusion liquid increase necrotic diameters.

Software-based quantification of contrast-enhanced ultrasound in focal liver lesions--a feasibility study.

PURPOSE: To compare software-based quantification of contrast-enhanced ultrasound (CEUS) examinations of focal liver lesions in the arterial and late phases with the enhancement patterns established by the sonologist. MATERIALS AND METHODS: The study cohort comprised 12 malignant and 21 benign hepatic lesions in 33 patients (18 female and 15 male; aged 57 +/- 13 years). All underwent dynamic real-time low mechanical index (<0.3) CEUS, which was stored as video sequences of the various enhancement phases. A software was used for analysis by using different regions of interest (ROI) in a double-blinded manner. The software generated and the visual enhancement patterns were compared, and the t-test was performed. RESULTS: The videos containing the arterial phase had a mean length of 37.5 +/- 36.7 s and the late phase sequences a mean length of 15.2 +/- 9.2 s. In the arterial phase complete agreement between software and sonologist was 100%, 93.9% and 87.9% with regard to the entire lesion, its centre and its periphery, respectively. The late phase analysis revealed corresponding figures of 90.9%, 87.9% and 90.9%. In the late phase, benign lesions revealed a mean relative enhancement of +65.1 +/- 103.6% and malignant lesions -56.9 +/- 26.3% (p=0.0005) vis-à-vis liver parenchyma. All the malignant and 14% of the benign tumors showed hypo-enhancement of less than -10%. CONCLUSION: The complete agreement between the quantitative analysis and the sonologist within the arterial and late phase showed excellent results. Software analysis of the late phase could dichotomise benign and malignant lesions. Objective establishment of iso-enhancement in the late phase excludes malignancy.

Percutaneous radiofrequency ablation of liver tumors using multiple saline-perfused electrodes.

PURPOSE: Radiofrequency ablation (RFA) with multiple saline-perfused electrodes is a minimally invasive alternative to archive large coagulation zones. Few long-term results have been published so far. This is a report of our long-term experience using multiple saline-perfused electrodes for the treatment of malignant hepatic tumors. MATERIALS AND METHODS: Thirty-eight patients with biopsy-proven hepatocellular carcinoma (HCC) or liver metastases of colorectal cancer (CRC) (17 CRC, 21 HCC) with a total of 56 tumors (26 CRC, 30 HCC) were treated with the Integra HiTT 106 RF generator using multiple saline-perfused electrodes. Mean size was 42 mm for HCC and 36 mm for CRC. Follow-up examinations took place after 2 days and 1, 3, 6, and 9 months after RFA and every 6 months thereafter. RESULTS: We performed 2.6 (2.7 CRC, 2.4 HCC) sessions per patient. Major complications occurred in 2% of patients. Ninety-two percent (35/38) were treated technically successfully. Local tumor progression was found in 8 patients out of 35 (22% overall, 21% HCC, 25% CRC). For HCC, 43% of patients suffered distant intrahepatic recurrence. One- and two-year survival for HCC patients was 71% and 58%. (Child-Pugh status A, one- and two-year survival was 90% and 80%; Child status B, 35% and 18%). For CRC, 11 of 17 (65%) patients suffered distant intrahepatic recurrence. One- and two-year survival for CRC patients was 94% and 86%. CONCLUSIONS: RFA using multiple saline-perfused electrodes shows results in the treatment of liver tumors comparable with other established ablation techniques.

Activation and dramatically increased cytolytic activity of tumor specific T lymphocytes after radio-frequency ablation in patients with hepatocellular carcinoma and colorectal liver metastases.

AIM: To assess if a specific cytotoxic T cell response can be induced in patients with malignant liver tumors treated with radio-frequency ablation (RFA). METHODS: Six Patients with liver metastases of colorectal cancer and 6 with hepatocellular carcinoma (HCC) underwent RFA. Blood was sampled before, 4 and 8 wk after RFA. Test antigens were autologous liver and tumor lysate obtained from each patient by biopsy. Peripheral T cell activation was assessed by an interferon gamma (IFNgamma) secretion assay and flow cytometry. T cells were double-stained for CD4/CD8 and IFNgamma to detect cytotoxic T cells. The ratio of IFNgamma positive and IFNgamma negative T cells was determined as the stimulation index (SI). To assess cytolytic activity, T cells were co-incubated with human CaCo colorectal cancer and HepG2 HCC cells and release of cytosolic adenylate kinase was measured by a luciferase assay. RESULTS: Before RFA SI was 0.021 (+/- 0.006) for CD4(+) and 0.022 (+/- 0.004) for CD8(+) T cells against nonmalignant liver tissue and 0.018 (+/- 0.005) for CD4(+) and 0.021 (+/- 0.004) for CD8(+) cells against autologous tumor tissue. Four weeks after RFA SI against tumor tissue increased to 0.109 (+/- 0.005) for CD4(+) and 0.11 (+/- 0.012) for CD8(+) T cells against HCC, and to 0.115 (+/- 0.031) for CD4(+) and 0.15 (+/- 0.02) for CD8(+) cells for colorectal metastases (P < 0.0001). No increased SI was observed with nonmalignant tumor tissue at all time points. Before RFA cytolytic activity against the respective cancer cells was low with 2.62 (+/- 0.37) relative luminescence units (RLU), but rose more than 100 fold 4 and 8 wk after RFA. Spontaneous release was < 2% of maximum release in all experiments. CONCLUSION: Patients with primary and secondary tumors of the liver show a significant tumor-specific cytotoxic T-cell stimulation with a dramatically increased tumor specific cytolytic activity of CD8(+) T cells after RFA.

Hepatic transit time of an echo enhancer: an indicator of metastatic spread to the liver.

OBJECTIVE: Can sonographic measurements of the transit time of an echo enhancer from the hepatic artery to the hepatic vein discriminate between patients with and without liver metastases? METHOD: The hepatic transit time (hepatic artery to hepatic vein delay) of an echo enhancer (Optison) was measured in pulse inversion mode on the basis of time intensity curves (TIC) in patients with gastrointestinal tumours with proven liver metastases and in patients without liver metastases. RESULTS: Sixty-four patients (46 males, 18 females, mean age 61 +/- 13 years) were admitted to the study. Fourteen patients had metastatic growth in the liver with a primary tumour in situ (group A). Fourteen patients had liver metastases following primary tumour resection (group B). Twenty-eight patients had a known primary tumour but no liver metastases (group C), and eight patients had neither liver symptoms nor a primary tumour (group D). The mean hepatic transit time in patients with liver metastases was 6.6 +/- 1.8 s in group A and 6.7 +/- 1.7 s in group B, whereas in patients without liver metastases it was significantly longer; namely, 15.7 +/- 4.4 s in group C and 15.0 +/- 2.0 s in group D (P < 0.001). The transit times in all patients with liver metastases were < or = 10 s, while in all patients without metastases except for four the times were > or = 12 s and one of the four had already developed liver metastases on early follow-up. CONCLUSIONS: Measurement of the hepatic transit time permits discrimination of patients with and without liver metastases.

Percutaneous US-guided radiofrequency ablation with perfused needle applicators: improved survival with the VX2 tumor model in rabbits.

PURPOSE: To evaluate survival, metastases, tumor necrosis, and prediction of local recurrence after percutaneous ultrasonographically (US) guided radiofrequency (RF) thermal ablation with electrodes perfused continuously with isotonic saline. MATERIALS AND METHODS: VX2 liver tumors were implanted in 31 rabbits according to a standardized protocol. After 21 days, 16 animals were treated percutaneously with RF ablation. Four animals died of complications related to anesthesia, and 12 animals were evaluated. All animals were followed for 110 days and monitored with computed tomography (CT) and US at 1, 7, and 30 days. A control group of 15 animals did not receive treatment. Autopsy was performed at the end of scheduled follow-up or immediately after death. For survival analysis, the Kaplan-Meier method was used; for nominal data, the Fisher exact test was used. RESULTS: In comparison to controls, animals in the treatment group showed significantly prolonged survival (P <.001). Eight of 12 animals (67%) treated with RF ablation survived to 110 days, while none of the controls did so. Metastases developed in all controls (100%) and in eight of 12 treated animals (67%) (P =.001). In comparison with controls, animals that developed metastases despite treatment also showed significantly prolonged survival (P =.02). Local recurrence was observed in three of 12 animals (25%) in the treatment group. CT and US performed 1 week after treatment did not allow prediction of local recurrence. CONCLUSION: RF ablation of liver tumors with perfused needle applicators prolongs survival in the VX2 rabbit liver tumor model, regardless of whether complete remission is achieved. In comparison with controls, RF ablation results in a lower frequency of metastases.

Doppler measurements: a surrogate marker of liver fibrosis?

OBJECTIVE: The potential diagnostic value of performing Doppler measurements of liver vasculature to assess early stages of liver fibrosis has not been established. Due to the potential clinical impact, this study focused on the correlation between Doppler measurements and histologically proven liver fibrosis. METHODS: Forty-three consecutive patients with chronic viral hepatitis (79% hepatitis C) were enrolled. At the time of liver biopsy, two independent investigators measured maximum and mean blood flow velocity, resistance indices, vessel diameter and blood flow volume in the portal vein, hepatic artery and hepatic veins. All measurements were taken in triplicate. The mean values were correlated to the degree of liver fibrosis using the Ludwig score. RESULTS: Sixty-seven per cent of the patients in our study group had no or only mild fibrosis (Ludwig score stage I or II). Thirty-three per cent showed progressive fibrosis or cirrhosis (Ludwig score stage III or IV). There was a large overlap in the Doppler measurements and findings between the various disease stages. No significant changes of Doppler parameters were detected, even between patients with no or mild fibrosis and patients with severe fibrosis (Ludwig score stage III or IV). CONCLUSIONS: Doppler measurements of the portal vein, hepatic artery and hepatic vein(s) are not a valid surrogate marker of liver fibrosis. Nor are Doppler measurements a useful method to estimate the degree of liver fibrosis.