Abdominal Radiology

, Volume 43, Issue 4, pp 819–847 | Cite as

Contrast-enhanced ultrasound of malignant liver lesions

  • Isabelle Durot
  • Stephanie R. Wilson
  • Jürgen K. Willmann


Contrast-enhanced ultrasound (CEUS) is a safe, relatively inexpensive, and widely available imaging technique using dedicated imaging ultrasound sequences and FDA-approved contrast microbubbles that allow detection and characterization of malignant focal liver lesions with high diagnostic accuracy. CEUS provides dynamic real-time imaging with high spatial and temporal capability, allowing for unique contributions to the already established protocols for diagnosing focal liver lesions using CT and MR imaging. In patients with lesions indeterminate on CT and MRI, CEUS is a helpful problem-solving complementary tool that improves patient management. Furthermore, CEUS assists guidance of liver biopsies and local treatment. Variations of CEUS such as DCE-US and ultrasound molecular imaging are emerging for quantitative monitoring of treatment effects and possible earlier detection of cancer. In this review, basic principles of CEUS techniques and ultrasound contrast agents along with a description of the enhancement patterns of malignant liver lesions are summarized. Also, a discussion of the role of CEUS for treatment guidance and monitoring, intraoperative CEUS, and an outlook on emerging applications is provided.


Ultrasound Contrast-enhanced Microbubbles Liver Malignant liver lesions Dynamic contrast-enhanced ultrasound (DCE-US) Molecular imaging 



Contrast-enhanced ultrasound


Computed tomography


Magnetic resonance imaging


Dynamic contrast-enhanced ultrasound


Ultrasound contrast agent


Food and Drug Administration


Contrast-enhanced computed tomography


Contrast-enhanced magnetic resonance imaging


Mechanical index


Organ Procurement and Transplant Network


Liver Imaging Reporting and Data System


American College of Radiology


Focal liver lesion


Hepatocellular carcinoma


Intrahepatic cholangiocarcinoma


Focal nodular hyperplasia




Hepatic epithelioid hemangioendothelioma


American Association for the Study of Liver Disease


Canadian Association for the Study of the Liver


Japan Society of Hepatology


Asian Pacific Association for the Study of the Liver


Italian Association for the Study of Liver


Regenerative nodule


Dysplastic nodule


Transarterial chemoembolization


Radiofrequency ablation


Response Evaluation Criteria in Solid Tumors






European Association for the Study of the Liver


European Organization for Research and Treatment of Cancer


Intraoperative ultrasound


Intraoperative contrast-enhanced ultrasound



Images are from the University of Calgary and Stanford University using the contrast agent Definity (Lantheus Medical Imaging, Billeria MA). Isabelle Durot was supported by the Swiss Society of Radiology.

Compliance with ethical standards


This paper was supported in parts by NIH R01CA209888 grant.

Conflict of interest

Isabelle Durot declares that she has no conflict of interest. Stephanie R. Wilson received research support from Siemens and Philips and has an advisory function for Lantheus. Jürgen K. Willmann received a research grant from Siemens, GE, Philips, and Bracco; is a consultant for Bracco and Triple Ring Technologies; and is a member of the Scientific Advisory board for Lantheus, Bracco, and SonoVol.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material (13 mb)
Online Resource 1 Liver metastasis from breast cancer. 61-yo female with history of breast cancer and newly diagnosed liver lesion on CT. CEUS shows rapid and homogenous enhancement in the early arterial phase, followed by a rapid and pronounced washout still within the arterial phase with a punched-out appearance. This is a non-hepatocellular malignancy, classic for a metastasis (MOV 13346 kb) (5.2 mb)
Online Resource 2 Intrahepatic cholangiocarcinoma. 47-yo female with a history of abdominal pain for 2 months. Following intravenous administration of contrast, there is peripheral arterial hyperenhancement with marked washout seen within 1 min (see Online Resource 3). Histology showed an intrahepatic cholangiocarcinoma (MOV 5284 kb) (4.2 mb)
Online Resource 3 Intrahepatic cholangiocarcinoma. The portal venous sweep (same patient as Online Resource 2) shows the marked washout of the mass and increases conspicuity of the multiple additional lesions present, not well seen initially. In addition, the patent hepatic veins can be seen coursing through the large mass. Histology showed an intrahepatic cholangiocarcinoma (MOV 4343 kb) (4.1 mb)
Online Resource 4 Hepatocellular carcinoma within a dysplastic nodule. 47-yo male with HCV liver cirrhosis. CEUS in the arterial phase shows a hyperenhancing focus within a hypoenhancing nodule. The diagnosis of HCC within a dysplastic nodule was made with the classic nodule-in-nodule pattern (MOV 4180 kb)
261_2017_1360_MOESM5_ESM.mp4 (17.9 mb)
Online Resource 5 Mosaic pattern hepatocellular carcinoma in a cirrhotic liver. 72-yo male with chronic HCV liver cirrhosis. Following intravenous administration of contrast, there is non-homogeneous rapid and strong enhancement in the early arterial phase and progressive, slightly more homogeneous enhancement in the portal venous phase followed by slow and weak washout of different tumor areas (“mosaic architecture”) (MP4 18340 kb) (7.7 mb)
Online Resource 6 Tumor thrombus (tumor in vein). 56-yo male with HCV and ethanol liver cirrhosis. CEUS shows the main portal vein and its branches with hyperenhancement in the arterial phase at approximately 13 s with subsequent slow washout (not shown), consistent with tumor thrombus (tumor in vein). Hepatic tumor is not shown (MOV 7894 kb)


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of Radiology, School of MedicineStanford UniversityStanfordUSA
  2. 2.Department of RadiologyUniversity of CalgaryCalgaryCanada
  3. 3.Department of Radiology, School of MedicineStanford UniversityStanfordUSA

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