Intraoperative contrast-enhanced ultrasound (CEUS) with time intensity curve (TIC) analysis for better assessment of liver tumor margins

Abstract

Purpose

The purpose of this study was to conduct an intraoperative evaluation of focal liver lesions using time intensity curve (TIC) analysis of contrast-enhanced ultrasound (CEUS) to better assess liver tumor margins.

Materials and Methods

This study included 28 patients (21 men 75%, 7 women 25%) with malignant liver lesions (cholangiocellular carcinoma (CCC), n = 9; hepatocellular carcinoma (HCC), n = 6; hepatic metastases (HepMET), n = 13). A B-mode scan, color-coded Doppler sonography, and CEUS were performed intraoperatively to analyze the focal lesions. The generated parametric images were based on continuous cine loops, acquired with a multifrequency T-probe (6–9 MHz), from the early arterial phase (0–15 seconds) to the portal venous phase (1 minute), generated by integrated perfusion software. Analyses of the CEUS loops were performed using TICs with respect to time-to-peak (TTP) and area under the curve (AUC). Perfusion analysis was performed in the center and periphery of the tumor as well as in healthy liver tissue. All tumor lesions were evaluated histopathologically to verify the diagnosis.

Results

Sufficient image quality was achieved in all cases using CEUS for TIC analysis. A comparison of all groups showed a clear difference compared with the center, margin, and healthy liver tissue in the measured parameters of TTP and AUC (p = 0.035 and p = 0.045, respectively). In detail, differences were observed in the CCC group (TTP: p = 0.025) and in the HepMET group (TTP: p = 0.009), particularly in the peripheral areas (strong arterial flooding with a rapid increase in the flooding curve), with equally clear tumor edge representation compared with healthy liver tissue, as shown by the AUC analysis (CCC AUC: p = 0.032 and HepMET AUC: p = 0.029). In patients with HCC, the perfusion pattern (starting from the center) showed the center to be more clearly distinguishable from the edge with significant TTP and AUC (p = 0.035 and p = 0.038).

Conclusion

Intraoperative TIC analysis of malignant liver tumors is an important diagnostic tool for better highlighting liver tumor margins during surgery.

Key Points

• CEUS with dynamic vascularization. Analysis of liver malignancies and tumor margins. Intraoperative time intensity curve analysis.

Citation Format

• Dropco I, Kaiser U, Jung F et al. Intraoperative contrast-enhanced ultrasound (CEUS) with time intensity curve (TIC) analysis for better assessment of liver tumor margins. Rofo 2025; DOI 10.1055/a-2600-7229

Zusammenfassung

Ziel

Ziel dieser Studie war es, eine intraoperative Bewertung fokaler Leberläsionen mit Hilfe der Zeit-Intensitäts-Kurven-Analyse (TIC) des kontrastverstärkten Ultraschalls (CEUS) durchzuführen, um Lebertumorränder besser beurteilen zu können.

Material und Methoden

Diese Studie umfasste 28 Patienten (21 Männer 75%, 7 Frauen 25%) mit bösartigen Leberläsionen (cholangiozelluläres Karzinom CCC, n = 9; hepatozelluläres Karzinom HCC, n = 6; Lebermetastasen HepMET, n = 13). Zur Analyse der fokalen Läsionen wurden intraoperativ ein B-Scan, eine farbkodierte Dopplersonografie und ein CEUS durchgeführt. Die erzeugten parametrischen Bilder basierten auf kontinuierlichen Cine-Loops, die mit einer Multifrequenz-T-Sonde (6–9 MHz) von der frühen arteriellen Phase (0–15 Sekunden) bis zur portalvenösen Phase (1 Minute) aufgenommen und von einer integrierten Perfusionssoftware generiert wurden. Die Analyse der CEUS-Schleifen erfolgte mithilfe von TICs in Bezug auf die Zeit bis zum Spitzenwert (TTP) und die Fläche unter der Kurve (AUC). Die Perfusionsanalyse wurde sowohl im Zentrum und in der Peripherie des Tumors als auch im gesunden Lebergewebe durchgeführt. Alle Tumorläsionen wurden histopathologisch untersucht, um die Diagnose zu bestätigen.

Ergebnisse

In allen Fällen wurde mit CEUS eine ausreichende Bildqualität für die TIC-Analyse erreicht. Ein Vergleich aller Gruppen zeigte einen deutlichen Unterschied in den gemessenen Parametern TTP und AUC gegenüber dem Zentrum, dem Rand und dem gesunden Lebergewebe (p = 0,035 bzw. p = 0,045). Im Einzelnen wurden Unterschiede in der CCC-Gruppe (TTP: p = 0,025) und in der HepMET-Gruppe (TTP: p = 0,009) vor allem in den peripheren Bereichen (starke arterielle Anflutung mit schnellem Anstieg der Anflutungskurve) bei ebenso deutlicher Tumorranddarstellung im Vergleich zum gesunden Lebergewebe beobachtet, wie die AUC-Analyse zeigte (CCC AUC: p = 0,032 und HepMET AUC: p = 0,029). Bei Patienten mit HCC zeigte das Perfusionsmuster (ausgehend vom Zentrum), dass das Zentrum deutlicher vom Rand zu unterscheiden war, mit signifikanter TTP und AUC (p = 0,035 und p = 0,038).

Schlussfolgerung

Die intraoperative TIC-Analyse bösartiger Lebertumore ist ein wichtiges diagnostisches Instrument zur besseren Hervorhebung der Lebertumorränder während der Operation.

Kernaussagen

• CEUS mit dynamischer Vaskularisierung. Analyse von Lebermalignomen und Tumorrändern. Intraoperative Zeit-Intensitätskurven-Analyse.

Keywords

contrast agents - parametric imaging - liver malignancies

Publication History

Received: 02 January 2025

Accepted after revision: 05 May 2025

Article published online:
26 May 2025

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