Table Of ContentWolfram Wermke & Bernhard GaBmann
Tumour Diagnostics of the
Liver with Echo Enhancers
Colour Atlas
, Springer
W. Wermke & B. GaBmann
Tumour Diagnostics of the Liver with Echo Enhancers
Prof. Dr. med. Wolfram Wermke
Humboldt University Hospital Berlin
Campus Charite Mitte
Gastroenterology, Hepatology and Endocrinology Clinic
Schumannstrasse 20-21
10117 Berlin
Germany
Dipl.-Phys. Bernhard GaBmann
Buch Hospital Berlin
Institute of Medical Physics
Wiltbergstrasse 50
13122 Berlin
Germany
ISBN-13: 978-3-642-46875-9 e-ISBN-13: 978-3-642-46873-5
001: 10.1007/978-3-642-46873-5
A catalogue record for this title is available from the British Library
Wermke, Wolfram; GaBmann, Bernhard: Tumour Diagnostics of the
Liver with Echo Enhancers - Colour Atlas
With 790 illustrations
Registered names, trade names and descriptions etc. mentioned in
this book are not exempt from the laws regulating the protection of
trade marks. Such names cannot be used by anyone without specific
acknowledgement.
This work is subject to copyright. No use of the material other than
specifically allowed under the provisions of copyright law may be
made without the written permission of the authors.
Copyright © by
Wolfram Wermke, Bernhard GaBmann, Berlin 1998
Softcover reprint of the hardcover 1st edition 1998
Set by Agentur B&S; Berlin
"It is better to see once than to hear a hundred times."
Ban Gu, 32-92 AD
Contents
Acknowledgements ............................................................... 8
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Physical and Technical Essentials .................................................... 10
Colour and Power Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
• Essentials .................................................................... 1 0
• Equipment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
• Useful Hints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Echo Enhancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• Essentials .................................................................... 15
• Artefacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2nd Harmonic Imaging ........................................................... 20
• Essentials .................................................................... 20
• Technical Information ........................................................... 22
• Tips and Tricks ................................................................ 24
Liver Haemangioma ............................................................... 26
Sonomorphology, Vascularisation and Signal Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Capillary Haemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Capillary Haemangioma • Fatty Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fibrosed Capillary Haemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Partially Thrombosed Cavernous Haemangioma ........................................ 37
Partially Thrombosed Cavernous Haemangioma • Fatty Liver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Thrombosed Cavernous Haemangioma ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Thrombosed Cavernous Haemangioma • Central Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Thrombosed Cavernous Haemangioma • Mixed Echogenicity ... . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Cavernous Haemangioma • Arteriovenous Malformations in M. Osler ........................ 51
High-flow Haemangioma .......................................................... 54
High-flow Haemangioma • Fatty Liver ................................................ 60
Differential Diagnostics • Haemangioma - Metastasis .................................... 64
Differential Diagnostics • High-flow Haemangioma - Metastasis ............................ 75
Focal Nodular Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Sonomorphology, Vascularisation and Signal Behaviour .................................. 78
Focal Nodular Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Focal Nodular Hyperplasia • Colour Power Angiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Focal Nodular Hyperplasia • Fundamental and Harmonic Modes Compared ................... 106
Focal Nodular Hyperplasia • Fatty Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Focal Nodular Hyperplasia • DD: Metastasis of a Mammary Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 109
Focal Nodular Hyperplasia • Degenerative Changes, Scar Tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Liver Cell Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Sonomorphology, Vascularisation and Signal Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Comparison of Tumour Vascularisation in Liver Cell Adenoma and FNH . . . . . . . . . . . . . . . . . . . . . . . 113
Liver Cell Adenoma .............................................................. 114
Liver Cell Adenoma • Fatty Infiltration ................................................ 118
Liver Cell Adenoma • Fatty Liver .................................................... 122
Liver Cell Adenoma • Cirrhosis in Budd-Chiari Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Liver Cell Adenoma • Degenerative Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Liver Cell Adenomatosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
6
Contents
Hepatocellular Carcinoma .......................................................... 132
Sonomorphology, Vascularisation and Signal Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Hepatocellular Carcinoma ......................................................... 133
Hepatocellular Carcinoma • Status post Alcohol Injection ................................. 152
Hepatocellular Carcinoma • Status post Arterial Chemoembolisation . . . . . . . . . . . . . . . . . . . . . . . . . 153
Hepatocellular Carcinoma • Colour Power Angiogram .................................... 156
Hepatocellular Carcinoma • Invasion of the Portal Vein ................................... 158
Hepatocellular Carcinoma • Obstruction of the Portal Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Hepatocellular Carcinoma • Invasion of the Hepatic Veins ................................. 170
Liver Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Sonomorphology, Vascularisation and Signal Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Liver Metastases • Colonic Carcinoma . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Liver Metastases • Rectal Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Liver Metastases • Intestinal Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Liver Metastases • Renal Carcinoma ................................................. 177
Liver Metastases • Pancreatic Carcinoma ............................................. 178
Liver Metastases • Bronchiolar Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Liver Metastases • Mammary Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Liver Metastases • Leiomyosarcoma ................................................. 187
Liver Metastases • Carcinoid ....................................................... 188
Liver Metastases • Caecal Carcinoid ................................................. 190
Liver Metastases • Pancreatic Carcinoid .............................................. 192
Liver Metastases • Non-Hodgkin's Lymphoma ......................................... 194
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Regenerative Nodules in Liver Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Scar Tissue Nodules in Liver Cirrhosis ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Scar Tissue Nodules in Closed Liver Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Focal Fatty Accumulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Focal Fatty Sparing .............................................................. 204
Nodular Regenerative Hyperplasia with a Congenital Portocaval Shunt ....................... 206
Amoebic Liver Abscess ........................................................... 210
Post-operative Liver Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Superinfected Necrotic Liver Metastasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Haemorrhagic Liver Cyst .......................................................... 216
Traumatic Liver Cyst with Transdiaphragmal Arteriovenous Shunt. . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Post-operative Seroma with Clot Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Splenic Metastases following Resection of a Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 219
Cholangiocarcinoma ............................................................. 221
Cholangiocellular Liver Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Acknowledgements
The diagnoses given in this book were confirmed by biopsy, lapa We are also grateful for the provision of the necessary technical
roscopy, surgery, spiral CT and MRI, scintigraphic procedures or equipment, for taking our ideas into account in programming, for the
angiography. We should like to thank all the physicians who were continuous servicing of equipment and for support in data processing
involved in these procedures. as well as for assistance in preparation of the manuscript and proofs
for this book.
Particular thanks are due to the nurses, doctors and graduate
students in the Sonography Department of the Gastroenterology, We would especially like to thank the numerous other colleagues
Hepatology and Endocrinology Clinic of the Charite (Campus Mitte) in private practice and in other hospitals, who will remain unnamed
whose work in patient management and whose assistance during and who have been referring patients to us for sonographic examina
procedures, ultrasound-guided tumour biopsies and data collection tion for several years.
have all contributed to the success of this book.
We thank:
PD Dr. w.-O. Bechstein Dr. R. Heyne C. Rahm M. Strelow
K. Bengelsdorf D. Kaharick K. Reifenrath F. Stromann
P. Bock P. Lichtman Dr. P. Rogalla PD Dr. K. Sydow
M. Bruce Prof. Dr. J. MUlier Prof. Dr. P. Romaniuk Dr. M. Taupitz
C. Diaz R. Nemitz L.E. Reimer-Hevia S. Theile
Prof. Dr. M. Dietel Prof. Dr. P. Neuhaus Dr. B. Rudolph Dr. V. Uhlendorf
P. EI Cherif Dr. J.W. Neumann T. Schade J. VI ad
E.-M. Fusenig H. Neye Dr. G. Schachschal K. Weber
Prof. Dr. K. Gellert Dr. V. Ivancevic W. Schimmel Th. Wermke
Prof. Dr. B. Hamm Dr. J. Petersein D. Schwartmann U. Wermke
Ch. Hass Dr. J. Powers Dr. J. Souquet Dr. U. Wruck
F. Hassel Dr. S. Paris K. Standtke Th. Zimmer
8
Foreword
This atlas covers "virgin territory in the field of sonography". tumours, all of these have allowed us to derive general statements as
Cultivation of this territory has been made possible a) by the develop to signal enhancement in different types of liver lesion.
ment of a signal enhancement agent consisting of gas microbubbles
which are able to pass through the lungs and are capable of re Here, similarities were found with other imaging procedures which
sonance and b) by the technical realisation of 2nd harmonic imaging. also make use of contrast agents.
Both of these have been available to us since April 1996.
Haemangiomas receive special attention in this book. This is due
This book stems from the particular situation of a long friendship to their frequent occurrence and the outstanding improvements in dia
between a physicist with medical knowledge and a physician with gnosis which are provided by echo enhancers.
technical expertise. The equipment settings and the examination pro
cedure which form the basis for the images in the atlas are the result We are convinced that an echo-enhanced sonography that pro
of intensive efforts, originating in a desire to achieve the maximum vides few artefacts will have an important role to play in the future.
that is physically feasible and clinically desirable. This procedure is Our results to date justify the assumption that additional diagnostic
now routine in our Sonography Department. procedures can be dispensed with when echo-enhanced ultrasound
findings are clear.
Suppression of artefacts using 2nd harmonic imaging, meticulous For this reason, the introduction of this method in clinical routine also
analysis of digitally stored images showing the development of con has economic importance.
trast,due regard for the particularities of the liver circulation with dif
ferences in the wash-in time of the enhancement agent and differing The essential aims of our book are to impart knowledge of new
flow velocities in arteries and portal veins, an understanding of the developments and to encourage imitation.
physically desirable and undesirable effects of echo enhancers in
the sound field and intensive study of the pathomorphology of liver Wolfram Wermke and Bernhard GaBmann Berlin, October 1998
9
Colour and Power Doppler • Essentials
Taking B-mode findings as a starting point, this book provides details Colour and power Doppler are alternative displays on the ultra
of a more far-reaching, functionally oriented diagnostic procedure, sound monitor.
which takes advantage of 2nd harmonic imaging and the use of echo
enhancers. The images presented and the knowledge derived from The reproducibility of measurements depends on objective and
them are the result of an intensive two-year theoretic-methodic and subjective influences. Two important reasons for insufficient detection
practical involvement with this procedure. of Doppler signals from small vessels with low flow velocities and
Clinical application of 2nd harmonic imaging with the image quality intensity can be mentioned:
shown here is routine.
• Tissue attenuates the ultrasound and tissue inhomogeneities
distort the signal.
Doppler Procedures • Tissue movement (e.g. heart muscle or respiration) gives rise to a
The step from assessing sonomorphology to assessing function has Doppler effect. All frequency shifts caused by movement relative to
been made possible by the introduction of Doppler procedures. While the transducer are included in the received signal. Movements of
the various ultrasound modes assist in establishing diagnoses, their the transducer relative to the tissue are also interpreted as Doppler
clinical relevance very often depends on the quality of the equipment signals. The examining physician needs a calm hand for optimal
and the experience of the investigator. In addition to skill, an under results.
standing of the processes that take place in the ultrasound equipment
is required. This is especially so if the presettings of the equipment Knowledge of these relationships leads to improved images with
are inadequate or investigation conditions difficult. The equipment the correct equipment settings and cooperation from the patient
should be adjusted to the situation at hand. Only in this way can the (position, breathing). Blood flow and respiratory movement - or
capabilities of the equipment and its modes be fully exploited. transmitted pulsation - cannot be separated by technology alone.
Doppler techniques for determination of flow velocities are standard. Interference which impairs the recognition of signals from an
The Doppler signal is selected from the backscatter. observed process is known as 'noise'. Two sources of noise can be
The backscatter amplitude of the solid components of the blood - distinguished in Doppler diagnostics:
essentially the erythrocytes - is only about a thousandth that of the
tissue. At equal velocities, the smaller the diameter of a vessel the • System noise
smaller the amplitude of the backscatter. System noise is caused by the ultrasound equipment itself. It is
Doppler signals from small vessels with low flow velocities have an of low amplitude and is detectable over the entire
amplitude below the limit of sensitivity of the equipment. Such signals frequency spectrum (so-called 'white noise'). The most
are not displayed. This does not mean that there is no flow in these important source is the ultrasound transducer.
locations. External noise due to inadequate isolation also causes
interference.
PW Doppler shows the time course (x-axis) of flow velocities The noise level depends on the amplification.
(y-axis) in a selected volume. The amplitudes of the velocities that
occur are shown as different values of brightness (spectrum). Signal • Clutter
processing makes use of Fourier techniques. Respiratory and heart muscle movements, transmitted pulsation
and movements of the transducer relative to the skin of the
Exact superposition of the B-mode image with colour-coded patient (the investigator's hand shaking or patient movement)
velocity values is known as colour Doppler. The statistical procedure are registered as Doppler signals. Typically such movements
used in registering signals consists of an autocorrelation function. have velocities of several centimetres per second. Their back
This gives the mean velocity, the corresponding amplitude and the scatter amplitude is some thousand times higher than that of
variance (square of standard deviation). The relative direction of flow erythrocytes with the same velocity. Thus, the flow velocities of
(towards the transducer, away from the transducer) is shown by the the erythrocytes cannot be separated from clutter.
use of a suitable colour (e.g. red/blue). The addition of green/yellow Clutter is characterised by a narrow bandwidth and high ampli
enables turbulence to be displayed in colour Doppler as variances are tude and is the most important obstacle in the detection of low
to be interpreted as turbulent flow. flow velocities.
Power Doppler shows the intensity of flow. This is determined by The quality of the image depends on the signal-to-noise ratio.
the number of scatterers in the selected region and is proportional to Procedures to reduce clutter are therefore of direct diagnostic
the square of the amplitude of the Doppler signal. It is often presented importance.
in a uni-directional form. Displays showing the direction of flow are
analogous to colour Doppler.
10
Colour and Power Doppler. Essentials
Comparison of Doppler Frequencies
Allocation of Colours in Colour and Power Doppler
- Blood Flow and Noise -
- Abdomen -
Q)
'"0
.t:::J: Power Doppler Scale
0.
E
«
Doppler Frequency (Flow Velocity)
-PAF/2 PAF/2
A Doppl r Frequency
Flow Velocity and Noise
Noise in Colour and Power Doppler
Comparison of diagnostically relevant flow velocities in the abdomen
and noise shows the problems encountered. Low velocities from ves
sels of small diameter cannot be separated from clutter. System noise
also limits sensitivity to higher flow velocities of low amplitude.
Colour Doppler and Power Doppler compared
System noise is seen in colour Doppler as random change or fluctua
tion between red and blue tones. As the amplitude of the noise is
dependent on the gain setting, this should be set so low that no
artificial colour pixels are displayed. This is difficult using a 3.5 MHz B Colour Doppler Scale
-PAF/2 Doppl r Frequ ncy +PAF/2
transducer to detect flow at depths of more than 10-12 cm, for
Comparison: Colour and Power Doppler
example. Diagnostic questions are frequently concerned with slow
A) In colour Doppler the different hues are allocated to the estimated
flow in narrow vessels. Signals from these vessels are very close to or
Doppler frequencies so as to show direction of flow (bi-directional).
below the noise limit. There is an unfavourable signal-to-noise ratio.
Power Doppler, on the other hand, is uni-directional; the colours show
the intensity (or power) of the flow.
Colour and power Doppler make use of the pulse-echo technique.
B) Amplification has a considerable influence on the accurate re
The pulse repetition frequency (PRF) defines the range of measure
presentation of flow. At high gain settings, all the hues are affected by
ment for colour Doppler. The velocity which is being determined can
noise in colour Doppler and the colours fluctuate. In power Doppler,
be clearly detected if the PRF is selected so that the Doppler
only a small range of colours is affected by noise. The background
frequency is in the range ± PRF/2. If it is greater than PRF/2, then
noise is easily filtered. High sensitivity is achieved with a clear image
aliasing occurs. This leads to an apparent change of direction in the
superimposed on the underlying B-mode scan. The dynamic range of
colour coding. The maximum setting for the PRF depends on the
power Doppler is greater than that of colour Doppler.
depth of penetration of the colour window. Power Doppler shows the
squared amplitude of the Doppler frequencies; aliasing does not
occur. Frequency shifts can be converted into flow velocities using the To detect the Doppler effect along a given scan line, it is necessary
Doppler equation. to transmit several pulses. The number and rate of these pulses have
a significant bearing on Doppler detection of low flow velocities.
e Higher numbers of pulses improve detection and reduce clutter but
2 . v . /trans' cos
f...j=---"....:.:...:::.:..:.::...~....:.. lower the frame rate. Wall filters can be used to suppress clutter.
C The limit is often of the same order of magnitude as the Doppler
e
f...j = 2 . v . !send' cos effect of low flow velocities (example: 100 Hz wall filter, 3 MHz transmit
f...j - Difference between tranSmit and receive frequency frequency; velocities of less than 4 cm/s are filtered).
V - Flow velocity
Aliasing does not occur in power Doppler. Longer integration times
c -Speed of sound in tissue (1540 m/s)
and higher numbers of pulses improve sensitivity; but susceptibility to
/trans - Transmit frequency (MHz)
artefacts increases. Power Doppler images are similar to angiographic
e -
Angle between the sound beam and the targeted motion vector images. Hence, the term 'angio mode' is also used.
11
