Learning objectives

Objectives

- Review common indications for contrast-enhanced ultrasound (CEUS) recommended by multi-disciplinary tumor board for hepatocellular carcinoma (HCC).

- Recognize the key roles of CEUS for the diagnosis and staging of HCC.

Background

- Definitive imaging diagnosis of HCC requires arterial-phase hyperenhancement (APHE). CEUS, with the ability to observe real-time arterial-phase enhancement, demonstrates advantages compared to CT/MRI where APHE may not be visualized due to arterial-phase mistiming.

- Imaging diagnosis of intrahepatic cholangiocarcinoma (ICC) or combined HCC-ICC is challenging. Rim APHE or early/marked washout (CEUS LR-M features) on CEUS are useful for distinguishing non-HCC malignancies from HCC.

- CEUS is accurate in differentiating tumor thrombosis (tumor in vein) from bland thrombosis when CT/MRI shows indeterminate venous thrombosis.

- CEUS is highly accurate to diagnose recurrent HCC after ablative therapy for HCC when CT/MRI shows equivocal findings for recurrence. CEUS also provides an excellent imaging guidance for repeat therapy.

- CEUS can be safely used in patients with renal failure when intravenous contrast is contraindicated for CT/MRI.

Imaging findings OR Procedure findings

Common indications for CEUS recommended by multi-disciplinary HCC tumor board from our 15-year experience.

1. Indeterminate liver lesions on CT/MRI due to the absence of APHE

2. LR-3 or LR-4 observations on CT/MRI

3. Newly detected liver lesions on surveillance ultrasound that are occult on CT/MRI

4. Indeterminate thrombosis in the portal or hepatic veins

5. Equivocal findings for recurrence after local ablative therapy for HCC

6. Liver lesions in patients with renal failure

Conclusion

CEUS is essential in multi-disciplinary practice for the management of HCC.

Objectives

-To describe the sonographic appearance of autoimmune pancreatitis (AIP) and its recurrence.

-To review the extrapancreatic manifestations of IgG-4 related disease (IgG4-RD) on ultrasound

Background

Sonography is a highly underutilized tool in the diagnosis, monitoring and post-treatment surveillance of AIP and IgG4-RD. Most cases of AIP are first investigated by sonography but often the specific findings of AIP are missed and patients are referred to CT/MR for assessment of a “malignant mass”. Multifocality is a key diagnostic feature and sonography allows the quick surveillance for other common sites of disease throughout the body when specific features of IgG4-RD are discovered on one organ. Multi-organ disease often clinches the diagnosis. Finally, ultrasound is a cost-effective method of assessing treatment effectiveness and surveillance for recurrence.

Imaging findings OR Procedure findings

Early pancreatic involvement manifests as subtle multifocal hypoechoic masses which coalesce within weeks to affect segment(s) or the entire pancreas diffusely. The pancreatic duct is strictured in areas of worse disease but shows irregular dilatation in intervening areas of milder disease. Halo sign is seen as a distinct hypoechoic rim framing the pancreas. Untreated disease often eventually shrinks and may spontaneously resolve, leaving a severely atrophic gland normalizing in echogenicity. Recurrence is easily detected as hypoechoic mass(es). Biliary disease manifests as regular circumferential thickening and can be differentiated from primary sclerosing cholangitis by a number of features. Salivary and lacrimal glands demonstrate typical sonographic patterns not detectable by CT/MR. Other sites of disease will be illustrated.

Conclusion

AIP/IgG4-RD has typical sonographic features useful for rapid diagnosis, response and surveillance.

Learning objectives