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1 Arts and Sciences 2 Diagnostic significance of contrast-enhanced ultrasonography for hepatocellular adenoma: experiences of two cases Key words: Abdominal ultrasonography Contrast-enhanced ultrasonography Hepatocellular adenoma Abstract We experienced two cases of hepatocellular adenoma in which contrast-enhanced ultrasonography (US) findings were helpful for diagnosis. In these cases, the absence of findings that indicated intratumoral bleeding of necrosis on computed tomography (CT) made the differential diagnosis between focal nodular hyperplasia and hepatocellular adenoma difficult, although hepatocellular carcinoma was unlikely based on the lack of the defect of the nodular defect on hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-DTPA)-enhanced magnetic resonance imaging (MRI). In addition, no information was obtained from B-mode US to diagnose hepatocellular adenoma. In contrast, contrast-enhanced US examination provides the findings that were characteristic for hepatocellular adenoma; i.e., droop-formed minute blood vessel construction in its arterial phase. 2 CT MRI wash out MRI Contrast- Enhanced Ultrasonography CEUS CT MRI Focal Nodular Hyperplasia Kenichi Takahashi Department of Clinical Research, Ogaki Municipal Hospital, Gifu, Japan Radiological Technologists FNH CT MRI CEUS CEUS TOSHIBA Aplio XG MRI PHLIPS Achieva 1.5T Nova CT TOSHIBA Aquilion16 1/ ml/kg 5.0MHz Differention CHI MI 0.18~ ~15fps vol.62 no.749

focus point 1 focus 30 30 120 10 Replenishment Micro Flow Imaging MFI Table 1 Table 1 Laboratory data on admission 04 3 1 37 2007 11 S6

SPIO-T2high intensity Long TEhigh intensity Fig. 1 Fig.

2 focus point 1 focus Replenishment Micro Flow Imaging MFI Table 1 Table 1 Laboratory data on admission S6 37mm MRI T1 low intensity T2 high intensity CT hypervascular MRI SPIO T1low intensity Heavy T2 high intensity SPIO-T1 SPIO-T2high intensity Long TEhigh intensity Fig. 1 Fig. 1 Magnetic resonance imaging of the liver a T1-emphasized image b Heavy T2-emphasized image c SPIO-contrast enhanced MRI T1-emphasized image d SPIO-contrast enhanced MRI T2-emphasized image e Long TE-emphasized image

CT CT low density CT iso density Fig. 2 MRI EOB low intensity iso intensity high intensity Fig.

Fig. 2 Computed tomography of the liver a pre-enhancement b arterial phase of enhancement c portal phase of

3 CT CT low density CT iso density Fig. 2 MRI EOB low intensity iso intensity high intensity Fig. 3 CT MRI S6 iso echoic Fig. 4 Fig. 5 CEUS hyper echoic Fig. Fig. 2 Computed tomography of the liver a pre-enhancement b arterial phase of enhancement c portal phase of enhancement d equilibrium phase of enhancement Fig. 3 Contrast-enhanced magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) a pre-enhancement b early phase c late phase d hepatobiliary phase 20 minutes after injection Fig. 4 Abdominal B-mode ultrasonography a right-subcostal view b right-intercostal view vol.62 no.749

原著学診断に造影超音波検査が有用であった肝細胞線腫の2症例術 Arts and Sciences 6 a f

Replenishment 法や MFI 法では微細な血管構築めなかった経皮針生検の組織所見がよく分かった

toward the tumor was observed by the FFT fast Fourier

6 Contrast-enhanced ultrasonography examination Vascular

4 原著学診断に造影超音波検査が有用であった肝細胞線腫の2症例術 Arts and Sciences 6 a f 矢印 TOSHIBA の装置に搭載されてい 7 矢印 CEUS 上も腫瘍内に出血や壊死は認る Replenishment 法や MFI 法では微細な血管構築めなかった経皮針生検の組織所見がよく分かった Fig. 6 g l 矢印後血管相は周囲肝と iso echoic であった Fig. ほぼ正常な肝細胞様の細胞が充実性に増殖し銀 Fig. 5 Doppler ultrasonography examination 04 Pulsative flow toward the tumor was observed by the FFT fast Fourier transform, The figure lower berth analysis. Fig. 6 Contrast-enhanced ultrasonography examination Vascular phase a f arterial phase g l after replenishment Fig. 7 Contrast-enhanced ultrasonography examination Post Vascular phase 学術

Fig. 8 2 26 2010 5 S4 31 27 Table 2 CT CT low density CT high density iso

8 Pathological findings (obtained by percutaneous needle biopsy) a 40 b 200

enhancement c delate phase of enhancement d equilibrium phase of enhancement

gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) a

5 Fig S Table 2 CT CT low density CT high density iso density Fig. 9 Table 2 Laboratory data on admission Fig. 8 Pathological findings (obtained by percutaneous needle biopsy) a 40 b 200 Fig. 9 Computed tomography of the liver a pre-enhancement b early phase of enhancement c delate phase of enhancement d equilibrium phase of enhancement Fig. 10 Contrast-enhanced magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) a pre-enhancement b early phase c late phase d hepatobiliary phase 20 minutes after injection vol.62 no.749

2 Arts and Sciences MRI EOB low intensity high

ow toward the tumor was observed by the FFT fast

6 2 Arts and Sciences MRI EOB low intensity high intensity high intensity Fig. 10 CT MRI S4 hyper echoic Fig. 11 Fig. 12 CEUS hyper echoic Fig. 13 a g Replenishment MFI 04 Fig. 11 Abdominal B-mode ultrasonography right-intercostal view Fig. 12 Doppler ultrasonography examination Pulsative fl ow toward the tumor was observed by the FFT fast Fourier transform, The fi gure lower berth analysis. Fig. 13 Contrast-enhanced ultrasonography examination Vascular phase a g arterial phase h m after replenishment

Fig. 14 Contrast-enhanced ultrasonography examination

15 Pathological findings obtained by percutaneous

Fig. 13 h m 矢印 b AZAN stain iso density から low density

においては iso density から low density を呈する 5 なかった経皮針生検の組織所見

に動脈相において強く造影され門脈相後期相では葉内に入り込む像を認め周囲の風船化編成を示す iso

での肝細胞造影相で肝細胞腺腫はほとんどが low intensity FNH は iso

肝細胞腺腫で矛盾しない所見であっている 2 6 らかな細胞異形は認めず Fig.

15 b 肝細胞腺腫の画像診断は一般的に多血性の肝細胞癌や FNH との鑑別が難しいとされている

7 Fig. 14 Contrast-enhanced ultrasonography examination Post Vascular phase Fig. 15 Pathological findings obtained by percutaneous needle biopsy a Hematoxylin-Eosin stain 微細な血管構築がよく分かった Fig. 13 h m 矢印 b AZAN stain iso density から low density を呈することが多く造影 CT は動脈相で比較的強い造影効果を認めこの造後血管相は周囲肝と iso echoic であった Fig. 影効果は肝細胞癌に比べ遷延し門脈相および平衡相 14 矢印 CEUS 上も腫瘍内に出血や壊死は認めにおいては iso density から low density を呈する 5 なかった経皮針生検の組織所見 HE 染色では肝細胞索の構造は保たれており明肝細胞腺腫の MRI 所見として造影 MRI は基本的に動脈相において強く造影され門脈相後期相では葉内に入り込む像を認め周囲の風船化編成を示す iso intensity から low intensity を呈する MRI Gd-EOB-DTPA での肝細胞造影相で肝細胞腺腫はほとんどが low intensity FNH は iso intensity から high intensity を呈する 5 といわれ肝細胞を認め肝細胞腺腫で矛盾しない所見であっている 2 6 らかな細胞異形は認めず Fig. 15 a AZAN 染色では青色の繊維性結合織が肝細胞索に沿って小た Fig. 15 b 肝細胞腺腫の画像診断は一般的に多血性の肝細胞癌や FNH との鑑別が難しいとされている今回経験した 2 症例は肝細胞腺腫を診断する上で 4 考察重要所見となる腫瘍内出血や壊死が認められず CT 肝細胞腺腫はまれな良性腫瘍であるおよび MRI 検査では肝細胞癌や FNH と鑑別が疑われ肝細胞腺腫の CT 所見として単純 CT は均一でほぼたが当院 CT MRI の所見では wash out がないこ日本診療放射線技師会誌 vol.62 no.749

8 2 Arts and Sciences Gd-EOB-MRI low intensity FNH B-mode pseudocapsule FNH 1 2 CEUS CT MRI vasculality 2 CEUS CT MRI CEUS CT MRI FNH CEUS CT MRI CEUS FNH spoke-wheel pattern 3 2 CEUS CEUS 2 CEUS FNH 5 CEUS FNH 2 Table 1 Table 2 Fig.1 1 MRI a. T1 b. Heavy T2 c. SPIO MRI T1 d. SPIO MRI T2 e. Long TE Fig.2 CT a. b. c. d. Fig.3 MRI Gd-EOB-DTPA a. b. c. d. 20 Fig.4 US B-mode a. b. Fig.5 FFT fast Fourier transform. Fig.6 CEUS Vascular phase a f. g l. Replenishment Fig.7 CEUS Post Vascular phase Fig.8 a. 40 b. 200 Fig.9 CT a. b. c. d. Fig.10 MRI Gd-EOB-DTPA a. b. c. d. 20 Fig.11 US B-mode Fig.12 FFT fast Fourier transform. Fig.13 CEUS Vascular phase a g. h m. Replenishment Fig.14 CEUS Post Vascular phase Fig.15 a. HE b. AZAN 1, Liver Cancer, 10, 1, ,, , ,, , , 2 Ⅱ ,,, ,, ,,

03_学術.indd

03_学術.indd Arts and Sciences CT Approach to the incidental discovery of early-stage breast cancer on a chest CT 33393 Key words: Breast cancer. CT. Mammography Abstract Recently, we have treated two patients in our