title: Contrast-enhanced intraoperative ultrasonography during surgery for hepatocellular carcinoma in liver cirrhosis: is it useful or useless? A prospective cohort study of our experience.
abstract: BACKGROUND
  Preliminary results showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) could provide information not obtainable with conventional IOUS during surgery for hepatocellular carcinoma (HCC). The aim of the study was to prospectively validate the role of CEIOUS on the basis of a larger experience and to establish a new classification that takes into account its findings.
  
  
  METHODS
  Eighty-seven consecutive patients underwent hepatecomies for HCC. Those patients with new lesions at IOUS underwent CEIOUS: for that patients received intravenously 4.8 mL sulphurhexafluoride microbubbles. Pattern of enhancement was classified in 4 categories: A1 (full enhancement in the arterial phase and wash-out in the delayed phases), A2 (intralesional signs of neovascularization during all phases), A3 (no nodular enhancement but detectability during the liver enhancement), and B (undetectability during the liver enhancement). Resection was recommended for A1-3 nodules and no treatment for B nodules.
  
  
  RESULTS
  Twenty-nine patients (33%) had 59 new lesions at IOUS and underwent CEIOUS. Twenty-seven nodules showed a B pattern at CEIOUS and were not removed; 32 nodules were classified as A1 in 5 patients, A2 in 11 patients, and A3 in 16 patients. The nodules were removed, and by histology, five A1, nine A2, and six A3 nodules were confirmed to be HCC. CEIOUS modified the operative decision making in 79% of these patients.
  
  
  CONCLUSIONS
  CEIOUS is useful during surgery for HCC; it complements the accuracy of IOUS and affects the radicalness of the surgical. Specificity of CEIOUS has to be further improved, although intrinsic drawbacks exist in the diagnostic criterion of tumor vascularity.
authors.affiliation: 3rd Department of Surgery, Istituto Clinico Humanitas, IRCCS, University of Milan, Via Manzoni, 56, I-20089 Rozzano, Milan, Italy. guido.torzilli@unimi.it
authors.forename: Guido
authors.initials: G
authors.lastname: Torzilli
authors.forename: Angela
authors.initials: A
authors.lastname: Palmisano
authors.forename: Daniele
authors.initials: D
authors.lastname: Del Fabbro
authors.forename: Matteo
authors.initials: M
authors.lastname: Marconi
authors.forename: Matteo
authors.initials: M
authors.lastname: Donadon
authors.forename: Antonino
authors.initials: A
authors.lastname: Spinelli
authors.forename: Paolo Pietro
authors.initials: PP
authors.lastname: Bianchi
authors.forename: Marco
authors.initials: M
authors.lastname: Montorsi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging* / Q000601:surgery*; D015331:Cohort Studies; D003287:Contrast Media; D005260:Female; D006498:Hepatectomy; D006801:Humans; D007432:Intraoperative Period; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D015996:Survival Rate; D014463:Ultrasonography
chemical_list: D003287:Contrast Media