Q J Med 2015; 108:669–670 doi:10.1093/qjmed/hcv016 Advance Access Publication 22 January 2015
Clinical picture Spoke-wheel sign of focal nodular hyperplasia revealed by superb micro-vascular ultrasound imaging central feeding vessel and multiple small vessels radiating to the peripheral of the tumor (Figure 1b). The patient was advised for yearly ultrasound follow-up. Focal nodular hyperplasia is the second common benign tumor of the liver. It is usually asymptomatic and found among young to middle-aged woman. It consists of aggregates of hyperplastic hepatocytes in response to alternation of local hepatic blood flow. The diagnosis is usually made with typical imaging findings and a liver biopsy is reserved for patients with atypical findings. A finding of ‘spoke-wheel’ sign and central scar on cross-sectional imaging is diagnostic.1–3 Although ultrasound is usually the first radiological approach for focal liver lesions, its role for differential diagnosis of various liver tumors is limited. Only contrast-enhanced ultrasound has shown some utility for this purpose but its wide spread use is limited. With the improvement of
Figure 1. (a) Abdominal computed tomography revealed a well-defined tumor with a central scar in the right liver (arrow). (b) Abdominal ultrasound with the SMI mode disclosed typical ‘‘spoke-wheel’’ sign of the tumor (arrow).
! The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 16, 2015
A 40-year-old man came to the hospital for followup of right hepatic tumor known for 3 years. His medical history is unremarkable. He received physical check-up 3 years ago and a 3.8 cm isoechoic hepatic tumor was found during the ultrasound examination. The previous abdominal computed tomography revealed a well-defined tumor with central scarring tumor in the right liver (Figure 1a). The tumor showed hyperdensity during heptic arterial phase and isodensity during delayed phase. A diagnosis of focal nodular hyperplasia was made. During this ultrasound examination, the tumor was well-defined with slightly hyperechoic pattern and no interval change in size. On color Doppler, a signal from central feeding was detected. When switching to the superb micro-vascular imaging (SMI) mode of the recently developed ultrasound system (Toshiba’s Aplio 500 ultrasound system), a ‘spoke-wheel sign’ can be clearly visualized with a
670
Clinical picture
ultrasound technology, the SMI mode4 allows the clinicians to visualize the vascular patterns of lesions in detail without additional use contrast agent. The technique is promising as shown in this case the typical finding of spoke-wheel sign from hepatic focal nodular hyperplasia in a quick and non-invasive way. Photographs and text from: L. Wu, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan; H.-H. Yen, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan and School of Medicine, ChunShan Medical University, Taichung, Taiwan; M-.S. Soon, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan. email: [email protected]
References 1. Marrero JA, Ahn J, Rajender Reddy K. Americal College of Gastroenterology. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol 2014; 109:1328–47. 2. Bertin C, Egels S, Wagner M, Huynh-Charlier I, Vilgrain V, Lucidarme O. Contrast-enhanced ultrasound of focal nodular hyperplasia: a matter of size. Eur Radiol 2014; 24:2561–71. 3. Wills M, Harvey CJ, Kuzmich S, Afaq A, Lim A, Cosgrove D. Characterizing benign liver lesions and trauma with contrastenhanced ultrasound. Br J Hosp Med 2014; 75:91–5. 4. Toshiba Medical System. Superb Micro-Vascular Imaging (SMI). http://medical.toshiba.com/products/ul/general/aplio500/clinical-applications (5 January 2015, date last accessed).
Conflict of interest: None declared.
Downloaded from by guest on November 16, 2015
Clinical picture Spoke-wheel sign of focal nodular hyperplasia revealed by superb micro-vascular ultrasound imaging central feeding vessel and multiple small vessels radiating to the peripheral of the tumor (Figure 1b). The patient was advised for yearly ultrasound follow-up. Focal nodular hyperplasia is the second common benign tumor of the liver. It is usually asymptomatic and found among young to middle-aged woman. It consists of aggregates of hyperplastic hepatocytes in response to alternation of local hepatic blood flow. The diagnosis is usually made with typical imaging findings and a liver biopsy is reserved for patients with atypical findings. A finding of ‘spoke-wheel’ sign and central scar on cross-sectional imaging is diagnostic.1–3 Although ultrasound is usually the first radiological approach for focal liver lesions, its role for differential diagnosis of various liver tumors is limited. Only contrast-enhanced ultrasound has shown some utility for this purpose but its wide spread use is limited. With the improvement of
Figure 1. (a) Abdominal computed tomography revealed a well-defined tumor with a central scar in the right liver (arrow). (b) Abdominal ultrasound with the SMI mode disclosed typical ‘‘spoke-wheel’’ sign of the tumor (arrow).
! The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 16, 2015
A 40-year-old man came to the hospital for followup of right hepatic tumor known for 3 years. His medical history is unremarkable. He received physical check-up 3 years ago and a 3.8 cm isoechoic hepatic tumor was found during the ultrasound examination. The previous abdominal computed tomography revealed a well-defined tumor with central scarring tumor in the right liver (Figure 1a). The tumor showed hyperdensity during heptic arterial phase and isodensity during delayed phase. A diagnosis of focal nodular hyperplasia was made. During this ultrasound examination, the tumor was well-defined with slightly hyperechoic pattern and no interval change in size. On color Doppler, a signal from central feeding was detected. When switching to the superb micro-vascular imaging (SMI) mode of the recently developed ultrasound system (Toshiba’s Aplio 500 ultrasound system), a ‘spoke-wheel sign’ can be clearly visualized with a
670
Clinical picture
ultrasound technology, the SMI mode4 allows the clinicians to visualize the vascular patterns of lesions in detail without additional use contrast agent. The technique is promising as shown in this case the typical finding of spoke-wheel sign from hepatic focal nodular hyperplasia in a quick and non-invasive way. Photographs and text from: L. Wu, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan; H.-H. Yen, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan and School of Medicine, ChunShan Medical University, Taichung, Taiwan; M-.S. Soon, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan. email: [email protected]
References 1. Marrero JA, Ahn J, Rajender Reddy K. Americal College of Gastroenterology. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol 2014; 109:1328–47. 2. Bertin C, Egels S, Wagner M, Huynh-Charlier I, Vilgrain V, Lucidarme O. Contrast-enhanced ultrasound of focal nodular hyperplasia: a matter of size. Eur Radiol 2014; 24:2561–71. 3. Wills M, Harvey CJ, Kuzmich S, Afaq A, Lim A, Cosgrove D. Characterizing benign liver lesions and trauma with contrastenhanced ultrasound. Br J Hosp Med 2014; 75:91–5. 4. Toshiba Medical System. Superb Micro-Vascular Imaging (SMI). http://medical.toshiba.com/products/ul/general/aplio500/clinical-applications (5 January 2015, date last accessed).
Conflict of interest: None declared.
Downloaded from by guest on November 16, 2015
