Previous studies using dynamic scintigraphy have shown that the measurement of changes in hepatic perfusion may be exploited to detect liver metastases. Similar hepatic haemodynamic changes also occur in cirrhosis, however, thereby reducing the diagnostic power of the technique. The ability of duplex colour Doppler sonography (DCDS) to differentiate between the changes in liver perfusion in patients with cirrhosis and those with hepatic metastases was assessed. Hepatic arterial and portal venous blood flows were measured in 30 control subjects, 20 patients with cirrhosis, and 55 patients with overt liver metastases.The Doppler perfusion index (DPI) (the rate of hepatic arterial to total liver blood flow) and the congestive index (ratio of the cross sectional area of the vessel to time averaged velocity of blood flow in the vessel) of the hepatic artery (HCI) and portal vein (PCI) were calculated. The hepatic arterial blood flow of the cirrhotic and metastatic groups was significantly raised compared with that of controls, and the portal venous blood flow of the former groups were reduced (p<00001). The DPIs of the cirrhotic and metastatic groups were therefore significantly raised compared with those of controls (p<0l0001). No significant difference was noted in HCI values between the three groups. The PCI values of the cirrhotic group, however, were significantly raised compared with those of controls and patients with metastases (p<00001). The data suggest that DCDS measurement of PCI may be of value in differentiating between the hepatic perfusion changes caused by cirrhosis and those resulting from hepatic metastases, thereby increasing the diagnostic power of this technique. (Gut 1993; 34: 554-557) The normal liver receives about 25% of its blood supply via the hepatic artery and the remainder through the portal vein. Parkin et al postulated that the presence of liver tumour might increase the hepatic arterial blood flow, as the blood supply of the tumour is almost exclusively arterial.' using dynamic scintigraphy as an indirect method of measuring blood flow, they calculated the ratio of hepatic arterial to total liver blood flow, the hepatic perfusion index (HPI), and found that it was raised in patients with liver metastases. In this study, we investigated the flow changes associated with hepatic metastases and cirrhosis to assess the value of DCDS in differentiating between the hepatic haemodynamic changes in patients with cirrhosis and those with colorectal liver metastases. MethodsThirty healthy volunteers (age range 23-77 years), 55 patients with histologically proved overt colorectal liver metastases (age range 31-75 years), and 20 patients with cirrhosis (age range 37-70 years) were included in the study. The cirrhosis was caused by alcohol abuse and all these patients had oesophageal varices at endoscopy. The severity of cirrhosis was evaluated according to Child-Pugh's classification. The score of the patients ranged from 2 to 13 with a mean of 7-1.All subjects were examined in the sup...

Results suggest that DCDS measurement of the DPI is the most sensitive technique in detection of colorectal liver metastases. All studies should attempt to define normal liver on the basis of follow-up results rather than those of laparotomy.

The results suggest that DPI is more sensitive than intraoperative ultrasound in the early detection of occult colorectal liver metastases. The Doppler technique can identify patients at high risk, suitable for adjuvant therapy. The routine use of intraoperative ultrasound in screening for occult colorectal liver metastases is not recommended.

The accuracy of preoperative assessment in determining invasion of the mandible by intraoral squamous cell carcinoma was analyzed in 48 patients who underwent mandibulectomy, and the results correlated with the histopathological reports of the resected specimens. Only 50% of the patients underwent the "ideal" surgery based primarily on clinical judgement, whereas 10 patients in the series were significantly undertreated. Clinical judgement and routine preoperative x-rays are accurate in cases where there is gross involvement of the mandible (17 of 19) but are significantly less successful in determining early bone invasion, invasion of the periosteum, or periosteal new bone formation. In such cases (26 of 48), a technetium-99m bone scan provides additional information. A grading system for reporting orthopantomographics (OPTs) and bone scans has been developed and utilized to form a reference grid to determine the optimum extent of mandibular surgery. The results show that using this protocol, unnecessary mandibular surgery may be reduced and inadequate surgical excision avoided.

The clinical application of ultrasonographic contrast agents in colour Doppler flow imaging of hepatic tumours is receiving increasing attention. Levovist is a suspension of galactose microparticles that provides reproducible concentrations of stabilized air bubbles with transpulmonary stability. Its effect on colour Doppler imaging was assessed in 26 patients with colorectal cancer and histologically proven hepatic metastases. Colour Doppler flow imaging was performed before and after intravenous injection of 10 ml Levovist 300 mg/ml. At 5-10 s after injection there was significant enhancement of the hepatic lesions with colour Doppler signals in 23 patients, lasting for a mean(s.d.) of 180(45) s. A consistent pattern of colour Doppler signal was observed, with increased enhancement predominantly around the tumour periphery and little or no central enhancement. These data suggest that Levovist may increase the sensitivity and specificity of colour Doppler flow imaging of colorectal hepatic metastases.

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