Purpose: The purpose of this study was to evaluate the usefulness of the combination guidance of contrast-enhanced US (CEUS) and fusion imaging in radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) with poor conspicuity on B-mode US and CEUS/fusion imaging. Materials and Methods: We conducted a retrospective cohort study, which included 356 patients with 556 HCCs that were inconspicuous on B-mode US. A total of 192 patients with 344 HCCs, 123 patients with 155 HCCs, and 37 patients with 57 HCCs underwent RFA under CEUS guidance, fusion imaging guidance, and the combination of CEUS and fusion imaging guidance. Results: The average number of treatment sessions was 1.1 (range: 1-2) in the CEUS guidance group, 1.1 (range: 1-2) in the fusion imaging guidance group, and 1.1 (range: 1-3) in the combination of CEUS and fusion imaging guidance group. Treatment analysis did not reveal significantly more RFA treatment sessions in the combination guidance group than in the other groups (p = 0.97, Student's t test). During the follow-up period (1.1-85.3 months, mean ± SD, 43.2 ± 59.5), the 3-year local tumor progression rates were 4.9, 7.2, and 5.9% in the CEUS guidance group, the fusion imaging guidance group, and the combination guidance group, respectively (p = 0.84, log-rank test). Conclusion: In spite of selection bias, session frequency and local tumor progression were not different under the combination guidance with CEUS and fusion imaging in RFA. The combination of fusion imaging and CEUS guidance in RFA therapy is an effective treatment for HCC with poor conspicuity on B-mode US and CEUS/fusion imaging.

1.
Lin SM, Lin CJ, Lin CC, et al: Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma < or=4 cm. Gastroenterology 2004;127:1714-1723.
2.
Shiina S, Teratani T, Obi S, et al: A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma. Gastroenterology 2005;129:122-130.
3.
Lu DS, Yu NC, Raman SS, et al: Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver. Radiology 2005;234:954-960.
4.
Kudo M: Local ablation therapy for hepatocellular carcinoma: current status and future perspectives. J Gastroenterol 2004;39:205-214.
5.
Livraghi T, Meloni F, Morabito A, Vettori C: Multimodal image-guided tailored therapy of early and intermediate hepatocellular carcinoma: long-term survival in the experience of a single radiologic referral center. Liver Transpl 2004;10(2 suppl 1):S98-S106.
6.
Omata M, Tateishi R, Yoshida H, Shiina S: Treatment of hepatocellular carcinoma by percutaneous tumor ablation methods: ethanol injection therapy and radiofrequency ablation. Gastroenterology 2004;127(5 suppl 1): S159-S166.
7.
Choi D, Lim HK, Rhim H, et al: Percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma as a first-line treatment: long-term results and prognostic factors in a large single-institution series. Eur Radiol 2007;17:684-692.
8.
Minami Y, Kudo M, Kawasaki T, et al: Treatment of hepatocellular carcinoma with percutaneous radiofrequency ablation: usefulness of contrast harmonic sonography for lesions poorly defined with B-mode sonography. AJR Am J Roentgenol 2004;183:153-156.
9.
Minami Y, Kudo M, Chung H, et al: Contrast harmonic sonography-guided radiofrequency ablation therapy versus B-mode sonography in hepatocellular carcinoma: prospective randomized controlled trial. AJR Am J Roentgenol 2007;188:489-494.
10.
Joo I, Choi BI: New paradigm for management of hepatocellular carcinoma by imaging. Liver Cancer 2012;1:94-109.
11.
Salvatore V, Bolondi L: Clinical impact of ultrasound-related techniques on the diagnosis of focal liver lesions. Liver Cancer 2012;1:238-246.
12.
Wilson SR, Burns PN, Muradali D, et al: Harmonic hepatic US with microbubble contrast agent: initial experience showing improved characterization of hemangioma, hepatocellular carcinoma, and metastasis. Radiology 2000;215:153-161.
13.
Wen YL, Kudo M, Zheng RQ, et al: Characterization of hepatic tumors: value of contrast-enhanced coded phase-inversion harmonic angio. AJR Am J Roentgenol 2004;182:1019-1026.
14.
Quaia E, Calliada F, Bertolotto M, et al: Characterization of focal liver lesions with contrast-specific US modes and a sulfur hexafluoride-filled microbubble contrast agent: diagnostic performance and confidence. Radiology 2004;232:420-430.
15.
Inoue T, Kudo M, Maenishi O, et al: Value of liver parenchymal phase contrast-enhanced sonography to diagnose premalignant and borderline lesions and overt hepatocellular carcinoma. AJR Am J Roentgenol 2009;192:698-705.
16.
Kudo M: Early hepatocellular carcinoma: definition and diagnosis. Liver Cancer 2013;2:69-72.
17.
Hatanaka K, Kudo M, Minami Y, et al: Differential diagnosis of hepatic tumors: value of contrast-enhanced harmonic sonography using the newly developed contrast agent, Sonazoid. Intervirology 2008;51:S61-S69.
18.
Hatanaka K, Chung H, Kudo M, et al: Usefulness of the post-vascular phase of contrast-enhanced ultrasonography with sonazoid in the evaluation of gross types of hepatocellular carcinoma. Oncology 2010;78(suppl 1):53-59.
19.
Goto E, Masuzaki R, Tateishi R, et al: Value of post-vascular phase (Kupffer imaging) by contrast-enhanced ultrasonography using Sonazoid in the detection of hepatocellular carcinoma. J Gastroenterol 2012;47:477-485.
20.
Alaboudy A, Inoue T, Hatanaka K, et al: Usefulness of combination of imaging modalities in the diagnosis of hepatocellular carcinoma using Sonazoid®-enhanced ultrasound, gadolinium diethylene-triamine-pentaacetic acid-enhanced magnetic resonance imaging, and contrast-enhanced computed tomography. Oncology 2011;81(suppl 1):66-72.
21.
Kudo M, Hatanaka K, Kumada T, et al: Double-contrast ultrasound: a novel surveillance tool for hepatocellular carcinoma. Am J Gastroenterol 2011;106:368-370.
22.
Numata K, Morimoto M, Ogura T, et al: Ablation therapy guided by contrast-enhanced sonography with Sonazoid for hepatocellular carcinoma lesions not detected by conventional sonography. J Ultrasound Med 2008;27:395-406.
23.
Maruyama H, Takahashi M, Ishibashi H, et al: Ultrasound-guided treatments under low acoustic power contrast harmonic imaging for hepatocellular carcinomas undetected by B-mode ultrasonography. Liver Int 2009;29:708-714.
24.
Minami Y, Kudo M, Hatanaka K, et al: Radiofrequency ablation guided by contrast harmonic sonography using perfluorocarbon microbubbles (Sonazoid) for hepatic malignancies: an initial experience. Liver Int 2010;30:759-764.
25.
Masuzaki R, Shiina S, Tateishi R, et al: Utility of contrast-enhanced ultrasonography with Sonazoid in radiofrequency ablation for hepatocellular carcinoma. J Gastroenterol Hepatol 2011;26:759-764.
26.
Hiraoka A, Hiasa Y, Onji M, Michitaka K: New contrast enhanced ultrasonography agent: impact of Sonazoid on radiofrequency ablation. J Gastroenterol Hepatol 2011;26:616-618.
27.
Minami Y, Kudo M: Review of dynamic contrast-enhanced ultrasound guidance in ablation therapy for hepatocellular carcinoma. World J Gastroenterol 2011;17:4952-4959.
28.
Kokudo N: Recent progress in the treatment and diagnosis of hepatocellular carcinoma. Liver Cancer 2013;2:4.
29.
Hirooka M, Iuchi H, Kurose K, et al: Abdominal virtual ultrasonographic images reconstructed by multi-detector row helical computed tomography. Eur J Radiol 2005;53:312-317.
30.
Hirooka M, Iuchi H, Kumagi T, et al: Virtual sonographic radiofrequency ablation of hepatocellular carcinoma visualized on CT but not on conventional sonography. AJR Am J Roentgenol 2006;186(5 suppl):S255-S260.
31.
Minami Y, Chung H, Kudo M, et al: Radiofrequency ablation of hepatocellular carcinoma: value of virtual CT sonography with magnetic navigation. AJR Am J Roentgenol 2008;190:W335-W341.
32.
Minami Y, Kitai S, Kudo M: Treatment response assessment of radiofrequency ablation for hepatocellular carcinoma: usefulness of virtual CT sonography with magnetic navigation. Eur J Radiol 2012;81:e277-e280.
33.
Numata K, Fukuda H, Morimoto M, et al: Use of fusion imaging combining contrast-enhanced ultrasonography with a perflubutane-based contrast agent and contrast-enhanced computed tomography for the evaluation of percutaneous radiofrequency ablation of hypervascular hepatocellular carcinoma. Eur J Radiol 2012;81:2746-2753.
34.
Lee MW, Rhim H, Cha DI, et al: Percutaneous radiofrequency ablation of hepatocellular carcinoma: fusion imaging guidance for management of lesions with poor conspicuity at conventional sonography. AJR Am J Roentgenol 2012;198:1438-1444.
35.
Song KD, Lee MW, Rhim H, et al: Fusion imaging-guided radiofrequency ablation for hepatocellular carcinomas not visible on conventional ultrasound. AJR Am J Roentgenol 2013;201:1141-1147.
36.
Lin SM: Local ablation for hepatocellular carcinoma in Taiwan. Liver Cancer 2013;2:73-83.
37.
Min JH, Lim HK, Lim S, et al: Radiofrequency ablation of very-early-stage hepatocellular carcinoma inconspicuous on fusion imaging with B-mode US: value of fusion imaging with contrast-enhanced US. Clin Mol Hepatol 2014;20:61-70.
38.
Minami Y, Nishida N, Kudo M: Therapeutic response assessment of RFA for HCC: contrast-enhanced US, CT and MRI. World J Gastroenterol 2014;20:4160-4166.
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