Usefulness of real-time contrast-enhanced ultrasound guided coaxial needle biopsy for focal liver lesions

Risk factors of non-diagnostic percutaneous liver tumor biopsy: a single-center retrospective analysis of 938 biopsies based on cause of error

PURPOSE

To evaluate the risk factors of non-diagnostic results based on cause of error in liver tumor biopsy.

MATERIALS AND METHODS

This single-institution, retrospective study included 843 patients [445 men, 398 women; median age, 67 years] who underwent a total of 938 liver tumor biopsies between April 2018 and September 2022. An 18-G cutting biopsy needle with a 17-G introducer needle was used. Ultrasound was used as the first choice for image guidance, and computed tomography was alternatively or complementarily used only for tumors with poor ultrasound visibility. Non-diagnostic biopsies were divided into two groups depending on the cause of error, either technical or targeting error. Biopsies in which the biopsy needle did not hit the target tumor were classified as technical error. Biopsies in which insufficient tissue was obtained due to necrosis or degeneration despite the biopsy needle hitting the target tumor were classified as targeting error. This classification was based on pre-procedural enhanced-imaging, intro-procedural imaging, and pathological findings. Statistical analysis was performed using binary logistic regression.

RESULTS

The non-diagnostic rate was 4.6%. Twenty-six and seventeen biopsies were classified as technical and targeting errors, respectively. In the technical error group, tumor size ≤ 17 mm and computed tomography-assisted biopsy due to poor ultrasound visibility were identified as risk factors (p < 0.001 and p = 0.021, respectively), and the tumors with both factors had a significantly high risk of technical error compared to those without both factors (non-diagnostic rate: 17.2 vs 1.1%, p < 0.001). In the targeting error group, tumor size ≥ 42 mm was identified as a risk factor (p = 0.003).

CONCLUSION

Tumor size ≤ 17 mm and computed tomography-assisted biopsy due to poor ultrasound visibility were risk factors for technical error, and tumor size ≥ 42 mm was a risk factor for targeting error in liver tumor biopsies.

Clinical value of CEUS with tumour marker monitoring in evaluating the prognosis of HCC after MWA

PURPOSE

This study aims to evaluate the prognostic value of contrast-enhanced ultrasound (CEUS) combined with tumour markers in patients with hepatocellular carcinoma (HCC) undergoing microwave ablation (MWA).

METHODS

MWA patients with HCC were divided into good prognosis (n ​= ​75) and poor prognosis (n ​= ​69) groups. The levels of alpha-fetoprotein (AFP), carbohydrate antigen (CA19-9), and carcinoembryonic antigen (CEA) before and after MWA were analysed using an independent sample t-test. The correlation between prognosis, ablation lesion area, and tumour marker levels were analysed by Pearson's correlation. The diagnostic power of the ablation lesion area combined with tumour marker levels for the prognosis of patients with MWA was analysed using receiver operating characteristic (ROC) curves.

RESULTS

The levels of AFP, CA19-9, and CEA in the good prognosis group were significantly lower than those in the poor prognosis group (all P ​< ​0.001). The levels of all tumour markers were significantly negatively correlated with the prognosis of patients who underwent MWA (all r ​< ​0, P ​< ​0.001) and positively correlated with the area of tumour-ablated lesions (r ​> ​0, P ​< ​0.001). Moreover, the diagnostic efficacy of CEUS combined with tumour markers for the prognosis of patients who underwent MWA was significantly higher than that of either single diagnostic modality.

CONCLUSIONS

CEUS combined with tumour marker monitoring can effectively improve the accuracy of prognostic diagnosis in patients with MWA and provide a reference for timely and reasonable treatment and therapeutic evaluation.

Increasing utilization of contrast-enhanced ultrasound during abdominal biopsies: impact of an educational training program

RATIONAL AND OBJECTIVES

To increase utilization of contrast-enhanced ultrasound (CEUS) during ultrasound-guided targeted liver biopsies.

MATERIAL AND METHODS

Two educational training interventions performed to increase use of CEUS. First, 14 radiologists (fellowship-trained in Abdominal Imaging) given didactic teaching and case presentations on the use of CEUS. Second, hands-on teaching on how to use CEUS provided to the same group. To determine the efficacy of these two interventions, radiologists completed anonymous surveys to determine the level of understanding and acceptability of using CEUS before and 6 months after CEUS training. In addition, the percentage of CEUS assisted liver biopsies was compared for the 6 months before and 6 months after the training.

RESULTS

Pre-training survey completed by 11 radiologists and post-training survey completed by 9 radiologists. Before training, 11% survey responders use CEUS routinely, whereas 89% never or rarely used it. After training, 54% of respondents were new users and 100% reported they planned to use CEUS in the future. Unfamiliarity (71%) was the main reason for not using it. After training, 25% reported lack of comfort with using CEUS as the main reason for not using CEUS. During six months before training, CEUS was administered in 6% (10/172) of targeted liver biopsies. Six months after training, CEUS was used nearly twice as often (10%, 16/160, P = 0.09, 1-sided Boschloo test). The number of radiologists using CEUS increased to 57% (8/14) after training compared to 20% (3/14, P = 0.03, 1-sided Boschloo) before training.

CONCLUSION

Educational training intervention increases use of CEUS during ultrasound-guided targeted liver biopsies.

Usefulness of contrast-enhanced ultrasound-guided biopsy for suspected viable hepatocellular carcinoma after treatment: a single-arm prospective study

PURPOSE

The utility of contrast-enhanced ultrasound (CEUS)-guided liver biopsy in patients with treated hepatocellular carcinoma (HCC) was evaluated.

METHODS

This study prospectively enrolled 36 patients (mean age±standard deviation [SD], 65.3±9.2 years; 31 men) who underwent CEUS-guided biopsy for treated HCC between September 2020 and April 2022, constituting the CEUS group. An additional 60 patients (mean age±SD, 60.7±12.3 years; 50 men) who underwent B-mode image-guided biopsy for treated HCC between January 2017 and December 2018 were retrospectively enrolled in the B-mode, or control, group. Biopsy success rates were compared between CEUS and B-mode groups using the chi-square test.

RESULTS

The biopsy success rate in the CEUS group was 88.9% (32 of 36 patients), which was significantly higher than the 70.0% (42 of 60 patients) observed in the B-mode group (P=0.044). No significant difference was found between CEUS and B-mode groups in the size of the lesions targeted for biopsy (mean±SD, 3.8±2.3 cm vs. 3.7±3.3 cm, respectively; P=0.332). For both the whole tumor and the viable tumor, conspicuity scores were significantly higher on CEUS than on grayscale ultrasound in the CEUS group (whole tumor: 2.7±0.5 vs. 1.8±0.9, P<0.001; viable tumor: 2.6±0.7 vs. 1.4±0.8, P<0.001). Relative to non-diagnostic results, diagnostic results more frequently exhibited a late mild washout pattern (87.5% [28 of 32] vs. 25.0% [1 of 4], P=0.004). No significant difference in the arterial enhancement pattern was noted between these subgroups (P=0.415).

CONCLUSION

By increasing the viable-tumor conspicuity, CEUS-guided biopsy is useful for confirmative histopathologic diagnosis in patients with treated HCC.

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 Contrast Agent Priming of Biopsy and Introducer Needles by Using a Small Syringe to Improve Needle Visibility in a Phantom Model

PURPOSE

Biopsy under the guidance of contrast-enhanced ultrasound is sometimes useful. Needle visualization in contrast-specific imaging-mode is often poor; however, it may be improved by priming the needles with an ultrasound contrast agent. This study aimed to evaluate needle priming methods using the ultrasound contrast agent sulfur hexafluoride and a 1 mL syringe.

MATERIAL AND METHODS

Two kinds of biopsy needles, side-notch and full core, and one kind of introducer needle were primed using non-primed needles as controls (n = 180). Recordings of punctures were performed in a water bath phantom to which the ultrasound contrast agent had also been added. Contrast-specific imaging-mode needle visibility was evaluated for the entire needles and the needle tips, respectively, quantitatively by calculating the contrast-to-noise ratio and qualitatively via grading by three radiologists.

RESULTS

The contrast-to-noise ratio following the ultrasound contrast agent priming was superior compared to the controls for the entire needles of all three types (p < 0.001) and for the needle tips of the core biopsy needles and introducer needles (p < 0.001). However, the ratio was equal to the controls for the needle tips of the side-notch biopsy needles (p = 0.19). Needle visibility following the ultrasound contrast agent priming was qualitatively superior compared to the controls for both the entire needles and the needle tips, and the difference was considered clinically relevant by the assessors (p < 0.001).

CONCLUSION

The ultrasound contrast agent needle priming methods described increased the contrast-specific imaging-mode needle visibility in a phantom model. Nonetheless, the results also need to be confirmed in vivo.

Efficacy and safety of ultrasound-guided core needle biopsies (US-CNBs) in cervical lymphadenopathy in patients with suspected head and neck cancer during the COVID-19 pandemic

BACKGROUND

Cervical lymphadenopathy can be benign or malignant. Its accurate diagnosis is necessary to determine appropriate treatment. Ultrasound-guided core needle biopsies (US-CNBs) are frequently used as a percutaneous sampling approach.

OBJECTIVES

Our aim was to identify the efficacy and safety of US-CNBs in 125 patients with cervical lymphadenopathy and clinically suspected head and neck cancer during the COVID-19 pandemic with limited surgical resources.

METHODS

US-CNBs of pathological lymph nodes were performed in 146 lymph nodes on 125 patients. Biopsies were performed ultrasound-guided with a reusable gun core biopsy system and a 10-cm-long 16-G needle. Standard of reference for the histological findings were panendoscopy, clinical and sonographic follow-up, surgical biopsy or a repeat US-CNB.

RESULTS

Adequate material for histologic diagnosis was obtained in 111 patients (89%), of these 83 patients (75%) were diagnosed as malignant, whereas benign lymphadenopathy accounted for 28 patients (25%). Therefore, US-CNB was able to identify malignant or benign lymphadenopathy with an overall accuracy of 88% and 90%, respectively.

CONCLUSIONS

Percutaneous US-CNB is a safe and effective alternative to surgical biopsy in the management of cervical lymphadenopathy in patients with clinically suspected head and neck cancer in a setting with limited resources.

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.

Real-time CEUS-guided biopsy revealing a littoral cell angioma of the spleen after inconclusive CT and MRI findings

The aim of this case report is to present real-time CEUS-guided biopsy for diagnosing rare benign splenic pathologies after inconclusive findings on cross-sectional imaging. We present the case of a 50-year-old male patient who received a contrast-enhanced computed tomography scan of the thorax during the evaluation for lung transplant due to lung fibrosis, with incidental finding of disseminated hypodense splenic lesions. During follow-up imaging, the patient did not tolerate a complete MRI examination, and two acquired pulse sequences did not confirm the final diagnosis. While CT-guided biopsy revealed no results, CEUS-guided target biopsy with repeated contrast injections showed a benign littoral cell angioma of the spleen. The use of real-time CEUS-guided target biopsy during lesion washout may be a useful tool to improve the accuracy of biopsy and accelerate the diagnosis in patients with parenchymal lesions after inconclusive cross-sectional imaging findings which may pose a challenge for CT-guided biopsy.

Contrast-enhanced US for the Interventional Radiologist: Current and Emerging Applications

US is a powerful and nearly ubiquitous tool in the practice of interventional radiology. Use of contrast-enhanced US (CEUS) has gained traction in diagnostic imaging given the recent approval by the U.S. Food and Drug Administration (FDA) of microbubble contrast agents for use in the liver, such as sulfur hexafluoride lipid-type A microspheres. Adoption of CEUS by interventional radiologists can enhance not only procedure guidance but also preprocedure patient evaluation and assessment of treatment response across a wide spectrum of oncologic, vascular, and nonvascular procedures. In addition, the unique physical properties of microbubble contrast agents make them amenable as therapeutic vehicles in themselves, which can lay a foundation for future therapeutic innovations in the field in drug delivery, thrombolysis, and vascular flow augmentation. The purpose of this article is to provide an introduction to and overview of CEUS aimed at the interventional radiologist, highlighting its role before, during, and after frequently practiced oncologic and vascular interventions such as biopsy, ablation, transarterial chemoembolization, detection and control of hemorrhage, evaluation of transjugular intrahepatic portosystemic shunts (TIPS), detection of aortic endograft endoleak, thrombus detection and evaluation, evaluation of vascular malformations, lymphangiography, and percutaneous drain placement. Basic physical principles of CEUS, injection and scanning protocols, and logistics for practice implementation are also discussed. Early adoption of CEUS by the interventional radiology community will ensure rapid innovation of the field and development of future novel procedures. Online supplemental material is available for this article. ^©RSNA, 2020.

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

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

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

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Complications After Percutaneous Ultrasound-Guided Liver Biopsy: A Systematic Review and Meta-analysis of a Population of More Than 12,000 Patients From 51 Cohort Studies

OBJECTIVES

Percutaneous liver biopsy (LB) has been considered the reference standard in distinguishing the degree of liver disease, but there has been no definitive systematic review to assess complication rates or potential risk factors for them.

METHODS

In this study, we searched the PubMed, Embase, Web of Science, and Scopus databases for studies appraising complication rates after percutaneous ultrasound (US)-guided LB published until October 11, 2018. The safety and efficacy of US-guided LB were estimated according to major and minor complications. Subgroups including the biopsy style, needle styles, mean number of needle insertions, study period, and specific complication items were analyzed.

RESULTS

Among 12,481 patients from 51 studies, pooled results showed a low rate (0; 95% confidence interval, 0-0) of major and minor complications. The subgroup analysis indicated that US-guided LB had a low major complication rate of 0 (0-0) for both fine-needle aspiration and core biopsy, with rates of 0.016 (0-0.032) for 14-gauge, 0.010 (0.003-0.017) for 15-gauge, 0.002 (-0.001-0.005) for 20-gauge, and 0 (0-0) for 16-, 17-, 18-, 21-, and 22-gauge needles, and low minor complication rates of 0 (0-0) for fine-needle aspiration and 0.001 (0-0.002) for core biopsy, with rates of 0.164 (0.137-0.191) for 15-gauge, 0.316 (0.113-0.519) for 16-gauge, and 0 (0-0) for 14-, 17-, 18-, 20-, 21-, and 22-gauge needles. Furthermore, specific complication rates of bleeding, pain, pneumothorax, vasovagal reactions, and death were all 0 (0-0).

CONCLUSIONS

These findings suggest that it is possible to safely perform percutaneous US-guided LB.