Fusion Imaging in the Diagnosis and Treatment of Liver Tumors in Taiwan

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Ultrasound in Medicine and Biology

It is well-known that contrast-enhanced ultrasound (CEUS) is most widely used for the evaluation of various hepatic diseases, especially for focal hepatic lesions. Of two 2nd generation US contrast agents, e.g., SonazoidTM (GE Healthcare, USA) and SonoVueTM (Bracco Imaging, Italy) that are available in Korea, SonazoidTM provides more information in characterizing various hepatic tumors, and even in guiding for interventional procedures, e.g., radiofrequency ablation of hepatocellular carcinoma, because it allows acquisition of the Kupffer phase, during which it is taken up actively by Kupffer cell, after acquisition of conventional multi-phase dynamic imaging. SonoVueTM is also easily applicable to evaluate various vascular compromises for which the Kupffer phase is unnecessary. In this lecture, we demonstrate essential characteristics of both US contrast agents, CEUS findings of various hepatic tumors with differential points, guiding methods using CEUS for radiofrequency ablation of hepatocellular carcinoma with brief introduction of fusion imaging techniques, and other applications for vascular compromises. T12-13-IN06 Novel Guidance for Percutaneous Treatment of Hepatic Tumors: Fusion Images and Cone-Beam CT Olivier Seror1,2,3 1 Unit of Interventional Radiology, Jean Verdier Hospital, Bondy, France, 2University Paris 13, Bobigny, France, 3Inserm, UMR-1162, Genomique fonctionnelle des tumeurs solides, Paris, France US fusion images guidance is now routinely used for percutaneous ablations of liver tumors. Indeed, real time display of US slice with corresponding refreshed MPR of co-registered 3D data set of pretherapeutic CT or MR examinations improves the conspicuity of the target. However, several conditions could limit even wreck the co-registration of US with 3D data set of referral examinations. Thus, spatial mismatching between the images of two modalities can be due to static or dynamic anatomic differences between pretherapeutic referral examinations commonly achieved several days before the intervention. Finding similar land marks between US and referral images to set the registration could be also some time too tricky. Automatic coregistration of US with referral volume of images acquired just before the procedure avoids these common pitfalls. Cone beam CT volume as referral image offers additional advantage to be used for 3D fluoroscopic display of the target. For very challenging liver ablation requiring the insertion of several applicators, double real-time guidance relying on US fused with cone beam CT and virtual 3D fluoroscopic display allows safe punctures within acceptable ranges of time and X-ray dose. T12-13-IN07 Doppler Ultrasound in Liver Diseases Antonio Carlos Matteoni de Athayde The hepatic ultrasonography associated with color Doppler, amplitude Doppler and spectral Doppler are very important tools in the daily routine of the professional that performs the ultrasound, being possible to diagnose pathologies and discard others, as well as, it allows to infer the possibility of extra illnesses -hepatic, such as heart disease. It is also of great importance in the evaluation of the transplanted hepatic patient. Color Doppler and Doppler amplitude and spectral Doppler are safe techniques and can be performed several times in a short time in patients of any age group. The identification of flow, whether arterial or venous, sense of the same, as well as, spectral study etc, provide us with relevant information that should always be used. We try to demonstrate situations that these techniques are extremely important and avoid other studies.

Volume 43, Number S1, 2017 T12-13-IN08 CEUS in the Diagnosis of Liver Tumor in Taiwan Yi-Hong Chou, M.D.,1,2 Hong-Jen Chiou, M.D.,1 Chui-Mei Tiu, M.D.,1 Yi-You Chiou,1 Ja-Der Liang,3 Shen-Yung Wang,4 Shih-Jer Hsu,5 Jui-Ting Hu,6 Sien-Sing Yang,6 Peter Lee7 1 Department of Radiology, Taipei Veterans General Hospital, and National Yang Ming University, Taipei, Taiwan, 2Medical Imaging and Radiological Technology, Yuan Pei University of Medical Technology, Hsinchu, Taiwan, 3Attending doctor of internal medicine department, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, 4 Senior Attending Physician, Division of Gastroenterology, Department of Medicine, MacKay Memorial Hospital Tamshui Branch, Taiwan, 5 Attending Physician, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, 6Director of Liver Unit, Liver Center, Cathay General Hospital, and School of Medicine, Fu-Jen Catholic University College of Medicine, Taipei, Taiwan, 7Yee Zen Hospital, Taoyuan, Taiwan During the past three decades, exciting advances have been made in contrast-enhanced ultrasound (CEUS) imaging. Before the currently available second-generation ultrasonic contrast agents(USCA), transarterial infusion of carbon dioxide microbubbles had been used to enhance US examination of hepatic tumors as early as mid-1990s, chiefly by the Jen-Ai Hospital group (Dr. Wang, Dr. Chen, Dr. Liaw). Levovist (Schering AG, Germany), the most important first-generation intravenous USCA is the first agent introduced to Taiwan ultrasound community in 1996 by Dr. Yi-Hong Chou. The clinical experience of Levovist was promising in characterization of focal liver lesions and in assessing treatment efficacy of malignant hepatic tumors. Sonovue (Bracco, Italy) was introduced to many laboratories in Taiwan since 2008 mainly for animal studies. ‘‘Lab-produced’’ USCAs were produced in some of the leading laboratories such as Tsing Hua University (Prof. Chih-Kuang Yeh) and National Taiwan University (Prof. Jen-Ho Tsao). One of the lab-produced USCAs is now registered in Taiwan with pending approval of Taiwan Food and Drug Administration (TFDA). Now, there are totally 12 medical centers and 8 teaching hospitals joining the USCA Working Group and a total of more than 40 research members are invited to form a subcommittee in Committee of Research and Development in Ultrasound Medicine under the umbrella of Society of Ultrasound in Medicine of the Republic of China (SUMROC, also known as CTSUM). Now we have 2 USCA available in Taiwan, i.e., Sonazoid and Definity. Although the Taiwan ultrasound community has been discussing on setting up a guideline of CEUS of the liver for at least 4 years, we still have not yet officially started to do that. We are now adopting the guideline from EFSUMB and WFUMB as references. The Advanced Ultrasound Technology Committee of SUMROC and US Contrast Agent Subcommittee (Chaired by Prof. Yi-Hong Chou) plan to invite the Taiwan Liver Cancer Association (TLCA) and Taiwan Academy of Tumor Ablation (TATA) to create a guideline most suitable for Taiwan physicians to follow. This can be after Q3 of 2017. Any aiready-proposed guidelines from any of the experienced regional or national societies may be also used as references. T12-13-IN09 Fusion Imaging in the Diagnosis and Treatment of Liver Tumors in Taiwan Sheng-Nan Lu Division of Hepatogastroenterology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County, Taiwan

Abstracts In Taiwan, hepatologists are in charge of daily ultrasonography (US) practice and familiar to upper abdominal US images. Most radiofrequency ablation (RFA) procedures for liver tumor are conducted by hepatologist. US contrast agent has been launched for only few months. Because we are not radiologists, CT guidance or evaluation immediately after RFA is not so convenient for us. Fusion image technology (FIT) becomes the inevitable technology in our daily RFA practice. We introduced FIT, or real-time virtual ultrasound (RVS) into our hospital since 2008 and use it in almost every RFA patient. Initially, FIT was reported to locate inconspicuous focal tumors, inclusion untreated and residual. This problems have been mostly resolved by CEUS. Actually, FIT for US-guidance intervention likes a global positioning system (GPS) for car driving. It can be widely used to resolve more problems. For example, it can be used (i) to find more adequate and safer puncture route, (ii) to predict the usefulness of artificial ascites/pleural effusion, (iii) to realize the nearby extrahepatic structure of ablation zone, (iv) to design the overlapping ablation for large lesion with irregular sharp, (v) to real-time evaluate the spatial relationships between ablation zone and nearby intrahepatic structure during ablation, and et al. Because of GPS-like function, FIT should be useful despite of CEUS launched, and should be a routine technology to achieved safe and effective RFA for hepatic tumors. T12-13-IN10 EUS in Diagnosis and Treatment of GI Tract Chien-Hua Chen Show-Chwan Memorial Hospital, Taiwan Endoscopic ultrasound (EUS), with endoscopic visualization and a high frequency ultrasound transducer, can be utilized to study both intramural structures and structures adjacent to the gastrointestinal tract without the interference of soft tissue interposition or bowel gas. The echoendoscopes compose of two designs: linear array and radial array. Radial array EUS can be used for luminal imaging and evaluation of the wall layers of the gastrointestinal tract. However, linear array EUS can allow imaging, tissue acquisition and therapeutic applications. Moreover, the miniprobe belongs to radial array EUS with a transducer of higher frequency and it can be inserted through the working channel of a esophagogastroduodenoscope or colonoscope. Mastering the manipulation of echoendoscope and the anatomy based on the linear and radial array EUS is the basic requirement of attaining useful images of EUS. With the technique advance of interventional EUS, several therapeutic EUS have been developed such as celiac plexus block and neurolysis, peripancreatic fluid collection drainage, intra-abdominal abscess drainage, EUS-guided angiotherapy, EUS-guided pancreaticobiliary access, EUS-guided fiducial placements, and local ablative therapy. However, therapeutic EUS requires great expertise and it carries a higher risk of adverse events such as bleeding, perforation, infection, and bile peritonitis. EUS elastography can differentiate the nature of lesions based on their stiffness, but the technique is operator dependent and its accuracy needs more assessments. Moreover, contrast-enhanced EUS provides better differentiation, localization, and post-treatment assessment of the target lesions. However, contrast-enhanced EUS cannot completely replace tissue acquisition to ascertain the tumor nature, particularly for the solid pancreatic tumors. T12-13-IN11 EUS in Diagnosis and Treatment of Biliary Diseases Kosuke Minaga Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan Although ERCP has long been considered the best endoscopic modality for diagnosis and treatment of biliary diseases, in the past decade, EUS, especially convex type, has been effectively applied.

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As for diagnosis of biliary diseases, in patients suspected to have common bile duct (CBD) stones, EUS is recommended when CBD stones are undetectable with other imaging modalities to avoid unnecessary ERCP. In patients with acute pancreatitis of unknown origin, EUS is useful for diagnosing gallstone pancreatitis. In patients with CBD stricture, EUS has been proved to be a useful modality in assessing differential diagnosis of bile duct strictures, and subsequent EUS-FNA could confirm pathological diagnosis with few complications. EUS is also useful for diagnosing gallbladder lesions. Recent advances in EUS imaging technology has led to the evolution of the image-enhanced EUS modalities called contrastenhanced harmonic EUS and EUS-elastography. These modalities has been described clinically helpful for diagnosing biliary diseases. As for treatment of biliary diseases, since first described in 2001, EUSguided biliary drainage (EUS-BD) has been increasingly used as an alternative in patients with biliary obstruction who failed standard ERCP. Its potential and efficacy has drawn attention and many articles about EUS-BD have been published in the last decade. Various endoscopic approaches have been described for EUS-BD including EUS-guided transluminal biliary stenting, EUS-guided rendezvous technique, and EUSguided antegrade biliary stenting. Recent meta-analyses have revealed that the cumulative technical success and adverse event rates were 90– 94% and 16–23%, respectively. The development of new dedicated devices for EUS-BD would help refine the technical aspects and minimize the possibility of complications, making it a more promising procedure. T12-13-IN12 EUS in Diagnosis and Treatment of Pancreatic Diseases Dong Wan Seo, MD, PhD Professor of Medicine, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Endoscopic ultrasound (EUS) is a very useful modality for the diagnosis and staging of pancreatic diseases. EUS can give high resolution image of the pancreas and can detect small solid or cystic lesions very sensitively. Therefore EUS is widely used for the diagnosis of pancreatitis, pancreatic duct changes, pancreatic solid tumors and cystic tumors. For cystic tumors of the pancreas, EUS can detect the internal structures such as locules, septum, mural nodule and wall thickening with high resolution images. With the advent of EUS-guided fine needle aspiration (EUS-FNA) technology, this modality has made a tremendous progress from imaging modality to histologic diagnosis and therapeutic intervention. Pancreatic ductal adenocarcinoma is one of the most difficult tumor to treat and has an extremely poor prognosis. Most patients die within a year or two after diagnosis and the overall 5 year survival rate is less than 5% even after extensive treatment including surgery, chemotherapy and/or radiation therapy. EUS offers high resolution images of the pancreas and unparalleled access to the pancreas. After location of the tip of echoendoscope in the duodenum or stomach, EUS-guided FNA is possible to get the cytologic or histologic diagnosis. Acute or chronic pancreatitis can cause several complication including pseudocyst and walled off necrosis. Under EUS guidance, cysto-gastrostomy or cysto-duodenostomy can be performed to cure pseudocyst. Multiple studies showed the superiority of this approach to percutaneous or surgical approach and widely performed in many centers. EUS-guided fine needle injection (EUS-FNI) for various solid or cystic lesions is a rapidly expanding field. Interventional EUS of aspiration followed by injection is applied to pancreatic cystic tumors. For cystic tumors of the pancreas, EUS-guided ethanol lavage with/without paclitaxel injection is tried and complete resolution of cystic tumor was observed up to 7080% of patients. Ethanol injection is also performed for the management of solid neuroendocrine tumor of the pancreas. Ethanol injection can effectively manage functioning neuroendocrine tumor such as insulinoma. The complete resolution of tumor