Objective:To investigate the correlation of hepatocellular carcinoma (HCC) classified by contrast-enhanced ultrasound (CEUS) Liver Imaging Data and Report System (LI-RADS) with differentiation degree and Ki-67 index.Methods:A multicenter, retrospective study was conducted.The clinical and CEUS imaging data of 208 patients with 208 HCC lesions from December 2017 to December 2020 in China CEUS database were included and analyzed. According to the CEUS LI-RADS version 2017 proposed by the American College of Radiology, the HCC was classified. The diagnosis and pathological information of all lesions were confirmed by pathology. The differentiation degree of HCC and the distribution of Ki-67 index in different LI-RADS categories were evaluated, and their correlation was analyzed.Results:The degree of differentiation and Ki-67 index among HCC of different CEUS LI-RADS were statistically significant ( P<0.001, P=0.009). LI-RADS M HCC was more likely to be poorly differentiated and showed a higher Ki-67 index. The category of LI-RADS was positively correlated with the degree of tumor differentiation (tau-b=-0.250, P<0.001) and the Ki-67 index (tau-b=0.178, P=0.002), that is, the higher the category of LI-RADS, the lower differentiation degree and the higher the Ki-67. Conclusions:The CEUS LI-RADS classification of HCC is correlating with the degree of differentiation and Ki-67 index.

Objective:To evaluate the feasibility and applicability of using phospholipid-hybridization method for preparing biomimetic microbubbles (Bio-MBs) ultrasound contrast agents.Methods:Leukocyte biomimetic microbubbles (MB leu), platelet biomimetic microbubbles (MB pla) and erythrocyte biomimetic microbubbles (MB ery) were prepared by multiple steps: film-hydration, phospholipid-hybridization, mechanical oscillation. The size and zeta potential of Bio-MBs were measured by dynamic light scattering. A laser scanning confocal microscopy experiment was performed to confirm the presence of membrane proteins on the shell of Bio-MBs. The fluorescence of FITC-labeled typical membrane protein was evaluated using a flow cytometer. Sodium dodecyl sulfate polyacrylamide gel electrophoresis was used to characterize the membrane protein. Biosafety of Bio-MBs was evaluated by CCK-8 counting kit, blood and major organs. The contrast enhancement effect and stability were observed in vitro and in vivo. An in vivo fluorescence imaging system was performed to evaluate the distribution of Bio-MBs. The application value of biomimetic microbubbles was measured by ultrasound molecular imaging by using ischemia-reperfusion rat models and acute hepatitis rat models. Results:Bio-MBs with spherical shape distributed homogenously, without obvious aggregation. The membrane proteins were successfully integrated into the shell of Bio-MBs.The diameter of three Bio-MBs was similar to that of control microbubbles (MB con) ( P>0.05), three Bio-MBs had a lower zeta potential than MB con ( P<0.05). The Bio-MBs had an appreciable performance in vitro and in vivo biosafety. The Bio-MBs retained the main proteins inherited from cell membrane. Contrast enhanced ultrasound imaging in vitro and in vivo showed that the Bio-MBs had a stable imaging ability.MB leu and MB pla have good targeted imaging effect in two disease models. Conclusions:A series of Bio-MBs ultrasound contrast agents, which have high stability, biosafety and targeted imaging efficiency, were successfully prepared by using phospholipid-hybridization method. This fabrication method for obtaining Bio-MBs can be applied to different clinical scenarios with different cell types in the future.

Objective To investigate the effectiveness and safety of thermal ablation of patients with 3－5 cm hepatocellular carcinoma ( HCC ) under the assistance of ultrasound fusion imaging . Methods From December 2010 to December 2017 ,76 HCC patients with 78 medium‐size ( 3 －5 cm ) lesions who underwent radiofrequency ablation ( RFA ) or microwave ablation ( M WA ) were included in the study . Ultrasound fusion imaging was used to assist the ablation procedures and assess the technical success immediately ,then guided supplementary ablation . Contrast‐enhanced CT/M R was performed one month after ablation to assess the technique efficacy rate . T he complication ,local tumor progression ( L T P ) rate were followed up . Results According to the ultrasound fusion imaging evaluation ,24 lesions ( 30 .8% , 24/78) received supplementary ablation immediately during the ablation procedure . Seventy‐one of 78 liver tumors were evaluated to achieve 5 mm ablative margin while the other 7 liver tumors were not achieved . T here were no ablation‐related deaths ,and the major complication rate was 6 .6% ( 5/76 ) .T he technique efficacy rate was 100% ( 78/78) according to the contrast‐enhanced CT/M R one‐month later . Patients were followed up from 6 to 79 months with a median time of 22 months . L T P occurred in 4 lesions and the LT P rate was 5 .1% ( 4/78) . Conclusions With the assistance of ultrasound fusion imaging ,thermal ablation of medium‐sized HCC is effective and safe w hich could achieve a higher technique efficacy rate and a lower L T P rate .

Objective To assess the applicability of sound touch elastography ( ST E) and sound touch quantify ( ST Q ) in measuring liver and spleen stiffness . Methods One hundred and eighteen healthy volunteers were included and underwent ST E and ST Q . T he success rate ,variability and reproducibility of ST E and ST Q were analyzed . T he accurate sampling size and number of tests for liver ST Q were also analyzed . Results T he success rates ,variability ,reproducibility of ST E and ST Q in liver were 97 .5% and 99 .2% ,8 .7% and 12 .0% ,0 .917 and 0 .916 , respectively . While those with spleen were 76 .3% and 66 .9% ,12 .4% and 16 .4% ,0 .847 and 0 .706 ,respectively . The sampling size of 1 .5 cm×1 .0 cm yield the lowest variability ( 8 .5% ) ( F ＝6 .562 , P ＝0 .002) ,and there was no significant difference between results of detecting 5 times and 10 times( P ＝0 .571) . T he liver and spleen stiffness of ST E were 5 .75 kPa ( 95%CI :5 .60－5 .91 kPa) and 15 .58 kPa ( 95% CI :14 .99 －16 .16 kPa) . Conclusions The measurement of liver stiffness using both ST E and ST Q have a high success rate and low variability . However ,ST E is better than STQ in measuring spleen stiffness .

To evaluate the impact of intrahepatic cholestasis on liver stiffness measurement ( LSM ) of two‐dimensional shear wave elastography ( 2D‐SWE ) in patients with chronic hepatitis B . Methods Between June 2011 and December 2016 , total of 1 188 patients with chronic hepatitis B infection were enrolled to collect clinical ,2D‐SWE ,biochemical variables and histological ( M ET AVIR scoring system ) datas . LSM was compared between normal total bilirubin group ( TB ＜ 23 .9 μmol/L ) versus abnormal TB group( ≥23 .9 μmol/L ) . Correlation of TB with LSM s was assessed . Results Nine hundred and seventy‐three patients with effective LSM in the study were analyzed . Within the same fibrosis stage ( F1‐F4) ,LSM showed significantly higher value in abnormal TB group than those of normal TB group ( r＝0 .328 ,0 .247 ,0 .495 ,0 .435 ,all P ＜ 0 .001 ) . Increased LSM for abnormal TB group was generally found within different subset of patients [ fibrosis stage ≤ F2 ,AL T ≥ 2 × upper limit of normal ( ULN ) ;fibrosis stage≤ F2 ,M ET AVIR activity grade ≤ A1 or ≥ A2 ] ,with r ＝ 0 .266 ,0 .210 ,0 .243 ( all P ＜0 .001) ,respectively .Increased LSM for abnormal TB group was also found within different subset of patients [ fibrosis stage≥F3 ,AL T＜2× ULN ,≥2×ULN ; fibrosis stage≥F3 ,M ET AVIR activity grade≥A2 ,with r ＝ 0 .671 ,0 .200 ,0 .468 ( all P ＜ 0 .05 ) ] . Conclusions Hepatogenous jaundice induced to intrahepatic cholestasis shows slight positive correlation with LSM s in patients with chronic hepatitis B .

Objective To explore the feasibility and convenience of automatic registration ultrasound-CT/MR fusion imaging based on hepatic vessel trees. Methods The PercuNav fusion imaging system of Philips Epiq 7 was used to perform ultrasound-CT/MR fusion imaging on 22 patients with focal liver lesions detected by contrast-enhanced CT or MR.Both automatic registration ultrasound-CT/MR fusion imaging based on hepatic vessel trees and the conventional ultrasound-CT/MR fusion imaging based on internal anatomic landmarks were employed for alignment in these patients.The results including the success rate of registration,duration time of initial registration,error of initial registration,number of times of fine-tuning, duration time of fine-tuning and the overall duration time of registration were compared between these two methods.Results The success rates of registration,duration time of initial registration,errors of initial registration,numbers of times of fine-tuning,duration time of fine-tuning and the overall duration time of registration for automatic registration ultrasound-CT/MR fusion imaging based on hepatic vessel trees and the conventional ultrasound-CT/MR fusion imaging based on internal anatomic landmarks were 72.73% and 95.45%,16.5 s (10~30 s) and 13 s (8~24 s),3 mm (1~14 mm) and 14 mm (2~43 mm),0 time (0 to 2 times) and 1 time (0~3 times),0 s(0~46 s) and 30 s (0~88 s),and 20 s (12~61 s) and 42 s (9~102 s),successively and respectively. There was no statistically significant difference in the success rates between these two methods ( P >0.05).The duration time of initial registration of conventional method was less than that of automatic registration method( P <0.05).The error of initial registration,number of times of fine-tuning,duration time of fine-tuning and the overall duration time of registration of automatic registration method were superior to those of conventional method ( P < 0.05).Conclusions Automatic registration ultrasound-CT/MR fusion imaging based on hepatic vessel trees is feasible. It is also more convenient than conventional ultrasound-CT/MR fusion imaging based on internal anatomic landmarks.

Objective To discuss the value of contrast-enhanced ultrasound (CEUS) in evaluating gallbladder injury during the thermal ablation of liver tumors adjacent to the gallbladder. Methods From January 2016 to March 2017, 40 patients with 42 hepatic tumors adjacent to the gallbladder who underwent ultrasonography-guided percutaneous microwave ablation or radiofrequency ablation in the Third Affiliated Hospital of Sun Yat-sen University were included in the study. Ultrasonography (US) was used to assess the change of gallbladder wall thickness before and after procedure. CEUS was used to assess the perfusion of gallbladder wall and determine the gallbladder injury immediately after ablation. Patients with bad perfusion of gallbladder wall accept combined treatment with cholecystectomy. The safety and therapeutic efficacy of the procedures were assessed in follow-up examinations. The change of gallbladder wallthickness were compared by signed ranks sum test. Results Assessed by US immediately after the ablations, gallbladder wall thickening adjacent to the ablated zone was noted in 8 of 40 patients. According the results of CEUS immediately after ablations, 38 patients was evaluated with good perfusion of gallbladder wall and 2 patients was evaluated with bad perfusion, who were treated with cholecystectomy. Perforation of the gallbladder was found in one of them. However, the necrosis of serosal tissue in gallbladder wall was confirmed by postoperative pathology. Another 4 patients with multiple gallbladder stones were also treated with cholecystectomy. Gallbladder wall thickening developed in six patients (17.6%) within 3 days after the ablation. Wall thickening showed complete disappearance on subsequent follow up US in 4 patients, and showed existence in 2 patients. However, complications related to the ablation such as acute cholecystitis and gallbladder perforation were not noted in 34 patients without cholecystectomy. There was significant difference in gallbladder wall thickness between preoperative and intraoperative assessment [5.00 mm (4.00-6.25 mm) vs 3.50 mm (3.00-5.00 mm), Z=-3.741, P < 0.001], as well as between preoperative and postoperative assessment[5.0 mm(3.0-8.0 mm)vs 3.5 mm(3.0-5.0 mm),Z=-3.735,P < 0.001].The complete ablation rate was 97.6% (41/42) based on one-month follow-up CT or MR imaging. Local tumor progression was not found in these completely ablated tumors during the follow-up period. Conclusion Immediate post-procedural CEUS can be used to demonstrate the perfusion of gallbladder wall in US-guided ablation of hepatic tumors adjacent to the gallbladder, which is helpful to determine thermal injury of the gallbladder.

Objective To explore the value of contrast-enhanced ultrasonography (CEUS) in the screening of malignant transformation from cirrhotic nodules.Methods Clinical data of 25 patients who were followed up by ultrasonography in the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to December 2016 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. All patients were males, aged 33-82 years old, with the median age of 55 years old, and with a total of 29 cirrhotic nodules. All patients were followed up regularly by ultrasonography which included conventional ultrasound and CEUS. The diameter, internal blood flow signal and CEUS features of the nodules were recorded. The diameter was compared by t test, and the CEUS features by Fisher's exact probability test. ROC curve was used for diagnostic test.Results During the follow-up, 14 cirrhotic nodules turned into hepatocellular carcinoma (HCC). The diameter of malignant nodule (19± 8) mm was significantly higher than (16±7) mm before malignant change (t=2.682, P<0.05). As the nodules transformed to malignancy, in the arterial phase of CEUS, signals changed gradually from equal enhancement (12/14) to hyper enhancement (13/14), and in the portal venous phase or delayed phase, it changed from equal enhancement (13/14) to low enhancement (13/14), where significant difference was observed (P<0.05). The area under the curve of AFP, conventional ultrasound and CEUS in diagnosing malignancy of cirrhotic nodules was 0.607, 0.679 and 1, respectively, where significant differences were observed (Z=4.837, 6.904, P<0.05).Conclusion In the continuous follow-up of cirrhotic nodules, CEUS can detect the hemodynamic changes in malignant nodules early, which has better diagnostic value than conventional ultrasound.

Objective To evaluate the clinical application value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) in the evaluation of degree of biliary obstruction.Methods Clinical data of 105 patients with biliary obstructive disease who were diagnosed and treated in the Third Affiliated Hospital of Sun Yat-sen University from January 2008 to December 2012 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. There were74 males and 31 females with the age ranging from 30 to 88 years old and the median age of 55 years old. Conventional ultrasound (CUS) and IB-CEUS were used to detect the biliary obstructive lesions in 105 patients. X-ray or CT cholangiography was used as the gold standard for diagnosis. The diagnostic efficacy of two methods was compared. The differences between these two methods and the gold standard in diagnosing the degree of biliary obstruction were evaluated by McNemar test. The consistency of the Results was assessed by Kappa consistency.Results The diagnostic sensitivity and negative predictive value of two methods were 100％ in diagnosing the complete obstruction of primary and second grade intrahepatic bile ducts. The specificity, positive predictive value and accuracy of IB-CEUS in diagnosing the complete obstruction of primary grade intrahepatic bile ducts was respectively 95.8％, 91.9％ and 97.1％, higher than 57.7％, 53.1％ and 71.4％ of CUS. The specificity, positive predictive value and accuracy of IB-CEUS in diagnosing the complete obstruction of second grade intrahepatic bile ducts was respectively 97.3％, 83.3％ and 97.6％, higher than 58.6％, 24.6％ and 63.5％ of CUS. Significant difference was observed in the diagnosis between CUS and gold standard (χ2=28.033, 46.000; P<0.05). CUS was fair or poor for the consistency of Results in diagnosing the complete biliary obstruction of primary and second grade intrahepatic bile ducts (k=0.470, 0.252), while no significant difference was observed between IB-CEUS and gold standard (P=0.250) and the consistency of Results was good (k=0.936, 0.896).Conclusions IB-CEUS can accurately evaluate the degree of intrahepatic biliary obstruction. The efficacy of IB-CEUS is better than that of CUS, and it has a good diagnostic consistency with the gold standard.

Objective To investigate the safety and efficacy of ultrasound-guided thermal ablation in the treatment of rare liver tumors.Methods Clinical data of 9 patients with rare liver tumors who underwent ultrasound-guided thermal ablation from January 2012 to December 2016 in the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among 9 cases (14 lesions),2 patients were male and 7 female,aged (42±12) years on average.All the patients underwent ultrasound or contrast-enhanced ultrasound-guided puncture and thermal ablation of the tumors.The ablation effect was evaluated immediately by contrast-enhanced ultrasound during the operation.The incidence of postoperative complications was observed.The complete ablation rate was evaluated by CT or MRI at postoperative 1 month.Results 11 lesions were treated with common ultrasound-guided thermal ablation and 3 lesions with contrast-enhanced ultrasound-guided ablation.The intraoperative complete ablation rate was 100％ (14/14),and the rate at postoperative 1 month was also 100％ (14/14).No ablation related complications was observed.During the follow-up,no local tumor progression or intrahepatic and extrahepatic tumors recurrence was observed in all patients.Conclusions For rare liver tumors,ultrasound-guided thermal ablation can achieve the effect of complete ablation,providing a new therapeutic option for the patients.