AJR:186, March 2006 763 AJR 2006; 186:763–773 0361–803X/06/1863–763 © American Roentgen Ray Society M E D I C A L I M A G I N G A C E N T U R Y O F M E D I C A L I M A G I N G A C E N T U R Y O F Rossi et al. Sonography of Portal and Hepatic Venous Thrombosis Hepatobiliary Imaging • Original Research Contrast-Enhanced Versus Conventional and Color Doppler Sonography for the Detection of Thrombosis of the Portal and Hepatic Venous Systems Sandro Rossi 1 Laura Rosa 1 Valentina Ravetta 1 Alessandro Cascina 1 Pietro Quaretti 2 Andrea Azzaretti 2 Paola Scagnelli 2 Carmine Tinelli 3 Paolo Dionigi 4 Fabrizio Calliada 2 Rossi S, Rosa L, Ravetta V, et al. Keywords: contrast medium, liver cancer, microbubble contrast agent, sonography, thrombosis DOI:10.2214/AJR.04.1218 Received August 2, 2004; accepted after revision February 3, 2005. 1 Department of Internal Medicine VI, IRCCS Policlinico “S. Matteo,” viale Golgi 19, Pavia 27100, Italy. Address correspondence to S. Rossi (s.rossi@smatteo.pv.it). 2 Department of Radiology, IRCCS Policlinico “S. Matteo,” Pavia 27100, Italy. 3 Department of Biometrics and Clinical Epidemiology, IRCCS Policlinico “S. Matteo,” Pavia 27100, Italy. 4 Department of Surgery, IRCCS Policlinico “S. Matteo,” Pavia 27100, Italy. OBJECTIVE. We conducted a prospective study to compare sonography, color Doppler sonography, and contrast-enhanced sonography for the detection and characterization of portal and hepatic vein thrombosis complicating hepatic malignancies. SUBJECTS AND METHODS. Three hundred sixteen patients with biopsy-proved he- patic tumors were studied at baseline and 3 months later with sonography, color Doppler sonog- raphy, and contrast-enhanced sonography. Thrombosis was defined as the presence of intralu- minal echogenic material at sonography, absence of intraluminal color signals at color Doppler sonography, and presence of nonenhancing intraluminal area at contrast-enhanced sonography. Thrombi were considered malignant if they displayed continuity with tumor tissue at sonogra- phy, intrathrombus color signals at color Doppler sonography, and enhancing signals at con- trast-enhanced sonography, both having arterial waveforms at Doppler spectral examination. Definitive diagnoses were obtained by sonographically guided biopsy except for thrombi dis- playing at conventional sonography unequivocal continuity with tumor tissue. RESULTS. Thrombosis was detected in 79 (25.0%) of 316 patients at baseline and in 83 (26.3%) of 316 patients after 3 months. Eighty-one (97.6%) of the 83 thrombi were malig- nant. Definitive diagnosis was performed by imaging in 60 (72.3%) of the 83 cases and by biopsy in 23 cases (27.7%). For thrombus detection, contrast-enhanced sonography dis- played significantly higher sensitivity than color Doppler sonography (p = 0.004) and bor- derline superiority over sonography (p = 0.058). For thrombus characterization, contrast-en- hanced sonography was significantly more sensitive than color Doppler sonography (p < 0.0005) and conventional sonography (p = 0.02). CONCLUSION. Contrast-enhanced sonography is superior to sonography and color Doppler sonography for the detection and characterization of portal and hepatic vein thrombo- sis complicating hepatic malignancies. ypercoagulability states, myelo- proliferative disorders, inflam- matory and neoplastic diseases, portal hypertension, and percuta- neous or endoscopic injection therapies can all be complicated by thrombosis of the por- tal or hepatic veins [1–5]. The detection and etiologic characterization of these thrombi are essential for treatment planning, particu- larly in patients with hepatic tumors because malignant thrombosis is a negative factor in terms of prognosis [6–8]. Sonography is generally the first imaging technique used in patients with liver disease, and its ability to detect portal vein thrombosis is reportedly comparable to that of other im- aging techniques [9–12]. Thrombi appear on sonography as solid intraluminal material that may have a hypo-, iso-, or hyperechoic pat- tern [13]. Findings of this type are nonspe- cific, however, and benign and malignant thrombi cannot be distinguished unless there is evidence of direct intraluminal tumor ex- tension [9, 13–15]. On color Doppler sonog- raphy the presence of intrathrombus signals with arterial waveforms on Doppler spectral examination is considered a highly specific sign of thrombus malignancy, although its sensitivity is only moderate [5, 14]. However, thrombi located in the left hepatic lobe or deep inside the right lobe cannot be ade- quately explored with color Doppler sonogra- phy; in cases of this type, sonographically guided biopsy of the thrombus is the only way to obtain definitive proof of malignancy [16]. Preliminary clinical studies indicate that contrast-enhanced sonography can be highly useful for the characterization of focal he- H