Activity-based cost analysis of contrast-enhanced ultrasonography (CEUS) related to the diagnostic impact in focal liver lesion characterisation

Non-radiomics imaging (US-CEUS) features and clinical text features: correlation with microvascular invasion and tumor grading in hepatocellular carcinoma

OBJECTIVES

To predict microvascular invasion (MVI) status and tumor grading of hepatocellular carcinoma (HCC) by evaluating preoperative non-radiomics ultrasound and contrast-enhanced ultrasound (US-CEUS) features and determine the influences of MVI/tumor grading on the category of CEUS LI-RADS for HCC.

METHODS

A total of 506 HCC patients who underwent preoperative US-CEUS examinations from 8 hospitals between July 2020 and June 2023 were enrolled. According to the MVI status, all the patients were classified, and HCC differentiation was assessed by using Edmondson-Steiner (ES) grading: MVI-negative (M0) and low-grade ES (GI/II) (MN-L, n = 297) and MVI-positive (M1/M2) and/or high-grade ES (GIII/IV) (MP-H, n = 209). Stratified analysis was performed based on fibrosis stage and tumor size.

RESULTS

The results proved that MN-L HCC was more frequently classified into the LR-5 category (p = 0.034), while MP-H HCC was more frequently classified into the LR-TIV (p = 0.010). The heterogeneously arterial phase hyperenhancement (APHE) is significantly correlated with MVI(+)/high grade-ES (p = 0.003). Compared with MN-L HCC, the onset of washout was earlier, washout rate was higher, and tumor-invasion border was larger (all p < 0.01) in MP-H HCC. In addition, fibrosis stage and tumor size significantly influenced the onset of washout and washout rate of HCC (all p < 0.01). The tumor-invasion border was only positively correlated with tumor size (p < 0.001) rather than fibrosis stage (p > 0.05).

CONCLUSIONS

MVI status and tumor grading influence the classification of LR-5 and LR-TIV. Heterogeneous APHE, higher washout rate, earlier onset of washout (≤65 s), larger tumor-invasion border (≥3 mm) and higher alpha fetoprotein level indicate the presence of MVI and/or high-grade ES.

Diagnosing Pancreatic Adenocarcinoma With Contrast-Enhanced Ultrasonography: A Literature Review of Research in Europe and Asia

The National Cancer Institute names pancreatic cancer the 11^th most common type of cancer in the United States. However, even with a somewhat low prevalence, in 2017, the American Cancer Society reported pancreatic cancer as the fourth leading cause of cancer-related death. With a lack of symptomology and a broad range of risk factors, pancreatic cancer is frequently diagnosed in a later phase than many other types of cancers, thus resulting in higher metastasis along with a poorer prognosis. This highlights the need for early detection and diagnosis. Currently, abdominal ultrasound or contrast-enhanced CT imaging of the abdomen are standard of care. A new technology: contrast-enhanced ultrasound (CEUS), which employs contrast agents to act as acoustic enhancers for ultrasound, has FDA approval for use in hepatic and renal lesions, but not pancreatic. By examining seven individual studies from Europe and Asia, this review aims to examine the diagnostic value of CEUS to initially diagnose pancreatic adenocarcinomas, potentially followed by a biopsy to confirm, when compared against modalities currently used such as conventional ultrasound and CT imaging. CEUS would potentially be more accurate when compared to conventional ultrasound due to the addition of contrast, and when compared against CT and MRI, CEUS would be advantageous in its low cost, similar sensitivities, and specificities, limited renal toxicity, lack of ionizing radiation, short half-life, and its safe use in both adult and pediatric patients. Due to this, additional research is warranted for further FDA approval and future clinical implementation.

Circulating MicroRNA-21 As A Novel Noninvasive Biomarker for Hepatocellular Carcinoma Compared with Alpha Fetoprotein Gold Test

Hepatocellular carcinoma (HCC) is the greatest traditional kind of pre-eminent cancer worldwide, which happens mainly in chronic liver disease and cirrhotic patients. The available surveillance strategies for suspected HCC patients include serum alpha-fetoprotein (AFP) and liver imaging have been mainly recommended. However, the sensitivity and selectivity of these diagnostic strategies especially in the early stages of HCC have many obstacles. MicroRNAs (miRNAs) are non-coding RNAs that are 18–25 nucleotides in length. Plasma miRNAs may be a promising new biomarker for cancer detection and prognosis in the early stages. Assessment of Plasma MicroRNA-21 (miRNA-21) significance as a noninvasive Hepatocellular carcinoma marker compared with AFP gold standard test to improve HCC early diagnostic power. This is a prospective research project that included 90 patients in total, split into three classes., liver cirrhosis patients (LC) without any malignancies and (HCC) patients in addition to the healthy control group. Patients and controls were subjected to the clinical studies, routine investigations, imaging studies, and detection of plasma miRNA-21 & AFP. miRNA-21 showed a highly significant difference in the 3 studied groups. Control group with LC group, control group with HCC group, and LC group with HCC group P value (P 0.0001, P1 0.0001, P2 0.0001and P3 0.0001) respectively. Also, a highly significant difference was observed between pre-TACE and post-TACE miRNA-21 in the HCC group P value (0.0001). Circulating miRNA-21 may be used as a noninvasive co biomarker with AFP to increase HCC diagnostic accuracy in its early stages.

Round table: arguments against using multiparametric prostate MRI protocols

Biparametric MRI (bpMRI), which uses only T2-weighted imaging and diffusion-weighted imaging, continues to gain support for the detection of prostate cancer, as this imaging technique offers many benefits over traditional mpMRI. However, the Prostate Imaging Reporting and Data System (PI-RADS) v2.1 document released in 2019 emphasized that mpMRI is still preferred over bpMRI in most clinical scenarios. As one article in a series of four providing arguments for and against using mpMRI and bpMRI protocols, this paper provides arguments against using mpMRI. Within this article, we discuss recent data suggesting equivalent performance between bpMRI and mpMRI in the detection of prostate cancer. The limited utility of dynamic contrast enhancement in the evaluation of prostate cancer according to the PI-RADS v2.1 document is also reviewed. Finally, we detail the large financial and time costs, legal and logistical issues, and potential for patient harm that must be considered with the administration of contrast.

CEUS LI-RADS: a pictorial review

Contrast-enhanced ultrasound (CEUS) greatly improved the diagnostic accuracy of US in the detection and characterization of focal liver lesions (FLLs), and it is suggested and often included in many international guidelines as an important diagnostic tool in the imaging work-up of cirrhotic patients at risk for developing hepatocellular carcinoma (HCC). In particular, CEUS Liver Imaging Reporting and Data System (LI-RADS) provides standardized terminology, interpretation, and reporting for the diagnosis of HCC. The aim of this pictorial essay is to illustrate CEUS features of nodules discovered at US in cirrhotic liver according to LI-RADS categorization.

Contrast-enhanced ultrasonography (CEUS) in the follow-up of pediatric abdominal injuries: value and timing

AIMS

Primary aim was to investigate the value and safety of contrast-enhanced ultrasonography (CEUS) during follow-up (FU) of splenic, hepatic and renal post-traumatic injuries in a pediatric population. Secondary aim was to extrapolate appropriate timing of FU-CEUS.

METHODS

In a retrospective study, post-traumatic parenchymal injuries diagnosed with CT or CEUS, were subjected to non-operative management and followed with CEUS.

RESULTS

Forty-six patients were enrolled, with isolated or combined injuries, for a total of 30 splenic, 15 hepatic and 12 renal injuries. At admission 42/46 patients underwent CT and 4/46 underwent CEUS. During FU a total of 65 CEUS were performed: 16 within 72 h to check delayed active bleeding or parenchymal rupture; 24 between 5 and 10 days post admission, to pose indication to active mobilization or to discharge; 21 between 20 and 60 days post admission to document complete healing of the lesion or pose indication to discharge in most severe injuries. No complications related to CEUS were encountered.

CONCLUSIONS

CEUS is valuable and safe to follow patients with post-traumatic abdominal injuries, even if further data are needed for renal injuries. We propose a tailored approach based on injury grade and clinical course: in the first 3 days only in case of delayed bleeding or rupture suspect; between 5 and 10 days post trauma to ensure a safe active mobilization and/or pose indication to discharge, and over 20-30 days post trauma to pose indication to discharge in most severe injuries or document complete healing and permit return to sport activities.

Contrast-Enhanced Ultrasound Features of Hepatic Reactive Lymphoid Hyperplasia: Correlation With Histopathologic Findings

OBJECTIVES

To find certain specifics of hepatic reactive lymphoid hyperplasia (HRLH) on contrast-enhanced ultrasound (CEUS) imaging as diagnostic imaging clues by retrospectively analyzing its enhancement features.

METHODS

From June 2010 to June 2017, 18 histopathologically confirmed HRLH lesions in 18 patients were included in this retrospective study. The lesion's location, maximum diameter, shape, margin, echogenicity, and color flow signal on conventional ultrasound (US) imaging and enhancement pattern, presence of a feeding artery, and donutlike enhancement on CEUS imaging were observed and recorded. The lesion size on CEUS imaging at peak enhancement and that on conventional US imaging were compared and recorded.

RESULTS

All of the lesions showed homogeneous hypoechogenicity with a regular well-defined margin on conventional US imaging, with a mean diameter ± SD of 14.3 ± 4.6 mm (range, 8-24 mm). On CEUS imaging, all of the lesions showed "quick-wash-in and quick-wash-out," which showed complete homogeneous hyperenhancement in the arterial phase and wash-out in the second half of the arterial phase or first half of the portal phase. In 83.3% (15 of 18) of the lesions, the lesion size that was enhanced at peak was enlarged compared with the hypoechoic area on conventional US imaging, and transient donutlike enhancement appeared when the lesion showed wash-out. In 55.6% (10 of 18) of cases, the feeding artery was detected.

CONCLUSIONS

Enlarged complete homogeneous hyperenhancement in the arterial phase, consequently followed by quick wash-out of the lesion and the appearance of donutlike enhancement, may be the CEUS features of HRLH.

Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma

Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.

A comparative study of color Doppler imaging and contrast-enhanced ultrasound for the detection of ulceration in patients with carotid atherosclerotic disease

OBJECTIVES

To evaluate the diagnostic accuracy of color Doppler imaging (CDI) and contrast-enhanced ultrasound (CEUS) for diagnosing carotid ulceration, having multi-detector computed tomography angiography (MDCTA) as the reference method.

METHODS

Patients with carotid disease referred for ultrasound (US), either due to the occurrence of neurovascular symptoms or for screening purposes, were included in this study if at least one plaque causing moderate (50-69%) or severe (70-99%) internal carotid artery stenosis was detected. Carotid US with CDI technique, CEUS, and MDCTA were performed in all patients, investigating the presence of ulceration. The agreement between modalities was evaluated using kappa statistics.

RESULTS

The study population included 54 patients (median age 62 years, inter-quartile range 16.2) and 66 carotid arteries. The mean degree of stenosis was 68.5% (SD 12.2%) while 47.1% of plaques were symptomatic. MDCTA characterized 28.8% of plaques as smooth, 45.5% irregular, and 24.3% ulcerated. Flow reversal was detected with CDI in 65.5% of ulcerations, while swirling of the microbubbles and neovessels adjacent to the ulcer were detected with CEUS in 17.64%. The agreement for ulceration diagnosis was moderate between CDI and CEUS (kappa 0.473) and between CDI and MDCTA (kappa 0.473) and very good between CEUS and MDCTA (kappa 0.921). The sensitivity, specificity, and positive and negative predictive values of CDI for the diagnosis of ulceration were 41.2%, 97.95%, 87.5%, 82.8% respectively, while CEUS respective measures were 94.1%, 97.95%, 94.1%, and 97.95%.

CONCLUSION

CEUS outperformed CDI in terms of agreement with MDCTA and diagnostic accuracy for the diagnosis of ulcerated carotid plaque.

KEY POINTS

• Superficial ulceration is a significant feature of carotid plaque vulnerability. • Color Doppler imaging has the potential to demonstrate carotid plaque ulceration but is characterized by limited sensitivity and moderate agreement with the reference method of multi-detector computed tomography angiography. • Contrast-enhanced ultrasound outperforms color Doppler imaging in terms of sensitivity for the detection of carotid plaque ulceration and in agreement with the reference method of multi-detector computed tomography angiography.

Contrast enhanced ultrasound for focal liver lesions: how accurate is it?

With the recent FDA approval for characterization of focal liver lesions (FLL) in both pediatric and adult patients using Lumason (sulfur hexafluoride microbubbles), increased use of ultrasound contrast for routine clinical use is expected. This agent has been available for many years in Europe and Asia, and a large body of literature is available regarding the sensitivity and specificity of this agent. In addition, a few studies have directly compared CEUS to CECT and CEMRI for the characterization of focal liver lesions. This paper reviews the literature to provide a background to investigators in the United States as to the accuracy of CEUS in the characterization of FLL. This paper reviews the literature regarding sulfur hexafluoride microbubbles (Lumason in the USA and Sonovue in the rest of the world) since it is the only FDA approved agent in the USA for characterization of FLL. The results of other ultrasound contrast agents which are not FDA approved for abdominal indications (approval for cardiac indications) most likely will have similar results.