Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver - Update 2020 - WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

Comparison of non-radiomics imaging features and radiomics models based on contrast-enhanced ultrasound and Gd-EOB-DTPA-enhanced MRI for predicting microvascular invasion in hepatocellular carcinoma within 5 cm

OBJECTIVES

The purpose of this study is to establish microvascular invasion (MVI) prediction models based on preoperative contrast-enhanced ultrasound (CEUS) and ethoxybenzyl-enhanced magnetic resonance imaging (EOB-MRI) in patients with a single hepatocellular carcinoma (HCC) ≤ 5 cm.

METHODS

Patients with a single HCC ≤ 5 cm and accepting CEUS and EOB-MRI before surgery were enrolled in this study. Totally, 85 patients were randomly divided into the training and validation cohorts in a ratio of 7:3. Non-radiomics imaging features, the CEUS and EOB-MRI radiomics scores were extracted from the arterial phase, portal phase and delayed phase images of CEUS and the hepatobiliary phase images of EOB-MRI. Different MVI predicting models based on CEUS and EOB-MRI were constructed and their predictive values were evaluated.

RESULTS

Since univariate analysis revealed that arterial peritumoral enhancement on the CEUS image, CEUS radiomics score, and EOB-MRI radiomics score were significantly associated with MVI, three prediction models, namely the CEUS model, the EOB-MRI model, and the CEUS-EOB model, were developed. In the validation cohort, the areas under the receiver operating characteristic curve of the CEUS model, the EOB-MRI model, and the CEUS-EOB model were 0.73, 0.79, and 0.86, respectively.

CONCLUSIONS

Radiomics scores based on CEUS and EOB-MRI, combined with arterial peritumoral enhancement on CEUS, show a satisfying performance of MVI predicting. There was no significant difference in the efficacy of MVI risk evaluation between radiomics models based on CEUS and EOB-MRI in patients with a single HCC ≤ 5 cm.

CLINICAL RELEVANCE STATEMENT

Radiomics models based on CEUS and EOB-MRI are effective for MVI predicting and conducive to pretreatment decision-making in patients with a single HCC within 5 cm.

KEY POINTS

• Radiomics scores based on CEUS and EOB-MRI, combined with arterial peritumoral enhancement on CEUS, show a satisfying performance of MVI predicting. • There was no significant difference in the efficacy of MVI risk evaluation between radiomics models based on CEUS and EOB-MRI in patients with a single HCC ≤ 5 cm.

Contrast-Enhanced Ultrasound for Image-Guided Procedures

Contrast-enhanced ultrasound (CEUS) uses intravenously injected gas microbubbles as a pure blood pool contrast agent to demonstrate blood flow and tissue perfusion at a much higher sensitivity than color Doppler and power Doppler ultrasound. CEUS has gained traction in abdominal diagnostic imaging for improved lesion detection and characterization and a complementary problem-solving tool to CT and MRI. In addition to its diagnostic applications, CEUS has also proven useful for pre-procedure planning, procedure guidance, and post-procedure evaluation. This review provides a practical overview and guides to the application of CEUS in percutaneous, ultrasound-guided, needle-driven procedures, focusing on 2 common procedures, which illustrate the many benefits of CEUS- core needle biopsy (CNB) and percutaneous hepatic lesion ablation.

[Ultrasound systems for abdominal diagnostics - current methods, clinical applications and new technologies]

Abdominal ultrasound is the method of first choice in many clinical situations. Gray scale imaging (B-mode) and conventional Doppler techniques are nowadays complemented by contrast-enhanced ultrasound (CEUS), elastography, fat quantification and further technologies which allow multimodal characterization of organs and tissue structure using panoramic imaging, 3D-techniques and image fusion. The development of small portable devices augments the spectrum for sonographic diagnostics. In this review, we describe the current status of ultrasound technology based on published evidence. In addition, we provide guidance for quality assurance.

Hepatic epithelioid hemangioendothelioma-a single-institution experience with 51 cases

Objectives

The aim of the present study was to describe the experience at a single institution in the management of hepatic epithelioid hemangioendothelioma (HEHE).

Methods

We included 51 patients with histologically confirmed HEHE. We performed log-rank (Cox-Mantel) survival analyses using Kaplan-Meier methods to test differences in survival between patients in different groups. Univariate Cox regression analyses and multivariate proportional hazards regression model were carried out to identify independent prognostic factors.

Results

Different imaging modalities were used to diagnose HEHE with various presentations. Liver resection (LR), liver transplantation (LT), systemic treatment (ST), and surveillance had been used in our study. A significant difference was noted between the LR group and the surveillance group with respect to mean survival (p = 0.006), as was in the LR group and the ST group (p = 0.036), and in surgical approach (LR and LT) and nonsurgical approach (ST and surveillance) (p = 0.008). The mean survival between the ST group and the surveillance group was not significantly different (p = 0.851). LR (p = 0.010) and surgical approach (p = 0.014) were favorable predictors of outcome, while macrovascular invasion (MaVI) (p = 0.037), lung metastasis (p = 0.040), and surveillance (p = 0.033) were poor prognostic factors in univariate analysis. Multivariate analysis showed that LR (p = 0.010) and surgical approach (p = 0.014) were independently associated with good OS, while surveillance (p = 0.033) was independently associated with poor OS. After adjusting for confounding factors, patients in the LR group have much better OS than those in the surveillance group (p = 0.013). However, there was no significant difference in OS between the LR group and ST group (p = 0.254), as was in the ST group and the surveillance group (p = 0.857).

Conclusions

The definitive diagnosis of HEHE was dependent on histopathology, and it was not possible to make a specific diagnosis without biopsy because the radiological findings were similar to those in some hepatic malignancies. ST was not recommended for patients who were not candidates for surgical approaches, and surgical approaches should be warranted regardless of disease stage. The retrospective nature and the small size of the data limited the generalizability of the study, designing a worldwide database that contains all data about patients with HEHE independent of their therapy, which was highly recommended.

Prognostic and pathological implications of contrast-enhanced ultrasound features in hepatocellular carcinoma

Background

Contrast-enhanced ultrasound (CEUS) plays a vital role in diagnosing hepatocellular carcinoma (HCC) and, to some extent, reflects tumor prognosis. This suggests that some pathological features of HCC may be associated with CEUS features.

Aim

This study aimed to verify the prognostic significance of four CEUS features and further explore their pathological significance.

Materials and Methods

This study included 243 HCC patients who underwent a preoperative CEUS examination. All pathological diagnoses and immunohistochemical information were obtained from the pathological report. The prognostic significance of four CEUS features, including nodule-in-nodule architecture, mosaic architecture, intratumoral feeding arteries, and peritumoral arterial phase (AP) hyperenhancement, was analyzed. The correlation between prognostic-related features and immunohistochemical information was further analyzed.

Results

The disease-free survival (DFS) of HCC was significantly affected by mosaic architecture or intratumoral feeding arteries (HR = 1.79; 95% confidence interval (95% CI), 1.09-2.95; P = 0.004; HR = 1.70; 95% CI, 1.07-2.71; P = 0.025, respectively). Intratumoral feeding arteries were positively correlated with the expression of serum alpha-fetoprotein (AFP), microvascular invasion (MVI), differentiation, size, and Ki-67, among which the correlation with size was the strongest, followed by Ki-67 and MVI. The mosaic architecture was positively correlated with serum AFP, MVI, differentiation, and size, among which the correlation with size was strongest, followed by MVI.

Conclusion

The mosaic architecture and intratumoral feeding arteries of CEUS were closely related to the postoperative progression of HCC. Mosaic architecture had a good correlation with tumor size and MVI, whereas intratumoral feeding arteries were closely associated with tumor size and Ki-67 expression.

Value of Multimodal Data From Clinical and Sonographic Parameters in Predicting Recurrence of Hepatocellular Carcinoma After Curative Treatment

OBJECTIVE

The objective of the work described here was to assess the value of the combination of pre-operative multimodal data-including clinical data, contrast-enhanced ultrasound (CEUS) information and liver stiffness measurement (LSM) based on 2-D shear wave elastography (SWE)-in predicting early (within 1 y) and late (after 1 y) recurrence of hepatocellular carcinoma (HCC) after curative treatment.

METHODS

We retrospectively included 101 patients with HCC who met the Milan criteria and received curative treatment. The multimodel data from clinical parameters, LSM by 2-D SWE and CEUS enhancement patterns were collected. The association between different variables in HCC recurrence was accessed using a Cox proportional hazard model. On the basis of the independent factors of early recurrence, models with different source variables were established (Clinical Model, CEUS-Clinical Model, SWE-Clinical Model, CEUS-SWE-Clinical Model). The goodness-of-fit of models was evaluated and the performance trends of different models were calculated by time-dependent area under the curve (AUC).

RESULTS

Two-dimensional SWE, CEUS enhancement patterns and clinical parameters (spleen length, multiple tumors, α-fetoprotein, albumin and prothrombin time) were independently associated with early recurrence (all p values <0.05). Multiple tumors and a decrease in albumin independently contributed to the late recurrence. The model fit of CEUS-SWE-Clinical Model was superior to other models in predicting early recurrence (all p values <0.05). The AUCs of the CEUS-Clinical Model were higher from 2 mo to 7 mo, while the SWE-Clinical Model had higher AUCs from 9 mo to 12 mo.

CONCLUSION

CEUS enhancement patterns and 2-D SWE were independent predictors of HCC early recurrence as the two factors contributed to the predictive performance at different times. The multimodal model, which included diverse data in predicting early HCC recurrence, had the best goodness-of-fit.

A deep learning model with data integration of ultrasound contrast-enhanced micro-flow cines, B-mode images, and clinical parameters for diagnosing significant liver fibrosis in patients with chronic hepatitis B

OBJECTIVE

To develop and investigate a deep learning model with data integration of ultrasound contrast-enhanced micro-flow (CEMF) cines, B-mode images, and patients' clinical parameters to improve the diagnosis of significant liver fibrosis (≥ F2) in patients with chronic hepatitis B (CHB).

METHODS

Of 682 CHB patients who underwent ultrasound and histopathological examinations between October 2016 and May 2020, 218 subjects were included in this retrospective study. We devised a data integration-based deep learning (DIDL) model for assessing ≥ F2 in CHB patients. The model contained three convolutional neural network branches to automatically extract features from ultrasound CEMF cines, B-mode images, and clinical data. The extracted features were fused at the backend of the model for decision-making. The diagnostic performance was evaluated across fivefold cross-validation and compared against the other methods in terms of the area under the receiver operating characteristic curve (AUC), with histopathological results as the reference standard.

RESULTS

The mean AUC achieved by the DIDL model was 0.901 [95% CI, 0.857-0.939], which was significantly higher than those of the comparative methods, including the models trained by using only CEMF cines (0.850 [0.794-0.893]), B-mode images (0.813 [0.754-0.862]), or clinical data (0.757 [0.694-0.812]), as well as the conventional TIC method (0.752 [0.689-0.808]), APRI (0.792 [0.734-0.845]), FIB-4 (0.776 [0.714-0.829]), and visual assessments of two radiologists (0.812 [0.754-0.862], and 0.800 [0.739-0.849]), all ps < 0.01, DeLong test.

CONCLUSION

The DIDL model with data integration of ultrasound CEMF cines, B-mode images, and clinical parameters showed promising performance in diagnosing significant liver fibrosis for CHB patients.

KEY POINTS

• The combined use of ultrasound contrast-enhanced micro-flow cines, B-mode images, and clinical data in a deep learning model has potential to improve the diagnosis of significant liver fibrosis. • The deep learning model with the fusion of features extracted from multimodality data outperformed the conventional methods including mono-modality data-based models, the time-intensity curve-based recognizer, fibrosis biomarkers, and visual assessments by experienced radiologists. • The interpretation of the feature attention maps in the deep learning model may help radiologists get better understanding of liver fibrosis-related features and hence potentially enhancing their diagnostic capacities.

Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study

BACKGROUND

The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery.

METHODS

In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs.

RESULTS

In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3).

CONCLUSIONS

The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

Non-invasive preoperative prediction of Edmondson-Steiner grade of hepatocellular carcinoma based on contrast-enhanced ultrasound using ensemble learning

Purpose

This study aimed to explore the clinical value of non-invasive preoperative Edmondson-Steiner grade of hepatocellular carcinoma (HCC) using contrast-enhanced ultrasound (CEUS).

Methods

212 cases of HCCs were retrospectively included, including 83 cases of high-grade HCCs and 129 cases of low-grade HCCs. Three representative CEUS images were selected from the arterial phase, portal vein phase, and delayed phase and stored in a 3-dimensional array. ITK-SNAP was used to segment the tumor lesions manually. The Radiomics method was conducted to extract high-dimensional features on these contrast-enhanced ultrasound images. Then the independent sample T-test and the Least Absolute Shrinkage and Selection Operator (LASSO) were employed to reduce the feature dimensions. The optimized features were modeled by a classifier based on ensemble learning, and the Edmondson Steiner grading was predicted in an independent testing set using this model.

Results

A total of 1338 features were extracted from the 3D images. After the dimension reduction, 10 features were finally selected to establish the model. In the independent testing set, the integrated model performed best, with an AUC of 0.931.

Conclusion

This study proposed an Edmondson-Steiner grading method for HCC with CEUS. The method has good classification performance on independent testing sets, which can provide quantitative analysis support for clinical decision-making.

Long-term liver lesion tracking in contrast-enhanced ultrasound videos via a siamese network with temporal motion attention

Propose: Contrast-enhanced ultrasound has shown great promises for diagnosis and monitoring in a wide range of clinical conditions. Meanwhile, to obtain accurate and effective location of lesion in contrast-enhanced ultrasound videos is the basis for subsequent diagnosis and qualitative treatment, which is a challenging task nowadays. Methods: We propose to upgrade a siamese architecture-based neural network for robust and accurate landmark tracking in contrast-enhanced ultrasound videos. Due to few researches on it, the general inherent assumptions of the constant position model and the missing motion model remain unaddressed limitations. In our proposed model, we overcome these limitations by introducing two modules into the original architecture. We use a temporal motion attention based on Lucas Kanade optic flow and Karman filter to model the regular movement and better instruct location prediction. Moreover, we design a pipeline of template update to ensure timely adaptation to feature changes. Results: Eventually, the whole framework was performed on our collected datasets. It has achieved the average mean IoU values of 86.43% on 33 labeled videos with a total of 37,549 frames. In terms of tracking stability, our model has smaller TE of 19.2 pixels and RMSE of 27.6 with the FPS of 8.36 ± 3.23 compared to other classical tracking models. Conclusion: We designed and implemented a pipeline for tracking focal areas in contrast-enhanced ultrasound videos, which takes the siamese network as the backbone and uses optical flow and Kalman filter algorithm to provide position prior information. It turns out that these two additional modules are helpful for the analysis of CEUS videos. We hope that our work can provide an idea for the analysis of CEUS videos.

Usefulness of Contrast-Enhanced Ultrasound in the Differentiation between Hepatocellular Carcinoma and Benign Liver Lesions

A differentiation between hepatocellular carcinoma (HCC) and benign liver lesions is required. The aim of the study was to perform an analysis of the time of enhancement of focal liver lesions in a contrast-enhanced ultrasound (CEUS) examination. The curves of enhancement and the homogeneity of the tumor enhancement were assessed. The study included 52 patients with diagnoses of hepatocellular adenoma (18), focal nodular hyperplasia (11) and HCC (28). The study included magnetic resonance imaging or computed tomography and a comparison of the obtained information with CEUS. In the benign lesions groups after 20-30 s, the enhancement was similar to the liver parenchyma. In the HCC group, the enhancement was slightly less intense compared to the liver parenchyma and the benign lesions. The difference of the enhancement in the arterial phase (benign lesions vs. HCC) was p = 0.0452, and the difference of enhancement in the late venous phase (benign lesions vs. HCC) was p = 0.000003. The homogeneity of the enhancement (benign lesions vs. HCC), respectively, was p = 0.001 in the arterial phase, p = 0.0003 in the portal venous phase and p = 0.00000007 in the late venous phase. Liver tumors can be classified as benign when they are homogenous in the arterial phase and don't present washout. HCC in the arterial phase is inhomogeneous and washout is observed in the venous phases. When radiological symptoms suggest malignant lesion, CEUS can be used to select the best biopsy access.

Preoperative Value of Contrast-Enhanced Ultrasound in Totally Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Liver Tumors: A Preliminary Study

ABSTRACT

The clinical data of 15 cases that planned to receive totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy were retrospectively collected. Before the stage 1 operation, the size and number of the tumors in future liver remnant (FLR) and the presence of cancer embolus in the portal vein were assessed using contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT). Before the stage 2 operation, CEUS was performed to assess the presence of traffic blood flow between the diseased liver and FLR after round-the-liver ligation. Before the stage 1 operation, 5 cases with tumors in FLR were found by CEUS and 6 cases were found by CECT ( P > 0.05). Similarly, CEUS found 5 cases with cancer thrombus in portal vein, and CECT found 7 cases ( P = 0.500). The consistency between the 2 modalities was good (κ = 0.857, P < 0.05, κ = 0.727, P < 0.05, respectively). Before the stage 2 operation, CEUS confirmed that there were 7 cases without traffic blood flow between the diseased liver and FLR, and 3 cases with residual traffic blood flow. The daily growth rate of FLR in the group without traffic blood flow (mean rank = 7.00) was higher than that in the group with traffic blood flow (2.00) significantly ( P < 0.05). Contrast-enhanced ultrasound is a promising application in the preoperative evaluation of totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy.

Ultrasound-responsive matters for biomedical applications

Ultrasound (US) is a biofavorable mechanical wave that has shown practical significance in biomedical fields. Due to the cavitation effect, sonoluminescence, sonoporation, pyrolysis, and other biophysical and chemical effects, a wide range of matters have been elucidated to be responsive to the stimulus of US. This review addresses and discusses current developments in US-responsive matters, including US-breakable intermolecular conjugations, US-catalytic sonosensitizers, fluorocarbon compounds, microbubbles, and US-propelled micro- and nanorobots. Meanwhile, the interactions between US and advanced matters create various biochemical products and enhanced mechanical effects, leading to the exploration of potential biomedical applications, from US-facilitated biosensing and diagnostic imaging to US-induced therapeutic applications and clinical translations. Finally, the current challenges are summarized and future perspectives on US-responsive matters in biomedical applications and clinical translations are proposed.

Head-to-head comparison of Sonazoid and SonoVue in the diagnosis of hepatocellular carcinoma for patients at high risk

Objectives

To compare the diagnostic efficacy of SonoVue-enhanced and Sonazoid-enhanced ultrasound (US) for hepatocellular carcinoma (HCC) in patients at high risk.

Methods

Between August 2021 and February 2022, participants at high risk for HCC with focal liver lesions were enrolled and underwent both SonoVue- and Sonazoid-enhanced US. Vascular-phase and Kupffer phase (KP) imaging features of contrast-enhanced US (CEUS) were analyzed. The diagnostic performance of both contrast agent-enhanced US according to the CEUS liver imaging reporting and data system (LI-RADS) and the modified criteria (using KP defect instead of late and mild washout) were compared. Histopathology and contrast-enhanced MRI/CT were used as reference standards.

Results

In total, 62 nodules, namely, 55 HCCs, 3 non-HCC malignancies and 4 hemangiomas, from 59 participants were included. SonoVue-enhanced US had comparable sensitivity to Sonazoid-enhanced US for diagnosing HCC [80% (95% confidential interval (CI): 67%, 89.6%) versus 74.6% (95% CI: 61%, 85.3%), p = 0.25]. Both SonoVue and Sonazoid-enhanced US achieved a specificity of 100%. Compared with CEUS LI-RADS, the modified criteria with Sonazoid did not improve sensitivity for HCC diagnosis [74.6% (95% CI: 61%, 85.3%) versus 76.4% (95% CI: 63%, 86.8%), p = 0.99].

Conclusions

Sonazoid-enhanced US had comparable diagnostic performance to SonoVue-enhanced US for patients with HCC risk. KP did not considerably improve the diagnostic efficacy, whereas KP defects in atypical hemangioma may be pitfalls in diagnosing HCC. Further studies with larger sample sizes are needed to further validate the conclusions in the present study.

Contrast-Enhanced Ultrasound Findings in Patients with Rare Solitary Necrotic Nodule of the Liver - a Multicenter Report

PURPOSE

 This multicenter retrospective study highlights the contrast-enhanced ultrasound (CEUS) findings in a series of histologically proven solitary necrotic nodules (SNN) of the liver, a poorly understood pathologic entity of uncertain origin that mimics malignancy.

MATERIALS AND METHODS

 22 patients (M/F 13/9; mean age 59.4 years, SD ± 10.7, range 35-81) with histological diagnosis of SNN and CEUS were selected from clinical, imaging, and pathological archives of 7 US interventional centers, each of which provided 1 to 6 cases (mean 2.8). Pathological diagnosis was made on 20 US-guided biopsies and 2 surgical specimens. 2 patients had 2 SNNs with identical CEUS findings so that imaging analysis was carried out on 24 nodules.

RESULTS

 SNN was an incidental finding in healthy people in 10 cases (45.5 %), and it was discovered during follow-up for either known extrahepatic malignancies (9 cases = 41 %) or chronic liver disease (3 cases = 13.5 %). SNNs had a mean size of 19.3 mm (SD ± 6.5, range 9-40). On B-mode US, SNNs appeared hypoechoic in 14 cases (66.7 %), "target-like" in 7 cases (29.2 %), and homogeneously hyperechoic in 1 case (4.1 %). On CEUS, all lesions appeared devoid of contrast enhancement ("punched out" aspect) in the arterial, portal venous, and late phases after US contrast agent injection. A uniformly thin, hyperenhancing ring in the early arterial phase and isoenhanced with the surrounding parenchyma in the portal venous and late phases was found in 10 nodules (41.6 %). Clinical and imaging follow-up (mean duration 42.2 months, SD ± 34.9, range 2-108) was available in 15 patients with 16 SNNs: no changes in size and echostructure were seen.

CONCLUSION

 CEUS can contribute to the diagnosis of SNN when a "punched out" appearance in all vascular phases with or without thin rim enhancement in the very early arterial phase is present in healthy subjects in whom a focal liver lesion is incidentally found. In patients with a history of chronic liver disease or malignancy, US-guided biopsy represents the unavoidable first-line diagnostic modality.

Safety Analysis of Adverse Events of Ultrasound Contrast Agent Lumason/SonoVue in 49,100 Patients

This study assessed the incidence of mild, moderate and severe adverse events (AEs) and examined their association with age, sex, body region examined, time to event and duration of the AE(s) in a large cohort of patients who underwent contrast-enhanced ultrasound (CEUS) with Lumason/SonoVue. In this retrospective observational study, 49,100 patients who underwent CEUS were analyzed. Forty-three (0.088%) patients experienced AEs, with 23 (0.047%) patients experiencing mild AEs, 13 (0.026%) experiencing moderate AEs and 7 (0.014%) experiencing severe AEs. No fatal event occurred. There was no age- or sex-related difference in the incidence of the AE(s) (p = 0.158 and p = 0.474). Inpatients (0.17%) more often experienced AEs than outpatients (0.06%, p = 0.003). The mean time to event for mild and moderate AEs was 14.50 ± 6.96 and 15.75 ± 10.40 min, respectively, whereas that for severe AEs was 1.89 ± 1.21 min after the injection. The remission time for mild and moderate AEs was approximately 30-40 min, and all patients with severe AEs recovered within 12 h. Twenty-one (48.8%) patients received medical treatment. In summary, Lumason/SonoVue has a good safety profile with a low incidence of AEs, most of which are mild with a short time to event and duration.

Non-invasive evaluation of vascular architecture of focal liver lesions by micro vascular imaging

OBJECTIVE

To explore the value of vascular architecture detected by micro vascular imaging (MVI) in preoperative diagnosis of focal liver lesions (FLLs).

METHODS

In this retrospective study, patients with surgery and histopathologically proved or radiologically confirmed FLLs were included. Vascular architecture of FLLs were acquired by color Doppler flow imaging (CDFI) and MVI on LOGIQ™ E20 ultrasound machine (C1-6 convex array probes). Alder semiquantitative analysis (grade 0-3) and morphologic features of blood vessels (pattern a-f) were used to assess the blood flow within the FLLs. Interobserver agreement for evaluating blood flow of FLLs was analyzed. Using Adler's grading or morphologic patterns as diagnostic criteria for malignant FLLs, the diagnostic efficiency was analyzed and compared.

RESULTS

From October 2021 and February 2022, 50 patients diagnosed with 40 malignant FLLs and 10 benign FLLs were finally included. The Kappa value within two observers for evaluating the blood flow of FLLs was 0.78 for MVI and 0.55 for CDFI. According to Alder semiquantitative analysis, more high-level blood flow signals (grade 2-3) were detected by MVI than CDFI (P <  0.05). Based on high-level blood flow signals (grade 2-3) and hypervascular supply patterns (pattern e and f), the diagnostic accuracy for malignant FLLs were 76% and 68% for MVI, 56% and 38% for CDFI, respectively.

CONCLUSION

MVI is superior to CDFI in evaluating vascular architecture of FLLs. The high-level flow signals and hypervascular pattern detected by MVI have a useful and complementary value in preoperative non-invasive identification of malignant FLLs.

Focal Liver Lesions other than Hepatocellular Carcinoma in Cirrhosis: Diagnostic Challenges

Liver cirrhosis is associated with regenerative nodules and an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may also occur. Differentiating the other lesions from HCC is important for further therapeutic decisions. This review discusses the characteristics of non-HCC liver lesions in cirrhosis and their consequent appearance on contrast-enhanced ultrasonography (CEUS) with consideration of other imaging. Knowledge of this data would be helpful in avoiding misdiagnoses.

Current aspects of multimodal ultrasound liver diagnostics using contrast-enhanced ultrasonography (CEUS), fat evaluation, fibrosis assessment, and perfusion analysis - An update

Current ultrasound multifrequency probes allow both improved detail resolution and depth of penetration when examining the liver. Also, new developments in vascular diagnostics, elastography with fibrosis assessment, evaluation of possible steatosis, and parametric and time intensity curve (TIC) analysis of dynamic microvascularization of the liver with contrast-enhanced ultrasound sonography (CEUS) complement ultrasound-guided diagnostics. State-of-the-art high-resolution technology includes a high frame rate (HiFR) mode for CEUS, fast shear wave measurements with the sound touch quantify (STQ) mode, artifact-free flow detection using HR flow and glazing flow in combination with a special flow-adapted imaging (Ultra Micro Angiography, UMA) and additionally different assessments of possible fatty liver (UltraSound ATtenuation Imaging Technology, USAT). In 50 cases with focal liver lesions, a multimodal liver diagnosis was performed with a still new high-performance ultrasound system as part of the clarification of questions from the university liver consultation and tumor outpatient clinic.

Intraoperative ultrasound in minimally invasive thoracic surgery for the detection of pulmonary tumors: First intrathoracic application of TE9 and laparoscopic probe Lap 13-4cs (Mindray)

AIM

To apply intraoperative ultrasound (IO-US) for the first time using a laparascopic probe to detect malignancy-susceptible solitary pulmonary nodules (SPN) and assess macrovascularization using color-coded doppler sonography or power doppler. Description of technical feasibility.

METHODS

Technical description on intrathoracic endoscopic ultrasound. A positive ethics vote from the local ethics committee and written patient consent were available. Intraoperative ultrasound was performed using a laparascopic probe (Lap 13-4cs, Mindray) on the T9 ultrasound machine (Mindray, China). B-scan was used to detect the SPN. Color-coded doppler sonography (CCS) and power doppler were used to assess macrovascularization. Primary end point was the description of the technical performance of the Io-US. Secondary endpoints were the functions of Io-US in characterizing SPN.

RESULTS

Io-US was successfully applied using (n = 2) cases in video-assisted thoracic surgery. All SPN were successfully detected intraoperatively with the intrathoracically placed laparascopy probe using B-mode and examined using CCS or power Doppler (100%). Resection was sonography-guided with marking of the tumor area in all cases without complications. Histological workup revealed malignancy in both cases.

CONCLUSION

Intrathoracic application of laparascopically guided Io-US was technically feasible. In addition to B-mode detection, Io-US using power doppler and color-coded doppler sonography provided initial evidence for characterization of SPN based on macrovascularization.

Intrahepatic splenosis: Contrast enhanced ultrasound and magnetic resonance imaging findings

OBJECTIVE

To evaluate the contrast enhanced ultrasound (CEUS) and contrast enhanced magnetic resonance imaging (CEMRI) features of intrahepatic splenosis (IHS).

METHODS & MATERIALS

Five patients (three males and two females, median age, 44 years; range,32-73 years) with seven IHSs were retrieved from the database of our hospital from March 2012 to October 2021. All IHSs were confirmed histologically by surgery. The CEUS and CEMRI characteristics of individual lesion were fully analyzed.

RESULTS

All IHS patients were asymptomatic and four out of five patients had history of splenectomy. On CEUS, all IHSs were hyperenhancement in arterial phase. 71.4% (5/7) of IHSs manifested overall filling within few seconds, the other two lesions showed centripetal filling. Subcapsular vascular hyperenhancement and feeding artery was seen in 28.6% (2/7) and 42.9% (3/7) of IHSs, respectively. During portal venous phase, IHSs presented hyperenhancement (2/7) or isoenhancement (5/7). Moreover, rim-like hypoenhanced area was uniquely observed surrounding 85.7% (6/7) of IHSs. In late phase, seven IHSs remained continuous hyper- or isoenhancement. On CEMRI, five IHSs showed mosaic hyperintense in early arterial phase, the other two lesions showed homogeneous hyperintense. In portal venous phase, all IHSs revealed continuous hyper- (71.4%, 5/7) or iso-intense (28.6%, 2/7). During late phase, one IHS (14.3%, 1/7) became hypointense, the other lesions remained hyper- or isointense.

CONCLUSION

Diagnosis of IHS can be based on typical CEUS and CEMRI features in patients with history of splenectomy.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

A New Nanoscale Ultrasound Phase-Variant Contrast Agent for Phase Variant Low-Frequency Medical Ultrasound Imaging That Can Scavenge Reactive Oxygen Species

Nanoscale phase-variant ultrasound contrast agents have attracted the interest of many researchers. However, it is a challenge to design nanobubbles that are activated by low-frequency medical ultrasound that do not cause damage to normal tissues. In this study, we designed a new type of nanoparticle consisting of perfluoropentane and iron polyphthalocyanine loaded into liposomes. These nanoparticles can be activated by a low-frequency medical ultrasound imager at a frequency of 5 MHz for ultrasound imaging and clear reactive oxygen species at a rate of more than 50%. This ability to scavenge excess reactive oxygen species can alleviate the damage these species cause and protect macrophages. Moreover, these nanoparticles can effectively enhance ultrasound contrast imaging for real-time visualization in the diagnosis and treatment of diseases.

Dual-Mode Fluorescence/Ultrasound Imaging with Biocompatible Metal-Doped Graphene Quantum Dots

Sonography offers many advantages over standard methods of diagnostic imaging due to its non-invasiveness, substantial tissue penetration depth, and low cost. The benefits of ultrasound imaging call for the development of ultrasound-trackable drug delivery vehicles that can address a variety of therapeutic targets. One disadvantage of the technique is the lack of high-precision imaging, which can be circumvented by complementing ultrasound contrast agents with visible and, especially, near-infrared (NIR) fluorophores. In this work, we, for the first time, develop a variety of lightly metal-doped (iron oxide, silver, thulium, neodymium, cerium oxide, cerium chloride, and molybdenum disulfide) nitrogen-containing graphene quantum dots (NGQDs) that demonstrate high-contrast properties in the ultrasound brightness mode and exhibit visible and/or near-infrared fluorescence imaging capabilities. NGQDs synthesized from glucosamine precursors with only a few percent metal doping do not introduce additional toxicity in vitro, yielding over 80% cell viability up to 2 mg/mL doses. Their small (<50 nm) sizes warrant effective cell internalization, while oxygen-containing surface functional groups decorating their surfaces render NGQDs water soluble and allow for the attachment of therapeutics and targeting agents. Utilizing visible and/or NIR fluorescence, we demonstrate that metal-doped NGQDs experience maximum accumulation within the HEK-293 cells 6-12 h after treatment. The successful 10-fold ultrasound signal enhancement is observed at 0.5-1.6 mg/mL for most metal-doped NGQDs in the vascular phantom, agarose gel, and animal tissue. A combination of non-invasive ultrasound imaging with capabilities of high-precision fluorescence tracking makes these metal-doped NGQDs a viable agent for a variety of theragnostic applications.

Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age

BACKGROUND/PURPOSE

The incidence of hepatic artery thrombosis (HAT) in recipients is high after pediatric LT using young donors. In this study we investigated the management and outcome of HAT after whole-LT using donors less than one year of age. And evaluate the safety of pediatric donors, and increase the utilization of pediatric donors overall.

METHODS

We retrospectively analyzed the clinical data encompassing children who underwent whole-liver transplantation in our department from January 2014 to December 2019. Recipients receiving a liver from a donor ≥1 month and ≤12 months were included, and a total of 110 patients were included in this study.

RESULTS

The results showed an incidence for HAT of 20% and the median time to HAT diagnosis was 3.0 (2.0, 5.3) days post-operation. Anticoagulant therapy was used for 19 cases and 94.7% of them achieved hepatic artery recanalization or collateral formation. The median time of recanalization was 12 (5, 15) days. Bile leakage and biliary strictures occurring in the HAT group were higher than in the non HAT group (13.6% vs. 1.1% and 31.8% vs. 3.4%). There were no significant differences in the survival rates of recipients or grafts among the two groups (P = 0.474, P = 0.208, respectively).

CONCLUSION

We confirmed that the incidence of HAT in LT recipients use donors less than 1 year is high, but recanalization can be performed using anticoagulant therapy. Although biliary complications increased significantly after HAT, the survival rates of patients and grafts were satisfactory.

LEVEL OF EVIDENCE

Level III.

Sonazoid™ versus SonoVue® for Diagnosing Hepatocellular Carcinoma Using Contrast-Enhanced Ultrasound in At-Risk Individuals: A Prospective, Single-Center, Intraindividual, Noninferiority Study

OBJECTIVE

To determine whether Sonazoid-enhanced ultrasound (SZUS) was noninferior to SonoVue-enhanced ultrasound (SVUS) in diagnosing hepatocellular carcinoma (HCC) using the same diagnostic criteria.

MATERIALS AND METHODS

This prospective, single-center, noninferiority study (NCT04847726) enrolled 105 at-risk participants (71 male; mean age ± standard deviation, 63 ± 11 years; range, 26-86 years) with treatment-naïve solid hepatic nodules (≥ 1 cm). All participants underwent same-day SZUS (experimental method) and SVUS (control method) for one representative nodule per participant. Images were interpreted by three readers (the operator and two independent readers). All malignancies were diagnosed histopathologically, while the benignity of other lesions was confirmed by follow-up stability or pathology. The primary endpoint was per-lesion diagnostic accuracy for HCC pooled across three readers using the conventional contrast-enhanced ultrasound diagnostic criteria, including arterial phase hyperenhancement followed by mild (assessed within 2 minutes after contrast injection) and late (≥ 60 seconds with a delay of 5 minutes) washout. The noninferiority delta was -10%p. Furthermore, different time delays were compared as washout criteria in SZUS, including delays of 2, 5, and > 10 minutes.

RESULTS

A total of 105 lesions (HCCs [n = 61], non-HCC malignancies [n = 19], and benign [n = 25]) were evaluated. Using the 5-minutes washout criterion, per-lesion accuracy of SZUS pooled across the three readers (72.4%; 95% confidence interval [CI], 64.1%-79.3%) was noninferior to that of SVUS (71.4%; 95% CI, 63.1%-78.6%), meeting the statistical criterion for non-inferiority (difference of 0.95%p; 95% CI, -3.8%p-5.7%p). The arterial phase hyperenhancement combined with the 5-minutes washout criterion showed the same sensitivity as that of the > 10-minutes criterion (59.0% vs. 59.0%, p = 0.989), and the specificities were not significantly different (90.9% vs. 86.4%, p = 0.072).

CONCLUSION

SZUS was noninferior to SVUS for diagnosing HCC in at-risk patients using the same diagnostic criteria. No significant improvement in HCC diagnosis was observed by extending the washout time delay from 5 to 10 minutes.

Nanoscale Contrast Agents for Ultrasound Imaging of Musculoskeletal System

Musculoskeletal ultrasound (MSKUS) has been recognized as an important method for the evaluation of diseases of the musculoskeletal system, and contrast-enhanced ultrasound (CEUS) technology is becoming an important branch of it. The development of novel materials and tiny nano-formulations has further expanded ultrasound contrast agents (UCAs) into the field of nanotechnology. Over the years, nanoscale contrast agents have been found to play an unexpected role in the integration of precise imaging for diagnosis and treatment of numerous diseases. It has been demonstrated that nanoscale UCAs (nUCAs) have advantages in imaging over conventional contrast agents, including superior biocompatibility, serum stability, and longer lifetime. The potential value of nUCAs in the musculoskeletal system is that they provide more reliable and clinically valuable guidance for the diagnosis, treatment, and follow-up of related diseases. The frontier of advances in nUCAs, their applications, and insights in MSKUS are reviewed in this paper.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Short Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Circulating tumour cell counts and ultrasomics signature-based nomogram for preoperative prediction of early recurrence of hepatocellular carcinoma after radical treatment

METHODS

Between December 2017 and December 2018, 153 HCC patients (134 males and 19 females; mean age, 56.0 ± 10.2 years; range, 28-78 years) treated with radical therapy were enrolled in our retrospective study and were divided into a training cohort (n = 107) and a validation cohort (n = 46). All patients underwent preoperative CTC tests and CEUS examinations before treatment. The ultrasomics signature was extracted and built from CEUS images. Univariate and multivariate logistic regression analyses were used to identify the significant variables related to ER, which were then combined to build a predictive nomogram. The performance of the nomogram was evaluated by its discrimination, calibration and clinical utility. The predictive model was further evaluated in the internal validation cohort.

RESULTS

HBV DNA, serum AFP level, CTC status, tumour size and ultrasomics score were identified as independent predictors associated with ER (all p < 0.05). Multivariable logistic regression analysis showed that the CTC status (OR = 7.02 [95% CI, 2.07 to 28.38], p = 0.003) and ultrasomics score (OR = 148.65 [95% CI, 25.49 to 1741.72], p < 0.001) were independent risk factors for ER. The nomogram based on ultrasomics score, CTC status, serum AFP level and tumour size exhibited C-indexes of 0.933 (95% CI, 0.878 to 0.988) and 0.910 (95% CI, 0.765 to 1.055) in the training and validation cohorts, respectively, fitting well in calibration curves. Decision curve analysis further confirmed the clinical usefulness of the nomogram.

CONCLUSION

The nomogram incorporating CTC, ultrasomics features and independent clinical risk factors achieved satisfactory preoperative prediction of ER in HCC patients after radical treatment.

ADVANCES IN KNOWLEDGE

1. CTC status and ultrasomics score were identified as independent predictors associated with ER of HCC after radical treatment. 2. The nomogram constructed by ultrasomics score generated by 17 ultrasomics features, combined with CTCs and independent clinical risk factors such as AFP and tumour size. 3. The nomogram exhibited satisfactory discriminative power, and could be clinically useful in the preoperative prediction of ER after radical treatment in HCC patients.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Intravenous combined with intrabiliary contrast-enhanced ultrasound in the evaluation of resectability of hilar cholangiocarcinomas

OBJECTIVE

To investigate the application value of combined intravenous contrast-enhanced ultrasound (IV-CEUS) with intrabiliary contrast-enhanced ultrasound (IB-CEUS) in the preoperative evaluation of hilar cholangiocarcinoma (HCCA) resectability.

METHODS

Clinical data from 82 patients with HCCA confirmed by surgery and pathology were retrospectively analyzed. Preoperative IV-CEUS + IB-CEUS and magnetic resonance cholangiopancreatography (MRCP) were performed and the results were compared with surgical and pathological findings.

RESULTS

The accuracy of the Bismuth-Corlette classification confirmed by IV-CEUS + IB-CEUS and MRCP was 95.12% (78/82) and 87.8% (72/82), respectively. The diagnostic precision of IV-CEUS + IB-CEUS was better than MRCP (p = 0.001). The sensitivity, specificity, and precision of CEUS for diagnosing lymph node metastases (72.7%, 93.3%, and 87.8%), intrahepatic metastases (78.6%, 98.5%, and 93.9%), invasion of the hepatic artery (92.9%, 98.5%, and 97.6%) and invasion of the portal vein (93.8%, 98.5%, and 97.6%) of HCCA were, respectively. The consistency between the preoperative evaluation of resectability confirmed by IV-CEUS +IB-CEUS and MRCP was 85.4% (70/82) and 78.0% (64/82), respectively. In addition, the evaluations did not have statistically significant differences (p > 0.05). There were no significant differences between the two evaluations (p = 0.266).

CONCLUSION

IV-CEUS combined with IB-CEUS has significant value in classifying HCCA and evaluating the resectability of lymph node metastases, liver metastases, and vessel invasion.

Contrast-Enhanced Ultrasound Features of Histopathologically Proven Hepatocellular Carcinoma in the Non-cirrhotic Liver: A Multicenter Study

Current literature on the role of contrast-enhanced ultrasound (CEUS) in the diagnosis of hepatocellular carcinoma (HCC) in non-cirrhotic patients is limited. The aim of this retrospective multicenter study was to analyze CEUS features of histologically proven HCC in patients with non-cirrhotic liver. In this multicenter study, 96 patients from eight medical institutions with histologically proven HCC lesions in non-cirrhotic liver were retrospectively reviewed regarding SonoVue-enhanced CEUS features. Two ultrasound experts assessed the CEUS enhancement pattern and came to a consensus using the World Federation of Societies for Ultrasound in Medicine and Biology guideline criteria. The mean size of HCC lesions included was 60.3 ± 37.8 mm (mean ± standard deviation). Most of the lesions were heterogeneous but predominantly hypo-echoic on B-mode ultrasound (64.5%, 62/96), with ill-defined margins and irregular shapes. During the arterial phase of CEUS, most of the HCC lesions in non-cirrhotic liver exhibited heterogeneous hyperenhancement (78.1%, 75/96) compared with the surrounding liver parenchyma. Almost 30% of HCC lesions (28.1%, 27/96) exhibited early wash-out (<60 s). All lesions exhibited wash-out and hypo-enhancement in the late phase. CEUS features of HCC lesions in non-cirrhotic patients typically include hyperenhancement in the arterial phase and relatively rapid wash-out in the portal venous phase, which is different from HCC in cirrhotic livers and more similar to liver metastasis.

Microbubbles in the belly: optimizing the protocol for contrast-enhanced ultrasound of the pediatric abdomen

Intravenous contrast-enhanced ultrasound (CEUS) can serve as a diagnostic or problem-solving tool in pediatric imaging. CEUS of abdominal solid organs has been reported for a number of indications. The approach to the examination broadly falls into two categories: evaluation of a focal lesion or surveillance of an organ or organs for lesions or perfusion abnormalities. A consistent, technical imaging protocol for both of these clinical scenarios facilitates integration of routine use of CEUS in an imaging department. Here we review the CEUS imaging protocols for abdominal organs in children, including technical and solid-organ-specific considerations.

Endocavitary Contrast-Enhanced Ultrasound

BACKGROUND

 Ultrasound is one of the most important imaging methods in the daily routine. Contrast-enhanced ultrasound (CEUS) has put ultrasound on equal footing with computed tomography and magnetic resonance imaging in many areas. Although ultrasound contrast agents are commonly administered intravenously, endocavitary application as performed in the case of iodine-containing contrast agents is also possible.

METHOD

 Based on the current literature, this overview provides information regarding possible endocavitary applications of ultrasound contrast agents as they are used and could be used in the daily routine in radiology. Examples are provided to illustrate the advantages and disadvantages of clinical use.

RESULTS AND CONCLUSION

 Endocavitary CEUS broadens the spectrum of possible ultrasound applications and can be safely used for patient diagnosis and treatment. The method can be safely used for diagnosis and patient management, particularly in patients in whom examinations including exposure to radiation with iodine-containing contrast agents may be contraindicated and who have limited mobility due to disease severity.

KEY POINTS

  · Endocavitary CEUS is a safe method that can be readily learned by those with prior ultrasound training. Radiologists benefit from their existing knowledge of contrast-enhanced imaging.. · With ultrasound contrast agents, endocavitary examinations comparable to CT and fluoroscopy can be performed without having to take radiation exposure, preexisting conditions, and patient mobility into consideration.. · In principle, endocavitary CEUS can access every body cavity (physiological and pathological) and body orifice with any access device.. · The method is mainly used for interventions including puncture and drainage. The diluted ultrasound contrast agent can be continuously visualized in the access device and in the target region, including distribution within the target region, with high spatial and temporal resolution. Voiding urosonography and visualization of the salivary duct system should also be mentioned in the radiological context.. · Poor B-mode imaging conditions typically also mean poor CEUS conditions. Imaging methods that can reliably evaluate low-lying structures and structures with overlying air, particularly in obese patients, without artifacts and can provide a good overview have a clear advantage here..

CITATION FORMAT

· Vollert K, Clevert DA, Kleffel T. Endocavitary Contrast-Enhanced Ultrasound. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1826-0325.

Application of DCE-US using the LI-RADS for patients with liver nodules at high risk for hepatocellular carcinoma: A preliminary study and comparison with visual interpretation

OBJECTIVE

To explore the value of dynamic contrast-enhanced ultrasound (DCE-US) for the Liver Imaging Reporting and Data System (LI-RADS).

METHODS

We included 220 liver nodules at high risk for hepatocellular carcinoma (HCC) from January 2019 to October 2021. Visual interpretation and DCE-US-based quantitative categories using VueBox® software were compared for consistency, nodule enhancement intensity, and washout onset following the contrast-enhanced ultrasound LI-RADS. Taking the cut-off value of the ROC curve on washout onset as the time criterion of early washout of LR-M nodules, analyzed the diagnostic performance of LR-5 for HCC and compared it to that of washout onset within 60 s.

RESULTS

The LI-RADS visual and DCE-US interpretation results showed good consistency (Kappa = 0.730), but differed significantly in determining the LR-5 washout onset (91.2 ± 30.2 vs. 82.0 ± 32.8 s, P = 0.020) and detecting early washout (<60 s) in 196 nodules (P = 0.047). Distinguishing HCC from non-HCC malignancies had: area under the ROC curve, 0.85 (95 % confidence interval, 0.8-0.9); Youden index, 0.69; cut-off value, 48 s; sensitivity, 74.4 %; specificity, 95.0 %. When LR-M diagnosis used washout onset within 48 s, LR-5 diagnosis had sensitivity, 72.8 %; specificity, 95.0 %; positive predictive value, 98.5 %; showing a higher sensitivity than with washout onset in 60 s (62.2 %; P = 0.033).

CONCLUSION

DCE-US and visual interpretations showed high consistency in LI-RADS categories but differed in assessing the washout time. According to the DCE-US interpretation, the diagnostic performance of LR-5 could be improved using washout onset of 48 s for LR-M.

Comparison of contrast-enhanced ultrasonography and magnetic resonance imaging in the evaluation of tumor size and local invasion of surgically treated cervical cancer

OBJECTIVES

This retrospective study aimed to compare the performance of contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI) in staging surgically treated early-stage cervical cancer.

METHODS

Patients with surgically treated cervical carcinoma confirmed by post-operative pathological findings were included between December 2016 and December 2018. All included patients underwent both CEUS and MRI examinations before the surgery. Post-operative pathology was used as the gold standard. The κ values were calculated to assess the agreements of CEUS and MRI in staging cervical carcinoma in comparison with post-operative pathology.

RESULTS

Complete data were available for 39 patients. CEUS showed great inter-observer reproducibility in tumor measurement [Intra-class Correlation Coefficient (ICC) 0.831] and moderate inter-observer reproducibility in the evaluation of vaginal infiltration and parametrial invasion (Cohen's κ 0.692 and 0.624). Tumor size was comparable as measured by CEUS and MRI (ICC 0.769). Both CEUS and MRI presented good concordance with post-operative pathology in staging cervical cancer (weighted κ 0.732 and 0.761).

CONCLUSION

CEUS was comparable to MRI in staging surgically treated cervical cancer and might be considered in the pre-treatment work-up for cervical cancer.

Differentiation Between Granulomatous Lobular Mastitis and Breast Cancer Using Quantitative Parameters on Contrast-Enhanced Ultrasound

Objective

To investigate the Contrast-enhanced ultrasound (CEUS) imaging characteristics of granulomatous lobular mastitis (GLM) and the value of differentiating GLM from breast cancer.

Materials and methods

The study included 30 women with GLM (mean age 36.7 ± 5 years [SD]) and 58 women with breast cancer (mean age 48. ± 8 years [SD]) who were scheduled for ultrasound-guided tissue biopsy. All patients were evaluated with conventional US and CEUS prior to the biopsy. In both groups, the parameters of the quantitative and qualitative analysis of the CEUS were recorded and compared. The receiver-operating-characteristics curves (ROC) were created. Sensitivity, specificity, cut-off, and area under the curve (AUC) values were calculated.

Results

TTP values in GLM were statistically higher than in breast cancer (mean, 27.63 ± 7.29 vs. 20.10 ± 6.11), but WIS values were lower (mean, 0.16 ± 0.05 vs. 0.28 ± 0.17). Rich vascularity was discovered in 54.45% of breast cancer patients, but only 30.00% of GLM patients had rich vascularity. The AUC for the ROC test was 0.791 and 0.807, respectively. The optimal cut-off value for TTP was 24.5s, and the WIS cut-off value was 0.185dB/s, yielding 73.33% sensitivity, 84.48% specificity, and 86.21% sensitivity, 70% specificity respectively in the diagnosis of GLM. The lesion scores reduced from 4 to 3 with the addition of CEUS for the patients with GLM. However, the scores did not change for the patients with breast cancer.

Conclusion

CEUS could help distinguish GLM from breast cancer by detecting higher TTP and WIS values, potentially influencing clinical decision-making for additional biopsies.

Diagnostic value of CEUS LI-RADS and serum tumor markers for combined hepatocellular-cholangiocarcinoma

PURPOSE

To analyze the contrast-enhanced ultrasound (CEUS) manifestations of combined hepatocellular-cholangiocarcinoma (CHC) and to investigate the diagnostic value of the 2017 version of the CEUS Liver Imaging Reporting and Data System (LI-RADS) and serum tumor markers in CHC.

METHODS

A total of 66 pathologically confirmed CHC nodules were retrospectively analyzed. We summarized the CEUS manifestations of CHC and analyzed the relationship between serum tumor markers and the enhancement pattern of CHC. We also classified CHC according to CEUS LI-RADS criteria. The Kappa test was used to assess the interreader agreement of CEUS LI-RADS between radiologists.

RESULT

According to the results, 52 of 62 (83.9%) patients had elevated alpha-fetoprotein (AFP), 19 of 61 (31.1%) had elevated carbohydrate antigen 199 (CA 199), and 13 of 61 (21.3%) had both elevated AFP and CA 199. Of the 66 CHC nodules, 64 (97.0%) were identified as malignant lesions by CEUS, 13 (19.7%) showed a hepatocellular carcinoma-like enhancement pattern, and 21 (31.8%) showed a cholangiocarcinoma-like enhancement pattern. For the CEUS LI-RADS categories, 39 of 53 (73.6%) CHC nodules were classified as LR-M, 12 (22.6%) were classified as LR-5, and 2 (3.8%) were classified as LR-4. The interreader agreement for the LI-RADS categories was 0.60.

CONCLUSIONS

Although CHC lacks specific CEUS features, CEUS LI-RADS and serum tumor markers can be useful tools for reducing the misdiagnosis of CHC. In addition, due to the relative complexity of the CEUS features involved in CHC, it is necessary for beginning radiologists to learn more about CEUS features.

Repeated ultrasound-guided percutaneous thermal ablation combined with systemic therapy achieves a stable condition in an end-stage patient with more than 10 liver metastases from breast cancer: The importance of sonazoid assisted contrast-enhanced ultrasound and fusion imaging

The liver is one of the most frequent metastatic sites of breast cancer with a relatively poor prognosis. Systemic chemotherapy is an effective treatment but the efficacy is different between the subtypes of breast cancer. Percutaneous thermal ablation is considered to be a minimally invasive and effective local treatment for breast cancer liver metastases (BCLM). This case report described a patient with BCLM who adopted a strategy of systemic chemotherapy and repeated ultrasound (US) -guided percutaneous thermal ablation procedures. The survival time already reached 8 years till now with the metastases well-controlled and acceptable life quality was achieved.

Application of the CT/MRI LI-RADS Treatment Response Algorithm to Contrast-Enhanced Ultrasound: A Feasibility Study

Purpose

The contrast-enhanced ultrasound (CEUS) Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) is still in development. The aim of this study was to explore whether the CT/MRI LI-RADS TRA features were applicable to CEUS in evaluating the liver locoregional therapy (LRT) response.

Patients and Methods

This study was a retrospective review of a prospectively maintained database of patients with hepatocellular carcinoma undergoing ablation between July 2017 and December 2018. The standard criteria for a viable lesion were a histopathologically confirmed or typical viable appearance in the follow-up CT/MRI. Performance of the LI-RADS TRA assessing tumor viability was then compared between CEUS and CT/MRI. Inter-reader association was calculated.

Results

A total of 244 patients with 389 treated observations (118 viable) were evaluated. The sensitivity and specificity of the CEUS TRA and CT/MRI LI-RADS TRA viable categories for predicting viable lesions were 55.0% (65/118) versus 56.8% (67/118) (P = 0.480) and 99.3% (269/271) versus 96.3% (261/271) (P = 0.013), respectively. The PPV of CEUS was higher than that of CT/MRI (97.0% vs 87.0%). Subgroup analysis showed that the sensitivity was low in the 1-month assessment for both CEUS (38.1%, 16/42) and CT/MR (47.6%, 20/42) and higher in the 2–6-month assessment for both CEUS (65.7%, 23/35) and CT/MR (62.9%, 22/35). Interobserver agreements were substantial for both CEUS TRA and CT/MRI LI-RADS TRA (κ, 0.74 for both).

Conclusion

The CT/MRI LI-RADS TRA features were applicable to CEUS TRA for liver locoregional therapy. The CEUS TRA for liver locoregional therapy has sufficiently high specificity and PPV to diagnose the viability of lesions after ablation.

Alternatives for MRI in Prostate Cancer Diagnostics-Review of Current Ultrasound-Based Techniques

The purpose of this review is to present the current role of ultrasound-based techniques in the diagnostic pathway of prostate cancer (PCa). With overdiagnosis and overtreatment of a clinically insignificant PCa over the past years, multiparametric magnetic resonance imaging (mpMRI) started to be recommended for every patient suspected of PCa before performing a biopsy. It enabled targeted sampling of the suspicious prostate regions, improving the accuracy of the traditional systematic biopsy. However, mpMRI is associated with high costs, relatively low availability, long and separate procedure, or exposure to the contrast agent. The novel ultrasound modalities, such as shear wave elastography (SWE), contrast-enhanced ultrasound (CEUS), or high frequency micro-ultrasound (MicroUS), may be capable of maintaining the performance of mpMRI without its limitations. Moreover, the real-time lesion visualization during biopsy would significantly simplify the diagnostic process. Another value of these new techniques is the ability to enhance the performance of mpMRI by creating the image fusion of multiple modalities. Such models might be further analyzed by artificial intelligence to mark the regions of interest for investigators and help to decide about the biopsy indications. The dynamic development and promising results of new ultrasound-based techniques should encourage researchers to thoroughly study their utilization in prostate imaging.

Contrast enhancement for ultrasound-guided interventions: when to use it and what to expect?

The use of contrast-enhanced ultrasonography (CEUS) has recently become synonymous with high-standard ultrasonography (US). From expanding the reach of US diagnostics to improving the precision of various invasive procedures, CEUS is rapidly becoming a standard in numerous niches. However, proficiency in CEUS comes with a cost, both from a learning curve and material standpoint, and as every growing field, lacks firm evidence and standardization. Therefore, in the current paper, we aim to provide an evidence-based review of available methods and to discuss the advantages and pitfalls of CEUS in interventional procedures, trying to provide strong evidence whenever available, or at least an educated expert opinion if data are lacking.

Frequency of synchronous malignant liver lesions initially detected by ultrasound in patients with newly diagnosed underlying non-hematologic malignant disease: a retrospective study in 434 patients

INTRODUCTION

This study described the frequency of malignant synchronous focal liver lesions (FLLs) in patients with newly diagnosed non-hematologic malignant disease.

METHODS

From June 2013 to January 2017, 434 patients with synchronous FLLs and newly diagnosed underlying malignant disease were included in the study. The diagnosis of the FLLs was made by histology and/or contrast-enhanced imaging. The final medical report was used for analysis in the study.

RESULTS

Of the 434 liver lesions, 258 (59.4%) were malignant and 176 (40.6%) benign. All malignant lesions were metastases. The benign liver lesions were comprised of 93 cysts (21.4%), 52 hemangiomas (12.0%), 20 focal fatty sparing (4.6%), 4 focal nodular hyperplasia (0.9%), 3 unspecified benign lesions (0.7%), 2 regenerative nodules (0.5%), 1 calcification (0.2%), and 1 adenoma (0.2%). Diseases with the highest percentage frequency of synchronous malignant FLLs were cholangiocarcinoma with 86.7%, neuroendocrine tumor with 72.7%, and pancreatic carcinoma with 72.0%. Gastric carcinoma (33.3%), breast carcinoma (44.4%), and urothelial cell carcinoma (45.5%) were the diseases with the lowest percentage frequency of synchronous malignant FLLs.

CONCLUSION

In total, the frequency of malignant synchronous FLLs in newly diagnosed non-hematologic malignant disease was 59.4%. In particular, cholangiocarcinoma, neuroendocrine tumor, and pancreatic carcinoma were the diseases with the highest rate of synchronous malignant FLLs.