J Liver Cancer.  2023 Sep;23(2):272-283. 10.17998/jlc.2023.08.25.

Diagnosis of hepatocellular carcinoma using Sonazoid: a comprehensive review

• Jeong WK

• KMID: 2546409
• DOI: http://doi.org/10.17998/jlc.2023.08.25

Abstract

Sonazoid contrast-enhanced ultrasonography (CEUS) is a promising technique for the detection and diagnosis of focal liver lesions, particularly hepatocellular carcinoma (HCC). Recently, a collaborative effort between the Korean Society of Radiology and Korean Society of Abdominal Radiology resulted in the publication of guidelines for diagnosing HCC using Sonazoid CEUS. These guidelines propose specific criteria for identifying HCC based on the imaging characteristics observed during Sonazoid CEUS. The suggested diagnostic criteria include nonrim arterial phase hyperenhancement, and the presence of late and mild washout, or Kupffer phase washout under the premise that the early or marked washout should not occur during the portal venous phase. These criteria aim to improve the accuracy of HCC diagnosis using Sonazoid CEUS. This review offers a comprehensive overview of Sonazoid CEUS in the context of HCC diagnosis. It covers the fundamental principles of Sonazoid CEUS and its clinical applications, and introduces the recently published guidelines. By providing a summary of this emerging technique, this review contributes to a better understanding of the potential role of Sonazoid CEUS for diagnosing HCC.

Keyword

Ultrasonography; Contrast-enhanced ultrasound; Carcinoma, hepatocellular; Sonazoid; Perfluorobutane

Figure

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  Figure 1. Examination protocol and typical findings of HCC, intrahepatic cholangiocarcinoma, hemangioma, and focal nodular hyperplasia on Sonazoid contrast-enhanced ultrasound. HCC, hepatocellular carcinoma; APHE, arterial phase hyperenhancement; WO, washout; KPWO, Kupffer phase washout; ICC, intrahepatic cholangiocarcinoma; FNH, focal nodular hyperplasia.

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  Figure 2. Examples of arterial phase hyperenhancement. Nonrim APHE refers to arterial phase enhancement without a rim pattern (A), while rim APHE exhibits a peripheral enhancement pattern (B). Spoke-wheel APHE resembles spokes and is associated with focal nodular hyperplasia (C). Peripheral discontinuous nodular APHE exhibits nodular enhancement with interruptions, and is observed in hepatic hemangiomas (D). APHE, arterial phase hyperenhancement.

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  Figure 3. Examples of washout. Washout on contrast-enhanced ultrasound can be classified by the degree (mild or marked) and onset time (early or late). Mild washout shows partial reduction (A), while marked washout indicates near-complete loss of enhancement (B). Early onset occurs within 60 seconds (C), while late onset takes longer than 60 seconds (D).

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  Figure 4. Examples of tumor in vein (A), mosaic (B), and nodule in nodule (C) architecture. (A) Tumor in vein and microbubbles in the tumor thrombus were seen in the early arterial phase (arrows). (B) The other two findings are ancillary findings favoring HCC. Mosaic architecture is the composition of fibrous septa (arrowheads) between the cellular components (arrow), and (C) nodule in nodule architecture is a distinct growth pattern of HCC, which involves the presence of a larger outer nodule (arrowheads) containing a smaller inner nodule (arrows). HCC, hepatocellular carcinoma.

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  Figure 5. A 56-year-old male with hepatocellular carcinoma. The B-mode ultrasound image revealed a peripheral hypoechoic nodule located in the subcapsular area of the liver. (A) During the arterial phase of the contrast-enhanced ultrasound, the nodule exhibited gradual enhancement. (B) The microbubbles began to wash out from 1 minute and 30 seconds after contrast injection (arrow), (C) becoming even more pronounced at 2 minutes and 20 seconds (arrow). (D) During the Kupffer phase, the nodule became more evident, indicating Kupffer phase washout (arrow). The patient underwent treatment with radiofrequency ablation for the hepatocellular carcinoma.

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  Figure 6. A 63 -year- old male with intrahepatic cholangiocarcinoma. A rim-like hyperenhancement was observed in the arterial phase of contrast-enhanced ultrasound (A). Subsequently, at a delay of 1 minute and 30 seconds, marked washout of the contrast agent was evident (B). Additionally, prominent washout was observed during the Kupffer phase (C). Following surgical resection, the lesion was confirmed to be a moderately differentiated adenocarcinoma.

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  Figure 7. A 37-year-old female with a liver lesion found incidentally. (A) A B-mode ultrasound image revealed two nodules; one with a hypoechoic center, hyperechoic rim, and posterior enhancement (solid arrow), and an ill-defined, hyperechoic nodule (open arrow). (B-G) During the arterial phase of the contrast-enhanced ultrasound exam, (B) the first nodule displayed rapid peripheral enhancement that gradually expanded in a discontinuous pattern (solid arrow). (F) The second nodule exhibited slow, gradual growth with centrifugal enhancement (open arrow). During the Kupffer phase (H), the first nodule showed mild washout (solid arrow), which is indicative of a typical hepatic hemangioma. The second nodule appeared isoechoic on the Kupffer phase image (open arrow), suggesting a benign lesion, such as atypical focal nodular hyperplasia or peliosis hepatis.

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