Purpose: To compare the applicability of fusion imaging between contrast-enhanced ultrasound (CEUS) and computed tomography (CT) or magnetic resonance imaging (MRI) (CT/MRI-CEUS fusion imaging) and fusion imaging between CEUS and ultrasound (US-CEUS fusion imaging) in the assessment of treatment response during liver cancer ablation. Methods: From August to December 2015, patients who underwent US-guided thermal ablation of liver tumors at our hospital with available CT/MRI images were enrolled consecutively. Both CT/MRI-CEUS and US-CEUS fusion imaging were performed in all patients to evaluate treatment responses. The applicable rate, success rate of registration and duration time were recorded. Complications were monitored in the follow-up period, and CECT/MRI within three months were taken as the standard reference of technical efficacy. Results: A total of 157 liver tumors (19 ± 8 mm, range 8-55 mm) in 115 patients (54 ± 11 years old, range 2 7$ 84 years old) were enrolled. The applicable rate of US-CEUS fusion imaging was 61.1% (96/ 157) because of inconspicuous lesions in US, lower than that of CT/MRI-CEUS fusion imaging (99.7% (155/157)) (p < .05). However, the success rate of registration in US-CEUS fusion imaging (93.8% (90/ 96)) was superior to that of CT/MRI-US fusion imaging (81.3% (126/155)) (p < .05), especially for cases combined with alternative preablation surgeries or procedures (p < .05). The technical efficacy rate was 99.3% (150/151) according to the CECT/CEMRI. Conclusions: Both CT/MRI-CEUS and US-CEUS fusion imaging are feasible means for intraprocedural immediate evaluation of treatment response for liver thermal ablation. US-CEUS fusion imaging is preferred because of its convenience and higher success rate of registration.

Objectives: This randomized controlled trial (RCT) aims to compare the clinical application values of contrast-enhanced ultrasound (CEUS), computed tomography/magnetic resonance-CEUS (CT/MR-CEUS), and three-dimensional ultrasound-CEUS (3DUS-CEUS) Fusion imaging (FI) techniques in the assistance of thermal ablation for hepatocellular carcinoma (HCC). Methods: A RCT was conducted on 374 patients with 456 HCCs between January 2016 and September 2017. CEUS, CT/MR-CEUS, and 3DUS-CEUS FI techniques were randomly used to assist HCC ablation. All lesions were ablated according to a previously determined plan, and FI groups required a 5-mm ablative margin. The primary endpoints were technical efficacy of thermal ablation and local tumor progression (LTP). Results: According to randomization, 153 (18.8 ± 8.0 cm), 153 (18.3 ± 6.6 cm) and 150 (19.1 ± 6.9 cm) HCCs were assigned to CT/MR-CEUS, 3DUS-CEUS and CEUS groups respectively. Technical efficacy rates (99.3% vs. 100% vs. 100%) were achieved in the three groups, showing no statistical differences (p ¼ 1.000). The median follow-up time was 24 (1-37) months. LTP rates at 1 and 2 years were 3.4%, 12.2% for CT/MR-CEUS FI, 4.8%, 9.0% for 3DUS-CEUS FI, and 8.6%, 19.9% for CEUS, respectively (p ¼ .105). The results of subgroup analysis for LTP were statistically significant when patients with albumin-bilirubin (ALBI) grade 2 and 3 (p ¼ .000), and tumor located at risky positions (p ¼ .042). In addition, the p value in group of multiple tumors was close to .05 (p ¼ .052). Conclusions: All the three techniques are feasible for intraoperative HCC thermal ablation. Compared with CEUS, FI techniques are more suitable in patients with ALBI grade 2 and 3, multiple tumors, and in tumors at risky locations.

BackgroundTo assess the accuracy of contrast-enhanced ultrasound (CEUS)-CT/MR image fusion in evaluating the radiofrequency ablative margin (AM) of hepatocellular carcinoma (HCC) based on a custom-made phantom model and in HCC patients.MethodsTwenty-four phantoms were randomly divided into a complete ablation group (n = 6) and an incomplete ablation group (n = 18). After radiofrequency ablation (RFA), the AM was evaluated using ultrasound (US)-CT image fusion, and the results were compared with the AM results that were directly measured in a gross specimen. CEUS-CT/MR image fusion and CT-CT / MR-MR image fusion were used to evaluate the AM in 37 tumors from 33 HCC patients who underwent RFA.ResultsThe sensitivity, specificity, and accuracy of US-CT image fusion for evaluating AM in the phantom model were 93.8, 85.7 and 91.3%, respectively. The maximal thicknesses of the residual AM were 3.5 ± 2.0 mm and 3.2 ± 2.0 mm in the US-CT image fusion and gross specimen, respectively. No significant difference was observed between the US-CT image fusion and direct measurements of the AM of HCC. In the clinical study, the success rate of the AM evaluation was 100% for both CEUS-CT/MR and CT-CT/MR-MR, and the duration was 8.5 ± 2.8 min (range: 4–12 min) and 13.5 ± 4.5 min (range: 8–16 min) for CEUS-CT/MR and CT-CT/MR-MR, respectively. The sensitivity, specificity, and accuracy of CEUS-CT/MR imaging for evaluating the AM were 100.0, 80.0, and 90.0%, respectively.ConclusionsA phantom model composed of carrageenan gel and additives was suitable for the evaluation of HCC AM. CEUS-CT/MR image fusion can be used to evaluate HCC AM with high accuracy.

Purpose: To evaluate whether local tumor progression (LTP) would be further reduced when contrastenhanced ultrasound (CEUS)-CT/MR fusion imaging was used as intraprocedural assessment method in hepatocellular carcinoma (HCC) thermal ablation compared with routine CEUS. Materials and methods: This prospective non-randomized study was conducted from December 2010 to July 2012. CEUS-CT/MR fusion imaging and routine CEUS were used for treatment response assessment in the ablation procedure of 146 HCCs and 122 HCCs, respectively. Supplementary ablations were performed immediately if necessary. The primary technique efficacy rate, LTP rate and overall survival (OS) rate were calculated. Results: For CEUS-CT/MR fusion imaging and routine CEUS, the technical success rate, technique efficacy rate and supplementary ablation rate were 86.3% (126/146) and 98.4% (120/122) (p ¼ .000), 99.2% (125/126) and 94.2% (113/120) (p ¼ .032), and 14.3% (18/126) and 4.2% (5/120) (p ¼ .006), respectively. The cumulative LTP rate and OS rate were not significantly different between fusion imaging group and routine CEUS group. However, for lesions that were larger than 3 cm or close to major vessels (41 lesions in fusion imaging group and 44 lesions in routine CEUS group, who received transcatheter arterial chemoembolization before ablation), the cumulative LTP rate was significantly lower in fusion imaging group than in routine CEUS group (p ¼ .032). Conclusion: Although intraprocedural CEUS-CT/MR fusion imaging has certain limitations in application, it might provide a potential more efficient method compared with routine CEUS in reducing LTP in HCC thermal ablation, especially for difficult ablation lesions.

Purpose The aim was to assess the value of intra-procedural CT/MR-ultrasound (CT/MR-US) fusion imaging in the management of thermal ablation for hepatocellular carcinoma (HCC). Materials and Methods This retrospective study was approved by the institutional review board. From May 2010 to October 2016, 543 HCC nodules in 440 patients (387 men and 53 women; age range: 25–84 years) that met the Milan Criteria were treated by percutaneous thermal ablation using intra-procedural CT/MR-US fusion imaging. The HCC nodules were divided into subgroups and compared (≤ 3 cm and > 3 cm, or high-risk and low-risk location, or inconspicuous and conspicuous, respectively). Technique efficacy and major complication were calculated. Cumulative local tumor progression (LTP), tumor-free and overall survival rates were estimated with the Kaplan-Meier method. Results CT/MR-US fusion imaging was successfully registered in 419 patients with 502 nodules. The technique efficacy rate of thermal ablation was 99.4 %. The major complication rate was 1.9 %. The cumulative LTP rates were 3.2 %, 5.6 % and 7.2 % at 1, 3, and 5 years, respectively. There were no significant differences for the comparisons of cumulative LTP rates between different subgroups (P = 0.541, 0.314, 0.329). The cumulative tumor-free survival rates were 74.8 %, 54.0 % and 37.5 % at 1, 3, and 5 years, respectively. The cumulative overall survival rates were 97.8 %, 87.1 % and 81.7 % at 1, 3, and 5 years, respectively. Conclusion Intra-procedural CT/MR-ultrasound fusion imaging is a useful technique for percutaneous liver thermal ablation. It could help to achieve satisfying survival outcomes for HCC patients who meet the Milan Criteria.