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Usefulness of Acoustic Radiation Force Impulse Imaging in the Differential Diagnosis of Benign and Malignant Liver Lesions

Posted Jun 30, 2011 Updated Apr 10, 2023
By Tian Shuang-Ming MD , Zhou Ping PhD , Qian Ying MD , Chen Li-Rong MD , Zhang Ping MD , Li Rui-Zhen MM
8 min read

Rationale and Objectives

Acoustic radiation force impulse imaging (ARFI) is a newly developed technique for the evaluation of tissue stiffness. It has been applied to evaluate liver fibrosis, but only limited data for liver lesions are available. The aim of this study was to evaluate the tissue stiffness of liver lesions by using ARFI to differentiate benign from malignant liver lesions.

Materials and Methods

ARFI was performed in 116 consecutive patients who had 128 liver lesions (60 benign, 68 malignant). The elastographic images of virtual touch tissue imaging (VTI) and the values of virtual touch tissue quantification (VTQ) were obtained and analyzed. The area under the curve and cutoff value for VTQ value, both of which were obtained by using a receiver operating characteristic curve analysis, were used to assess diagnostic performance.

Results

On the elastographic images of VTI, 57 (83.8%) malignant liver lesions and 33 (55.0%) benign liver lesions appeared stiffer compared with the surrounding liver parenchyma. There were statistical differences between malignant and benign liver lesions ( P < .05). The VTQ median value of malignant and benign liver lesions were 3.14 m/sec (average value 3.16 ± 0.80 m/sec, range 1.17‒4.45 m/sec) and 1.35 m/sec (average value 1.47 ± 0.53 m/sec, range 0.74‒3.26 m/sec), respectively ( P < .001). With a cutoff value of 2.22 m/sec for VTQ value, the sensitivity, specificity, and accuracy for malignancy were 89.7%, 95.0%, and 92.2%, respectively.

Conclusions

ARFI can provide the elastographic images and elastographic values of liver lesions by VTI and VTQ, which is helpful in the differentiation between benign and malignant liver lesions and might become the imaging modality of the future.

Since Ophir et al first used the term “elastography” to describe the method of quantitative imaging of the distribution of biological tissue strains and elastic modulus in 1991, it has obtained wide attention and been developed for potential clinical imaging modalities. Unlike conventional B-mode ultrasonography, which shows the diversity of anatomical structure organization according to the acoustic impedance difference of tissue, elastography can get the relative information such as tissue deformation and elastic modulus through the displacements of a small strain on tissue. It is now widely used in ultrasound (US) diagnosis of diseases of superficial parts such as breast , prostate , thyroid , and neck vessels . Clinical practice confirms that elastography is helpful in identification of benign and malignant solid tumors of superficial organs, evaluation of physical properties of intravascular plaque and diagnosis of tendon disease .

Because of rib obstruct and high-frequency probe cause, elastography in the diagnosis of liver disease is limited. Many studies in the liver diseases field are focusing on some liver tumors located in the wall or nearby gastrointestinal tract, which can be visualized and characterized by endoscopic US elastography and intraoperative US elastography . Acoustic radiation force impulse imaging (ARFI) is a new US elastographic imaging methods. Unlike the traditional compression elastography, a short-duration (0.03–0.4 ms), high-intensity acoustic “pushing pulse” (frequency 2.67 MHz) in ARFI imaging is transmitted to generate a internal tissue excitation (1–20 μm) in the region of interest (ROI) by the transducer, and followed by a series of diagnostic intensity pulses (frequency 3.08 MHz, pulse repetition frequency 3–12 KHz), which are used to track the displacement of the tissue caused by the pushing pulse. It is possible to display the quantitative shear wave velocity of ARFI displacement. Because the velocity of the shear wave depends on the tissue stiffness, it is possible to apply ARFI technology to evaluate the deep tissue stiffness.

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Materials and methods

Subjects

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Table 1

Final Pathologic and Clinical Imaging Results of Liver Lesions

Pathology Number of lesions Malignant liver lesions 68 (53.1%) Hepatocellular carcinoma 31 (24.2%) Liver metastasis 30 (23.4%) Cholangiocarcinoma 7 (5.5%) Benign liver lesions 60 (46.9%) Hemangioma 28 (21.9%) Focal nodular hyperplasia 7 (5.5%) Regenerative nodule 7 (5.5%) Focal fatty sparing 9 (7.0%) Focal fatty change 3 (2.3%) Liver Abscess 4 (3.1%) Liver Adenoma 1 (0.8%) Solitary necrotic nodule 1 (0.8%)

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ARFI Technique

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VTI

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VTQ

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Statistical Analysis

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Results

VTI Technique

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Figure 1, Bar graph demonstrates distribution of stiffness for liver lesions compared with surrounding liver tissue with virtual touch tissue imaging (VTI). Numbers on bars indicate the number of lesions. (a) The distribution of stiffness for malignant liver lesions compared with surrounding liver tissue. (b) The distribution of stiffness for benign liver lesions compared with surrounding liver tissue.

Figure 2, Sonograms for a 56-year-old man with a hepatocellular carcinoma (HCC). (a) On conventional B-mode image, the lesion appears as hypoechoic mass ( left image ). On virtual touch tissue imaging (VTI) elastographic image, the lesion appears as stiffer mass than the surrounding liver tissue ( right image ). (b) Virtual Touch Tissue Quantification (VTQ) value measured when region of interest was placed within the lesion was 3.58 m/sec.

Figure 3, Sonograms for a 43-year-old man with a liver hemangioma. (a) On conventional B-mode image, the lesion appears as hyperechoic mass ( left image ). On virtual touch tissue imaging (VTI) elastographic image, the lesion appears as stiffer mass than the surrounding liver tissue ( right image ). (b) Virtual Touch Tissue Quantification (VTQ) value measured when region of interest was placed within the lesion was 1.81 m/sec.

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VTQ Technique

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Figure 4, Box plots of the Virtual Touch Tissue Quantification (VTQ) value for benign and malignant liver lesions. The top of and the bottom of the boxes are the first and third quartiles, respectively. The length of the box represents therefore the inter quartile range including 50% of the values. The line through the middle of each box represents the median.

Figure 5, Receiver operating characteristic curves for Virtual Touch Tissue Quantification (VTQ) value. Area under the receiver operating curve for VTQ value as predictor of the malignant liver lesions (AUROC = 0.95).

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Discussion

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Academic Radiology, Volume 18, Issue 7
Journals General Radiology
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