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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5762_Библиотеки_им_академика_М_И_Перельмана.pdf
Dynamic Vascular Pattern
andQuantitative Analysis
inLiver Tumors
Ernst Michael Jung andYiDong
12
12.1 Introduction
Contrast enhanced ultrasound (CEUS) allows differential
diagnosis between most benign and malignant focal liver
lesions (FLLs), based on enhancement patterns during arterial phase and wash-out during late phase. With the widely
used CEUS imaging helps to improve multidisciplinary
management of focal liver lesions, diagnosis of hepatocellular carcinoma without further biopsy. Advantages of CEUS
include the real-time imaging, accurate depiction of tumor
microvascular perfusion [1].
CEUS can be used to image dynamic changes of capillary
level. Ultrasound contrast agents result in signicant signal
amplication and enable the macro- and microvascularization to be evaluated dynamically from the early arterial phase
as early as 10s after intravenous injection up to a late phase
of 5–6 min. When using sulfur-hexauoride microbubbles
(SonoVue® BRACCO) as echo signal ampliers, strictly
intravascular dynamic changes were detected and there is no
transfer of the microbubbles into the liver parenchyma. This
is distinguished from contrast-enhanced imaging with computer tomography (CT) or magnetic resonance imaging
(MRI), which are always mixed imaging from vascular and
parenchymal contrast changes [2]. Furthermore, continuous
assessment of microvascularization is only really successful
with CEUS, because with contrast-enhanced CT or MRI,
imaging can only take place at certain points in time, such as
during the arterial phase (10–45s), the portal venous phase
(50–90s) and a late phase (2–5min) [3]. With bolus iv injection doses of 1–2.4ml SonoVue® during CEUS examina-
E. M. Jung (*)
Department of Radiology, University Hospital Regensburg,
Regensburg, Germany
e-mail: ernst-michael.jung@ukr.de
Y. Dong
Department of Ultrasound, Zhongshan Hospital, Fudan University,
Shanghai, China
e-mail: dong.yi@zs-hospital.sh.cn
tion, evaluation of perfusion and diagnostics are in the hands
of an experienced ultrasound examiner, while with CT or
MRI, examinations, evaluation, and diagnosis were often
separated.
12.2 Indications forCEUS Perfusion
There are numerous clinical indications for the CEUS perfusion assessment, some of which are still in the evaluation
phase, such as the assessment of liver function or the extent
of liver brosis up to cirrhosis. There are applications for
improved assessment of blood ow after liver transplantation
(LTX), but also for the characterization of different liver
tumors. However, increasing studies indicate that CEUS perfusion can facilitate monitoring and follow-up for different
tumor treatments. But even if there are approaches to a more
independent evaluation, the experience of the examiner
remains an important requirement for CEUS perfusion.
12.3 Preparation forContrast Agent
Application
Whenever possible, prior examinations written informed
consent is given. A sufciently cubital access is recommended for contrast agent application as a bolus with
5–10ml saline. The amount of contrast agent to be applied
depends on the examination conditions, body weight index
(BMI), and liver parenchymal structure, usually 1.5–2.4ml
in adults. Before the CEUS examination, possible tumor
areas are measured in three dimensions. The liver tumor
should be assessed with color ow imaging (CFI), Power
Doppler spectrum, and shear wave elastography beforehand
because these might be inuenced by CEUS.
Digital documentation with DICOM cine loops should
take place over at least 1min from the early arterial phase
(after 10–15s) up to 1min, for perfusion evaluation of the
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
W.-P. Wang et al. (eds.), Contrast-Enhanced Ultrasound Imaging of Hepatic Neoplasms,
https://doi.org/10.1007/978-981-16-1761-4_12
241
242
PE - Peak-Enhancement
E. M. Jung and Y. Dong
wash-in and wash-out kinetics on the tumor lesion to be
treated. After 1min until the late phase after 6min, short cine
loops (10–15s) should be documented, for detection of the
wash-out typical for malignant lesions or for characterization of the tumor foci.
Ideally, perfusion evaluation is carried out continuously for
up to 3min under standardized sound conditions using DICOM
loops, including the wash-in and wash-out kinetics. However,
this requires a high storage capacity. Ideal examination protocols have been included in the EFSUM Guidelines [2].
One can differentiate between device-internal evaluation
programs and external programs for CEUS perfusion analysis.
12.4 Evaluation Parameters oftheCEUS
Perfusion
The most common parameters of a dynamic perfusion analysis are time to peak (TTP) and area under the curve (AUC).
In addition, there is usually the determination of the mean
transit time (mTT), the wash-in and wash-out rate, and the
peak enhancement. When using special external software,
further dynamic perfusion parameters can be recorded using
motion correction analysis and individually adjusted regions
of interest (ROI). Particular attention should be paid to the
rise time (RT), the time of the middle enhancement in the
wash-in and wash-out phases [4]. The false colors of a hyperperfusion in red and yellow and a reduced perfusion in green
and blue make it easier to map the effect of tumor centers on
the surrounding tissue and enable therapy monitoring.
12.5 Perfusion Imaging ofDierential
Diagnosis ofLiver Tumors
A double mode B-mode and CEUS can facilitate the assessment of a target lesion or of dened areas in relation to the
dynamic contrast enhancement (wash-in) and a possible
wash-out and thus the characterization (Fig.12.1). A regular
arterial vascular pattern and an increasing contrast enhancement until the late phase indicate benign lesions. An irregular
arterial vascular pattern and a wash-out that increases toward
the late phase are typical of malignant lesions. This leads to
different perfusion curves. However, anonymized dynamic
a
c
b
Modell: Bolus
d
(1)
(2)
[a.u]
9257,51 166,04
10788,49
10896,92
[%]
193,50
195,44
Fig. 12.1 Perfusion Imaging of HCC. Small echoinhomogenous
tumor lesion less than 15mm on the left liver lobe, difcult to detect in
fundamental B-Mode. Irregular hypervascularization in CEUS in the
(3)
arterial Phase and wash-out beginning in the portal venous phase up to
the late phase. This could be evaluated and documented by PE enhancement parameters in a table or as a perfusion curve
5575,59
100,00
PE - Peak-Enhancement
12 Dynamic Vascular Pattern andQuantitative Analysis inLiver Tumors
243
a
c
b
Modell: Bolus
d
(1)
(2)
[a.u]
19815,70 87,20
13647,35
2251,69
[%]
60,05
9,91
Fig. 12.2 Tumor Perfusion Imaging. Small echoinhomogenous tumor
lesions up to 20mm on the right liver lobe with central irregular cystic
defects on B-Mode. Irregular hypervascularization in CEUS in the arterial Phase and wash-out beginning in the portal venous phase as criteria
gray value changes can also be carried out under CEUS perfusion (Fig.12.2).
With the wash-in and wash-out kinetics of the CEUS perfusion, different malignant or benign liver tumors can be
possible. For malignant lesions, the time intensity curve
(TIC) analysis is characterized by a wash-out beginning in
the portal venous phase (after 50–90s). However, for HCC,
the delayed wash-out can also start after 3min after injection
of contrast agents. For cholangiocellular carcinoma (CCC),
the wash-out is earlier, beginning on portal venous phase.
These criteria can be used as possible differential diagnosis
criteria between HCC and CCC.
CEUS perfusion parameters were evaluated, which were
used in the differential diagnosis of HCC and hypervascularity metastatic liver tumors (MLTs). Among all CEUS perfusion parameters, the time to peak (TTP), rise time (RT), and
wash-out time (WT) were signicantly longer in HCC than
in MLTs. Meanwhile, the area under the curve (AUC) and
the maximum intensity (IMAX) were signicantly higher.
Previous studies proved that both the tumor size and degree
(3)
for malignant tumor lesions with partial central necrosis. CEUSperfusion could be evaluated and documented by PE enhancement
parameters in a table or as a perfusion curve
22725,14
100,00
of differentiation affect the perfusion parameters in HCCs.
CEUS perfusion parameters, including WT, RT, TTP, IMAX,
and AUC were signicantly different between HCCs and
MLTs [5]. D-CEUS were also used for the discrimination of
different malignant liver lesions prospectively. DCEUS
parameters, especially at peak enhancement and during the
wash-out phases, could reect signicant differences
between malignant liver lesions [6].
Qualitative (visual) and quantitative (computer-assisted)
CEUS data has also been proposed to distinguish between
focal nodular hyperplasia and an inammatory hepatocellular adenoma. The reported accuracy of qualitative diagnostic
parameters was 93.6%, and 95.9% of the quantitative diagnostic parameters [7].
Differential diagnosis of benign liver tumors can sometimes be more difcult with CEUS. CEUS perfusion can
then be helpful for the differentiation of an atypical, partially
thrombosed echo-poor hemangioma, a FNH, or a hepatic
adenoma. since a dynamic analysis of the microvascularization and perfusion kinetics succeeds, whether nodular with
244
a
E. M. Jung and Y. Dong
iris diaphragm phenomenon, from central in the sense of
wheel spokes with central scar or increasingly from the edge
to the center. The multi-center study by DEGUM on the
diagnostic value of a dynamic assessment of liver tumors in
more than 1200 cases showed results with values up to 90%
comparable to ceCT and ceMRI [8]. The main limitations
were difcult sound conditions, the detection of all small
tumor areas, and the exact atypical benign lesions. According
to the LI-RADS classication of lesions in relation to HCC,
only irregular arterial hypervascularization can be decisive
for tumor foci with a diameter of 10mm or less. The pseudo
colors of a CEUS perfusion analysis and the evaluation of
the perfusion kinetics can be helpful to better illustrate these
features [9].
Fig. 12.3 Contrast enhanced
ultrasound (CEUS) perfusion
in a case of Osler disease.
CEUS with detection of
irregular hypervascularization
with changes of the
macrovascularization (a).
CEUS detected early and
irregular hyperenhancement
by micro-shunting in the
center of the liver (b).
Parametric perfusion imaging
could visualize in false colors
the mean regions of changes
by micro-shunting in a case of
Osler disease (c)
b
By using CEUS with perfusion imaging quantication, it
is able to sub-classify a high-risk cohort of asymptomatic
hereditary hemorrhagic telangiectasia (HHT) patients with
hepatic vascular malformations (HVaMs). Signicant differences could be found in peak enhancement (PE), wash-in
perfusion index (WiPI), and wash-in area under the curve
(WiAUC). This could be helpful to sub-classify a high-risk
group of HHT patients [10].
Other approaches to dynamic analysis include possible
micro or macro shunts, perfusion changes in thrombus formation or vascular inltration and the effects of embolisms
or infarcts. It is only with CEUS perfusion that the dynamics
of micro and macro shunts at M Osler can be clearly visualized and their extent recorded (Fig.12.3).
c
12 Dynamic Vascular Pattern andQuantitative Analysis inLiver Tumors
245
12.6 CEUS Perfusion Imaging ofTumor
Treatment Response Evaluation
12.6.1 CEUS Perfusion Imaging ofEarly
Chemotherapy Response Evaluation
In malignant liver lesions, CEUS Perfusion could be useful
in assessing early chemotherapy response. Initial investigations were performed to evaluate the potential of the TIC of
CEUS parameters as early imaging biomarkers in patients
with unresectable HCC.Data were analyzed in patients with
unresectable HCC treated with lenvatinib. CEUS was performed before treatment and on day 7 after treatment. While
taking tumor response assessed by CT using the modied
Response Evaluation Criteria in Solid Tumors (mRECIST)
at 8 weeks as gold standard, slope, TTP, and AUC parameters
showed signicant differences between the responders and
non-responders. CEUS may be very helpful for the early prediction of tumor response to lenvatinib therapy in patients
with unresectable HCCs [11].
12.6.2 CEUS Perfusion Imaging
ofTransarterial Chemoembolization
In cases where surgery or the curative approach of ablative
procedures for malignant liver lesions is not possible, transarterial chemoembolization (TACE) can enable targeted
treatment of HCC lesions. With CEUS, the most selective
intervention with TACE can be planned, carried out, and
monitored during the course. Without radiation exposure,
CEUS enables the dynamic detection of arterial capillary
hypervascularization of the HCC lesions to be treated. In
addition, CEUS monitoring enables selective application of
chemoembolization, particles, and BEADS.With CEUS it is
also possible to monitor chemoperfusion in more multifocal
tumor sites. With CEUS, the follow-up check according to
TACE can then be carried out in a targeted manner with
regard to reperfusion.
In our own investigations, the high diagnostic certainty of
CEUS with perfusion after TACE and chemoperfusion compared to ceCT or ceMRT was demonstrated. In the hands of
experienced examiners, there are no relevant differences
with regard to the detection of residual perfusion, tumor
expansion, and localization. The display in false colors as red
and yellow indicate an irregular nodular tumor perfusion or
ring-shaped hyperemia. Successfully treated, devascularized
tumor lesions are shown in the false colors blue and green.
With integrated perfusion software or external software,
dynamic DICOM cine-loops can be used to evaluate the
tumor lesions treated by TACE with regard to the extent of
devascularization. It can be analyzed in the form of a TIC or
based on various perfusion parameters such as PE, MTT, and
RT, which make it easier to assess the success of treatment
with TACE.In chemoperfusion, so with Embocept®, monitoring with CEUS perfusion can make a decisive contribution to successfully treating larger tumor areas and
dynamically mapping the extent of devascularization and
recirculation down to the capillary level.
In a previous study, post-interventional success control
following TACE in patients with HCC were evaluated by a
color-coded perfusion quantication software. Signicant
differences in CEUS parameters could be found between
center vs. margin of lesions regarding peak enhancement.
CEUS with color-coded perfusion imaging is also a helpful
imaging tool for evaluation of post-interventional success
following TACE of liver tumors. Among all CEUS parameters, peak enhancement might be the most valuable parameter [12].
12.6.3 CEUS Perfusion andLiver Tumor
Ablation Treatment
CEUS offers the diagnostic potential for reliable planning,
monitoring, implementation, and control of ablative treatments for malignant liver lesions. Tumor ablation with radiofrequency ablation (RFA), microwave ablation (MWA), or
irreversible electroporation (IRE) can be carried out after the
appropriate indication, ideally if the number of malignant
lesions does not exceed ve and the diameter is less than
3cm. CEUS Perfusion can make the representation of tumor
microvascularization, the detection of tumor extent in relation to the surrounding liver vessels and the detection of possible satellite foci in the area easier by the false colors alone.
Even small, irregularly hypervascularized tumor spots can be
easily distinguished from the darker background in red and
yellow. During percutaneous or intraoperative liver tumor
ablation, CEUS perfusion can be used to check whether the
ablation has already been successful or whether the probes
have to be repositioned. The amount of contrast medium is
not limited when using echo signal ampliers, in contrast to
CT or MRI with contrast medium. By monitoring with
CEUS and CEUS Perfusion, risks can be minimized and, for
the rst time, IRE can also dynamically record the destruction of irregular tumor vessels while maintaining the vessels
required for liver perfusion.
With high diagnostic certainty, a follow-up after ablative
tumor treatments can be carried out with CEUS perfusion
evaluation. Measurements are possible in the ablation area,
on the edge and in the surrounding liver tissue with individually adapted ROI. Perfusion parameters such as PE,
MTT, and RT can be helpful in assessing the extent to which
ablation was successfully carried out with devascularization
246
E. M. Jung and Y. Dong
of the tumor focus and with a sufcient safety margin, residual tumor is present or it is recurrence tumors occur during
follow- up checks (Fig. 12.4). CEUS perfusion achieves at
least the diagnostic certainty of the ceCT with regard to the
successful control after tumor ablation, is often comparable
to the ceMRI.A reactive hyperemia impresses in a ring with
persistent contrast enhancement and thus a prolongated
wash-out rate (Fig.12.5). A residual tumor or tumor recur-
a
c
rence appears as an irregular, nodular focus with an early
wash-out (Fig.12.6). This leads to different values of peak,
MTT, and RT.
CEUS with perfusion imaging is a valuable tool for evaluating post-interventional success following RFA and MWA
of primary and secondary liver tumors (Fig.12.7). CEUS
parameters including TTP, MTT, RT, PE, and WiAUC could
be compared between the center, the border area, and periph-
b
d
Fig. 12.4 CEUS perfusion analysis after ablation therapy. CEUS evaluation with an avascular defect up to 4cm after ablation therapy of an
HCC near the capsular Segment VIII.Color-coded perfusion after abla-
a
tion therapy shows a little hyperemia at the margin of the ablation zone
in yellow. Curve perfusion without perfusion in the center (green line)
and Peak enhancement values less than 2% in the table
b
Fig. 12.5 Perfusion analysis after ablation therapy. Evaluation of the
partial success of ablation therapy using an integrated software tool of
a high-end ultrasound machine. CEUS shows a nodular hyperenhance-
ment at the margin (arrow) during arterial phase, coded in yellow and
red as a sign of tumor. Irregular vascularization could be detected at the
left part of the ablation therapy
12 Dynamic Vascular Pattern andQuantitative Analysis inLiver Tumors
247
a
b
c
Fig. 12.6 CEUS Perfusion in a case of Osler disease. CCDS with
detection of irregular hypervascularization with changes of the macrovascularization. CEUS detected early and irregular hyperenhancement
d
by micro-shunting in the center of the liver. Parametric perfusion imaging could visualize in false colors the mean regions of changes by
micro-shunting in a case of Osler disease
a
Fig. 12.7 CEUS perfusion imaging after MWA.Evaluation after percutaneous microwave ablation therapy (MVA) by dynamic CEUS using
an integrated software during arterial enhancement. Left lesion with
b
complete devascularization (black arrow) and successful treatment,
right lesion with irregular margin as a sign of only partial success (white
arrow)
248
E. M. Jung and Y. Dong
ery of the lesion. In patients treated with RFA, PE differences signicantly between center of the lesion vs.
surrounding liver, as well as in center vs. margin of the
lesion. In patients treated with MWA, signicant differences
were found among PE, RI, and mTT between center vs. surrounding tissue of lesion [13].
After IRE, HCC with complete ablation showed a signicant difference among WiAUC and PE between the center
and the margin of the lesion. In the completely ablated MLTs,
signicant differences were found in WiAUC between the
center vs. the margins of the lesion and between the center
vs. the surrounding liver. CEUS imaging with perfusion
analysis is a valuable imaging tool for the evaluation of postinterventional efcacy in liver tumors following IRE. The
peak enhancement (PE) and the wash-in area under the curve
(WiAUC) might be useful parameters [14].
During the follow-up of patients with HCC undergoing
RFA, the correlation of ER measured by CEUS and survival
after RFA was analyzed by univariate and multivariate analysis. For predicting survival, the optimal cutoff ER value was
2.2dB/s. Univariate analysis demonstrated that while comparing patients with a low ER level, patients with a higher
ER level had poorer OS (62.8 months vs 48.8 months,
p<0.05) and recurrence-free survival (RFS=60.2 months
vs 47.4 months, p < 0.05). ER measured by CEUS was
proved to be an independent risk factor for overall survival
and RFS.ER measured by CEUS was a signicant predictive
factor for survival of HCC patients after RFA [15].
Using new perfusion software to show the success of percutaneous treatments of malignant liver tumors with CEUS,
all parameters were signicantly different in lesions treated
successfully and lesions with recurrence. With perfusion
imaging, a combination of CEUS enables critical assessment
of successful treatment after percutaneous interventional
procedures for a malignant liver lesion [16]. Possible complications after ablation of malignant liver tumors such as
reduced perfusion, partial infarctions, reactive inammatory
changes, and necrosis can also be clearly visualized with
CEUS Perfusion.
12.6.4 CEUS Perfusion andLiver Tumor
Surgery
In liver-transplanted patients, CEUS is gaining increasing
acceptance in the preoperative and postoperative evaluation,
with the potential of providing a comprehensive and noninvasive imaging diagnosis [17]. CEUS parameters were used
for preoperative assessment of liver reserve function. With
the optimal cut-off values of time to peak and arrival time,
qualitative assessment of patients with indocyanine green
(ICG) retention rate at 15min >10% with good diagnostic
abilities could be more easily achieved by CEUS [18].
A retrospective study analyzed the inuence of various
factors, including the tumor differentiation, the tumor size,
and the underlying hepatic condition on the enhancement
features of HCC on CEUS. During the arterial phase of
CEUS, most large (>3 cm) or poorly differentiated HCCs
showed inhomogeneous hyperenhancement. Most welldifferentiated HCCs showed late or no wash-out while compared to moderately or poorly differentiated HCCs.
Meanwhile, well-differentiated HCCs showed the longest
wash-out time, moderately differentiated HCCs showed the
moderate wash-out time and poorly differentiated HCCs
showed the shortest wash-out time. Larger lesions (>3 cm)
showed more rapid wash-out than small lesions (≤3 cm).
The CEUS enhancement features of HCC were inuenced
by the tumor size and the tumor differentiation degree [19].
12.7 Comparison ofCEUS Perfusion to
CT/MRI Perfusion oftheLiver
For the CT perfusion analysis, a signicantly higher radiation exposure and higher amounts of contrast medium with
corresponding risks are required. MRI perfusion analysis
requires a higher amount of contrast medium and longer
measuring times. CT perfusion and MRI perfusion are only
possible with special workstations with special software.
CEUS is becoming increasingly widespread, while CEUS
perfusion is only integrated into individual high-performance
ultrasound devices. As a rule, Store cine loops in DICOM
format digitally for at least 1min, which can be used for a
CEUS perfusion analysis. However, a comprehensive analysis is not always possible, usually only the determination of
TTP and AUC.With external software, a signicantly more
comprehensive perfusion analysis is possible, but this
requires more experienced examiners and is associated with
additional time expenditure. In principle, however, CEUS
perfusion is not associated with any risks for the examiner.
Typical contrast patterns for HCC lesions were arterial
enhancement and wash-out in the late phase, corresponding
to MRI with liver-specic contrast agent or ceCT.Mean TTP
(SD) in the tumor center (C), in the periphery (P) and in the
normal liver tissue with signicant differences between all
zones C/P (p = 0.013), C/LT (p = 0.005), and P/LT
(p = 0.022). AUC mean (SD) in the tumor center (C) in the
periphery (P) and in the normal liver tissue (LT) also with
signicant differences between all zones C/P, C/LT, and P/
LT.TIC analysis is an easy-to-use tool for the dynamic evaluation of microvascularization in HCC and allows a fast and
cost-efcient quantitative analysis [20].
While comparing the diagnostic performance of MRIbased T1 relaxometry with D-CEUS based liver microcirculation for evaluation of liver function, none of the CEUS
perfusion parameters correlated signicantly with T1 relax-
12 Dynamic Vascular Pattern andQuantitative Analysis inLiver Tumors
249
ation time (rrT1). Although CEUS-based perfusion parameters were not able to assess severity of liver disease, WiAUC,
RT and WIPI were signicant perfusion parameters to make
a rough assessment of liver function [21].
12.8 Summary
Indications CEUS perfusion liver
• Characterization of liver tumors
• Assessment of tumor neoangiogenesis
• Differentiation of smaller tumor-suspected foci
• Planning ablative procedures such as RFA, MWA, IRE
• Planning and monitoring of TACE and chemoperfusion
• Follow up after ablative procedures, TACE, and
chemoperfusion
• Assess the success of chemotherapy
• Quantication of shunts, as with Osler disease
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20. Schaible J, Stroszczynski C, Beyer LP, Jung EM.Quantitative perfusion analysis of hepatocellular carcinoma using dynamic contrast
enhanced ultrasound (CEUS) to determine tumor microvascularization. Clin Hemorheol Microcirc. 2019;73:95–104.
21. Haimerl M, Poelsterl S, Beyer LP, Wiesinger I, Nießen C,
Stroszczynski C, Wiggermann P, etal. Chronic liver disease: quantitative MRI vs CEUS-based microperfusion. Clin Hemorheol
Microcirc. 2016;64:435–46.
Contrast Enhanced Ultrasound (CEUS)
andImage Fusion forLiver
Interventions
ErnstMichaelJung andYiDong
13
13.1 Development ofUltrasound
Fusion Imaging
The rst examinations with an image fusion ultrasound (US)
with the CT, later also the MRI, were very time consuming
and could only be implemented with special additional US
navigation technology. The fusion technique on US devices
was initially only applicable to very experienced
investigators.
The next steps were to increasingly integrate the technology into high-performance ultrasound devices and to make
the technology more readily available. The examination
times could be shortened signicantly and advantages, such
as improved tumor detection and characterization, became
apparent in liver tumors. The faster and more precise the systems became, the more they were used to carry out targeted
punctures, biopsies, and especially ablative therapies and
transarterial chemoembolization (TACE), in order to plan
them and to monitor them in the follow-up.
The fusion techniques are expanding to more and more
indications and are regarded as the basis of automated navigation procedures. Fusion imaging opens up new possibilities for intervention planning, implementation, and control,
but also offers the opportunity to better assess remission or
progress in the follow-up of liver tumor treatment [1].
13.2 Basics ofImage Fusion
For a dynamic image fusion between ultrasound and a slice
image process in real time, a magnetic eld generator and a
corresponding transducer sensor are required as hardware. A
magnetic location system enables the transducer sensor position to be detected, and thus the exact spatial position of the
sensor in the room can be calculated. For image fusion, digital imaging, and communications in medicine (DICOM) data
sets of all common slice image methods (CT, MRI, PET-CT)
can be used. For this purpose, the DICOM data are loaded
into the ultrasound system and the data records are then registered manually using anatomical landmarks or automatically based on image recognition features. After a successful
data fusion, the registered sectional image data move simultaneously to the sonographic sectional plane. Various presets
are optionally available, which optionally display the registered images in the overlay technique or in the side-by-side
view. The color-coded duplex sonography (FKDS), Power
Doppler (PD), or CEUS can be easily integrated into the
merged image. Thus, the simultaneous use of the CEUS and
the image fusion gives the possibility of a tumor-related
assessment of the microvascularization in direct comparison
to the contrast medium-enhanced CT or MRI [2, 3].
13.3 Clinical Application ofImage Fusion
CEUS with image fusion enables the experienced radiological examiner to dynamically record the tumor microvascularization down to the capillary level. In addition to the
E. M. Jung (*)
Department of Radiology, University Hospital Regensburg,
Regensburg, Germany
e-mail: ernst-michael.jung@ukr.de
Y. Dong
Department of Ultrasound, Zhongshan Hospital, Fudan University,
Shanghai, China
e-mail: dong.yi@zs-hospital.sh.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
W.-P. Wang et al. (eds.), Contrast-Enhanced Ultrasound Imaging of Hepatic Neoplasms,
https://doi.org/10.1007/978-981-16-1761-4_13
primary applications of image fusion in the context of diagnostics, targeted biopsies, drainage systems, radio frequency
ablation (RFA), microwave ablation (MWA), irreversible
electroporation (IRE), and chemoembolization (TACE) can
also be planned and carried out. New possibilities open up
for effective diagnosis and therapy of oncological diseases
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