Intraoperative contrast-enhanced ultrasound has an outcome-relevant impact on surgery of primary and metastatic liver lesions.

PURPOSE: Complete resection of the affected tissue remains the best curative treatment option for liver-derived tumors and colorectal liver metastases. In addition to preoperative cross-sectional imaging, contrast-enhanced intraoperative ultrasound (CE-IOUS) plays a crucial role in the detection and localization of all liver lesions. However, its exact role is unclear. This study was designed to evaluate the clinical and oncological impact of using CE-IOUS in the surgical treatment of these diseases. MATERIALS AND METHODS: Over the three-year study period, 206 patients with primary liver tumors and hepatic metastases were enrolled in this prospective, monocentric study to evaluate the impact of CE-IOUS in liver surgery. Secondary outcomes included comparing the sensitivity and specificity of CE-IOUS with existing preoperative imaging modalities and identifying preoperative parameters that could predict a strategic impact of CE-IOUS. In addition, the oncological significance of CE-IOUS was evaluated using a case-cohort design with a minimum follow-up of 18 months. RESULTS: CE-IOUS findings led to a change in surgical strategy in 34% of cases (n=70/206). The accuracy in cases with a major change could be confirmed histopathologically in 71.4% of cases (n=25/35). The impact could not be predicted using parameters assumed to be clinically relevant. An oncological benefit of a CE-IOUS adapted surgical approach was demonstrated in patients suffering from HCC and colorectal liver metastases. CONCLUSION: CE-IOUS may significantly increase R0 resection rates and should therefore be used routinely as an additional staging method, especially in complex liver surgery.

EFSUMB Technical Review - Update 2023: Dynamic Contrast-Enhanced Ultrasound (DCE-CEUS) for the Quantification of Tumor Perfusion.

Dynamic contrast-enhanced ultrasound (DCE-US) is a technique to quantify tissue perfusion based on phase-specific enhancement after the injection of microbubble contrast agents for diagnostic ultrasound. The guidelines of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) published in 2004 and updated in 2008, 2011, and 2020 focused on the use of contrast-enhanced ultrasound (CEUS), including essential technical requirements, training, investigational procedures and steps, guidance regarding image interpretation, established and recommended clinical indications, and safety considerations. However, the quantification of phase-specific enhancement patterns acquired with ultrasound contrast agents (UCAs) is not discussed here. The purpose of this EFSUMB Technical Review is to further establish a basis for the standardization of DCE-US focusing on treatment monitoring in oncology. It provides some recommendations and descriptions as to how to quantify dynamic ultrasound contrast enhancement, and technical explanations for the analysis of time-intensity curves (TICs). This update of the 2012 EFSUMB introduction to DCE-US includes clinical aspects for data collection, analysis, and interpretation that have emerged from recent studies. The current study not only aims to support future work in this research field but also to facilitate a transition to clinical routine use of DCE-US.

[Use of Contrast enhanced Ultrasound (CEUS) in the Head and Neck Area: Update]. / Anwendung der Kontrastmittelsonografie im Kopf-Hals-Bereich: Update.

With the help of contrast enhanced ultrasound, the diagnostic accuracy of conventional sonography can be increased in many areas of otorhinolaryngology. Vascularisation and tissue perfusion can be objectified through the examination. This offers promising approaches for example to monitor the therapy of metastatic cervical lymph nodes or in the treatment of vascular malformations. Contrast Enhanced Ultrasound (CEUS) also offers great potential for differential diagnosis, for example of thyroid nodules. Valid threshold values for the quantitative time intensity curve (TIC) analysis of cervical pathologies are currently still not available. Further studies are necessary. As there is currently no license for the use of contrast enhanced ultrasound in otorhinolaryngology patients must be informed about its off-label use before the examination. This article is intended to provide an overview of the current possibilities and to serve as an introduction to the topic.

Technical Aspects of High-Resolution Color-Coded Duplex Sonography for the Design of Perforator Flaps.

BACKGROUND: Technical aspects are of utmost significance for an efficient execution in designing perforator flaps with high-resolution color-coded Duplex sonography (CCDS). The following study evaluates decisive factors for a successful microvessel examination conducted by the microsurgeon. METHODS: Technical knowledge presented in this study was based on a series of more than 200 perforator flaps planned with CCDS. Flap reconstructions were performed at the University Hospital Regensburg, Germany, from July 2013 to January 2021. Standard high-resolution ultrasound (US) devices with linear multifrequency transducers of 4 to 18 MHz were used. Modes and device settings were evaluated regarding applicability by microsurgeons. Key steps for safe perforator identification and further optional steps for additional assessment should be discriminated. RESULTS: Different US modes including brightness mode (B-mode), color flow (CF), power Doppler (PD), pulse wave (PW), and blood flow (B-Flow) were used. Transducers from 15 MHz and up were favorable to detect microvessels. Knobology of a standard US device regarding buttons, switches, and specific onscreen options with relevance for perforator mapping was subcategorized in four different groups. For qualitative and quantitative evaluation of microvessels, different US modes were tested with respect to their usefulness.Vital elements of the CCDS exam are disaggregated into three key steps for safe perforator identification and three optional steps for further perforator characterization. A standardized protocol for the CCDS exams was applied. Downregulation of pulse-repetition frequency/scale to adapt device sensitivity to slow-flow velocities represented the most important criterion to visualize microvessels.Qualitative microvessel evaluation was performed in B-mode, CCDS, PD mode, and B-Flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode. CONCLUSION: Technical aspects with respect to proper device trimming and application decisively impact CCDS-guided perforator vessel identification and evaluation.

Routine restaging after primary non-surgical treatment of laryngeal squamous cell carcinoma-a review.

PURPOSE: Treatment of patients with laryngeal squamous cell carcinoma with radiotherapy or chemoradiation is an established alternative to laryngeal surgery in many cases, but particularly for advanced tumors without cartilage invasion. Imaging modalities face the challenge of distinguishing between posttherapeutic changes and residual disease in the complex anatomic subsite of the larynx. Guidelines concerning restaging of head and neck squamous cell carcinomas (HNSCC) are presented by the National Comprehensive Cancer Network (NCCN) and other national guidelines, but clearly defined recommendations for routine restaging particularly for laryngeal cancer are lacking. METHODS: A systematic search was carried out in PubMed to identify studies evaluating routine restaging methods after primary non-surgical treatment of laryngeal squamous cell carcinoma from 2009 to 2020. RESULTS: Only three studies were deemed eligible, as they included at least ≥50% patients with laryngeal squamous cell carcinoma and evaluated imaging modalities to detect residual cancer. The small number of studies in our review suggest restaging with fluoro-deoxy-glucose positron-emission tomography/computed tomography (FDG PET/CT) 3 months after initial treatment, followed by direct laryngoscopy with biopsy of the lesions identified by FDG PET/CT. CONCLUSION: Studies evaluating restaging methods after organ-preserving non-surgical treatment of laryngeal carcinoma are limited. As radiotherapy (RT), chemoradiotherapy (CRT), systemic therapy followed by RT and radioimmunotherapy are established alternatives to surgical treatment, particularly in advanced laryngeal cancers, further studies are needed to assess and compare different imaging modalities (e.g. PET/CT, MRI, CT, ultrasound) and clinical diagnostic tools (e.g., video laryngoscopy, direct laryngoscopy) to offer patients safe and efficient restaging strategies. PET or PET/CT 3 months after initial treatment followed by direct laryngoscopy with biopsy of the identified lesions has the potential to reduce the number of unnecessary laryngoscopies.

Suspicious breast lesions incidentally detected on chest computer tomography with histopathological correlation.

OBJECTIVE: To evaluate incidental breast lesions on chest computed tomography with histopathological correlation. It is important for general radiologist to characterize a breast lesion as benign, indetermined, or sufficiently suspicious to warrant further work-up. METHODS: A total of 35.000 chest CT examinations were performed between January 2016 and December 2020. 27 patients (mean age 70 years, age range 48-87 years) with incidental breast lesions were identified in this retrospective study. Two radiologists scored incidental breast lesions independently regarding their morphology, and the results were compared to histopathology which was obtained by an ultrasound-guided core needle biopsy or a surgical excision. RESULTS: Out of 35.000 chest CT examinations, a total of 31 incidental breast lesions in 27 patients were detected. Among the 31 lesions, 23 were malignant and 8 benign. The malignant lesions included 17 carcinomas and 6 metastases (4 lymphomas and 2 melanomas). The benign lesions contained 2 hematomas, 4 fat necrosis, and 2 fibrosis lumps. CONCLUSION: Chest computed tomography as a standard imaging technique is helpful for evaluation of suspicious breast lesions. This may ultimately influence patient management and lead to further imaging.

Intraoperative Characterization of Pancreatic Tumors Using Contrast-Enhanced Ultrasound and Shear Wave Elastography for Optimization of Surgical Strategies.

OBJECTIVES: To evaluate intraoperative contrast-enhanced ultrasound (IoCEUS) and intraoperative shear wave elastography (IoSWE) for characterization of focal pancreatic lesions (FPLs) in correlation with postoperative histologic results. Thereby, the impact of intraoperative ultrasound (US) on pancreas surgery was evaluated. METHODS: Intraoperative CEUS and SWE data from 54 patients, who underwent pancreas surgery between 2017 and 2019, were analyzed retrospectively. Ultrasound examinations were performed with multifrequency linear/T-shaped transducers (3-9 MHz) on a high-end US device (LOGIQ E9; GE Healthcare, Chicago, IL). To analyze FPL stiffness by SWE, regions of interest were placed to measure the shear wave speed (meters per second) and stiffness (kilopascals). After intravenous bolus injections of 2.4 to 10 mL of sulfur hexafluoride microbubbles, a dynamic analysis of FPL microvascularization from arterial to late phases was performed using IoCEUS considering hypoenhancement/irregular vascularization of macrocystic/small solid FPL malignancy criteria. Ultrasound findings were correlated with postoperative histologic results. The impact of intraoperative US on surgery was documented in each case. RESULTS: Of 54 FPLs, IoCEUS could correctly characterize 39 of 39 malignant and 6 of 15 benign FPLs; IoSWE 29 of 39 as malignant and 7 of 15 as benign. Intraoperative CEUS's sensitivity was 100%; specificity, 40%; accuracy, 83.3%; positive predictive value, 81.3%; and negative predictive value, 100% (P < .05). Applying cutoff values of 3 m/s and 28.7 kPa, SWE's sensitivity was 74.4%; specificity, 46.7%; accuracy, 66.7%; positive predictive value; 78.4%; and negative predictive value, 41.2% for cancer detection (P < .05). The combined use of both techniques showed an accuracy rate of 76%, sensitivity of 74.4%, and specificity of 33.3%. In 29.6%, US results had an immediate impact on surgery. CONCLUSIONS: Intraoperative SWE and CEUS are highly valuable techniques for intraoperative characterization of FPLs. Although IoCEUS proved to be superior to IoSWE, the combined use can be helpful in particular cases.

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study.

BACKGROUND: This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients. METHODS: Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System). RESULTS: 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site. CONCLUSION: This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

Contrast-enhanced ultrasound perfusion imaging of organs.

In multimodal radiologic imaging, contrast-enhanced ultrasound (CEUS) is increasingly used. One of the advantages of CEUS is the possibility of repeated application of contrast media without decreasing renal function or affecting the thyroid gland. Small solid liver lesions can be diagnosed and detected with high accuracy. Moreover, solid lesions in other abdominal organs can also be characterized. Frequent applications for solid lesions in the near field concern thyroid tumors and lymph nodes. For prostate diagnostics, CEUS can be used with an endorectal probe and perfusion imaging. This review explains how the additional (semi-)quantitative perfusion analysis, especially time-intensity curve (TIC) analyses, and wash-in/wash-out kinetics of integrated or external perfusion software programs facilitate new options in dynamic assessment of microvascularization during tumor follow-up care and even minimally invasive tumor therapy.

High-Resolution Ultrasound-Guided Perforator Mapping and Characterization by the Microsurgeon in Lower Limb Reconstruction.

BACKGROUND: Preoperative ultrasound (US)-guided perforator mapping has immensely simplified perforator flap planning. It may be executed by the microsurgeon. Device settings and selection of ultrasound modes are of utmost significance for detection of low-flow microvessels. The following study evaluates different US modes. METHODS: A prospective complete data acquisition was performed from July 2018 to June 2019 in a subset of patients who underwent US-guided flap planning. Multifrequency linear transducers were used applying five US modes. Brightness (B)-mode, color flow (CF), power Doppler (PD), pulse wave (PW), and B-flow modes were evaluated regarding applicability by microsurgeons. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were chosen to evaluate flow characteristics. US results were correlated to intraoperative findings. RESULTS: A total number of eight patients (six males and two females) undergoing anterolateral thigh (ALT) or superficial circumflex iliac artery perforator (SCIP) flap surgery received an extensive standardized US-guided perforator characterization. Qualitative evaluation was performed in B-mode, color-coded duplex sonography (CCDS), PD, and B-flow mode. Quantitative assessment was executed using PW-mode and CCDS measuring the microvessels' diameter (mm) and flow characteristics (PSV, EDV, and RI). CCDS provided a mean diameter of 1.93 mm (range: 1.2-2.8 ± 0.51), a mean systolic peak of 16.9 cm/s (range: 9.9-33.4 ± 7.79), and mean RI of 0.71 (range: 0.55-0.87 ± 0.09) for lower limb perforators. All perforators located with US were verified by intraoperative findings. An optimized, time-effective US mapping algorithm was derived. Qualitative parameters may be evaluated with B-mode, CF, or B-flow. Smallest microvessels may be assessed in PD-mode. Lowering pulse-repetition frequency (PRF)/scale is mandatory to image low-flow microvessels as perforators. Quantitative information may be obtained using PW-mode and the distance-measuring tool in CF-mode. Image and video materials are provided. CONCLUSION: CCDS proved to be a powerful tool for preoperative perforator characterization when using a structured approach and mapping algorithm. Different techniques may be applied for specific visualizations and performed by the microsurgeon.

Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS).

BACKGROUND: Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values. METHODS: Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings. RESULTS: In the examined patient group with 24 perforator flaps a 100% correlation was seen when comparing perforators detected with CCDS/PD with intraoperative findings using optimized US settings. Sensitivity, PPV, and accuracy of CCDS were 100% respectively. Mean PSV of 16.99 ± 6.07 cm/s, mean EDV of 5.01 ± 1.84 cm/s and RI of 0.7 ± 0.07 were measured in microvessels (PW-mode). CCDS proved to be superior compared to PD in correct diameter assessment showing a mean diameter of 1.65 ± 0.45 mm, compared to PD-mode 1.31 ± 0.24 mm. Mean PSV and EDV were higher in ALT than in SCIP flaps, RI was slightly higher in SCIP flaps (p > .05). There were no significant differences in size of different flaps' perforators (p > .05). CONCLUSION: CCDS represents a highly valuable tool in the daily practice of free flap reconstructions using optimized low flow US settings and multifrequency linear probes.

Changes of Material Elastic Properties during Healing of Ruptured Achilles Tendons Measured with Shear Wave Elastography: A Pilot Study.

Therapy options for ruptured Achilles tendons need to take into account the right balance of timing, amount and intensity of loading to ensure a sufficient biomechanical resilience of the healing tendon on the one hand, and to enable an adequate tensile stimulus on the other hand. However, biomechanical data of human Achilles tendons after rupture during the separate healing stages are unknown. Shear wave elastography is an ultrasound technique that measures material elastic properties non-invasively, and was proven to have a very good correlation to biomechanical studies. Taking advantage of this technology, 12 patients who suffered from an acute Achilles tendon rupture were acquired and monitored through the course of one year after rupture. Nine of these patients were treated non-operatively and were included for the analysis of biomechanical behaviour. A significant increase of material elastic properties was observed within the first six weeks after trauma (up to 80% of baseline value), where it reached a plateau phase. A second significant increase occurred three to six months after injury. This pilot study suggests a time correlation of biomechanical properties with the biological healing phases of tendon tissue. In the reparative phase, a substantial amount of biomechanical resilience is restored already, but the final stage of biomechanical stability is reached in the maturation phase. These findings can potentially be implemented into treatment and aftercare protocols.

Is low dose radiotherapy an effective treatment for Baker's cyst?

PURPOSE: Osteoarthritis of the knee is a common disease, often associated with a Baker's cyst. Besides osteoarthritis, also other joint pathologies of the knee can be causative for a Baker's cyst. Radiotherapy is known to be an effective treatment for osteoarthritis, with an anti-inflammatory effect. As the excessive production of synovia usually is associated with intraarticular inflammation, our hypothesis was that radiotherapy might positively influence the synovial production and reduce the volume of a Baker's cyst. MATERIALS AND METHODS: We performed a prospective trial, including 20 knees receiving radiotherapy for knee arthritis. Besides documentation of NRS (numeric rating scale), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score and Knee Society Score, the volume of the Baker's cyst was calculated for a short- (6 to 12 weeks) and long-term (9 to 12 months) follow-up. Ultrasonic volumetry was performed using an ultrasound device with a high-resolution multifrequency linear probe (6-9 MHz). RESULTS: Low-dose radiotherapy improved NRS, WOMAC score and Knee Society Score significantly. The mean volume of Baker's cyst decreased from 22.3 ml to 10.7 respectively 3.1 ml during follow-up. A decrease in volume of more than 25% compared to the baseline could be achieved for 75% of the patients in the short-term and 79% of the patients in the long-term follow up. CONCLUSION: Radiotherapy of knee osteoarthritis is an effective treatment that decreases the volume of a Baker's cyst. Most patients respond to the treatment. Whether radiotherapy is an effective treatment for Baker's cyst without associated osteoarthritis has to be further examined.

Contrast-Enhanced Ultrasound (CEUS) and Quantitative Perfusion Analysis in Patients with Suspicion for Prostate Cancer.

PURPOSE: The aim of this study was to investigate contrast-enhanced ultrasound (CEUS) parameters acquired by software during magnetic resonance imaging (MRI) US fusion-guided biopsy for prostate cancer (PCa) detection and discrimination. MATERIALS AND METHODS: From 2012 to 2015, 158 out of 165 men with suspicion for PCa and with at least 1 negative biopsy of the prostate were included and underwent a multi-parametric 3 Tesla MRI and an MRI/US fusion-guided biopsy, consecutively. CEUS was conducted during biopsy with intravenous bolus application of 2.4 mL of SonoVue® (Bracco, Milan, Italy). In the latter CEUS clips were investigated using quantitative perfusion analysis software (VueBox, Bracco). The area of strongest enhancement within the MRI pre-located region was investigated and all available parameters from the quantification tool box were collected and analyzed for PCa and its further differentiation was based on the histopathological results. RESULTS: The overall detection rate was 74 (47 %) PCa cases in 158 included patients. From these 74 PCa cases, 49 (66 %) were graded Gleason ≥ 3 + 4 = 7 (ISUP ≥ 2) PCa. The best results for cancer detection over all quantitative perfusion parameters were rise time (p = 0.026) and time to peak (p = 0.037). Within the subgroup analysis (> vs ≤ 3 + 4 = 7a (ISUP 2)), peak enhancement (p = 0.012), wash-in rate (p = 0.011), wash-out rate (p = 0.007) and wash-in perfusion index (p = 0.014) also showed statistical significance. CONCLUSION: The quantification of CEUS parameters was able to discriminate PCa aggressiveness during MRI/US fusion-guided prostate biopsy.

Intraoperative Shear Wave Elastography vs. Contrast-Enhanced Ultrasound for the Characterization and Differentiation of Focal Liver Lesions to Optimize Liver Tumor Surgery.

PURPOSE: Assessment of intraoperative quantitative shear wave elastography (SWE) and contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions (FLLs) during liver surgery using postoperative histopathological results as the gold standard. MATERIALS AND METHODS: US data of 79 consecutive patients with 98 FLLs who underwent liver surgery between 08/2015 - 06/2017 were prospectively acquired and retrospectively analyzed. Multifrequency linear/T-shaped probes (6 - 9 MHz) were used to store cine loops of at least 5 s and images of B-mode, SWE and CEUS. The first CEUS loop was continuously documented over 1 min. in each case. Quantitative SWE analysis of FLLs was performed by placing 5 regions of interest to measure shear wave speed (m/s) and stiffness (kPa). CEUS was evaluated during the arterial, portal venous and late phase after i. v. bolus injections of 2.4 - 10 ml sulfur hexafluoride microbubbles. Postoperative histopathology after tumor resection or intraoperative biopsy was obtained to confirm findings of SWE and CEUS. RESULTS: Of 98 FLLs in 79 patients (mean age: 58 years sd ±â€Š12y) 88 were malignant and 10 were benign ranging from 0.69 to 15.2 cm in size (mean: 2.8 cm, sd ±â€Š2.25 cm). SWE characterized 73/88 FLLs correctly as malignant and 7/10 as benign using a cut-off value of 2.5 m/s/21.3 kPa (p < 0.0005). The sensitivity was 83 %, specificity 70 %, accuracy 82 %. CEUS could correctly identify 86/88 malignant and 8/10 benign FLLs. The sensitivity was 98 %, specificity 80 %, accuracy 96 %. SWE could correctly identify 2 malignant FLLs which CEUS falsely characterized as benign. CONCLUSION: Intraoperative CEUS and SWE are excellent tools for the highly accurate visualization, characterization and malignancy assessment of hepatic tumors during liver surgery.

A direct comparison of contrast-enhanced ultrasound and dynamic contrast-enhanced magnetic resonance imaging for prostate cancer detection and prediction of aggressiveness.

INTRODUCTION: Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) analyse tissue vascularization. We evaluated if CEUS can provide comparable information as DCE-MRI for the detection of prostate cancer (PCa) and prediction of its aggressiveness. MATERIAL AND METHODS: A post-hoc evaluation of 92 patients was performed. In each patient CEUS and DCE-MRI parameters of the most suspicious lesion identified on MRI were analysed. The predictive values for discrimination between benign lesions, low-/intermediate- and high-grade PCa were evaluated. Results of targeted biopsy served as reference standard (benign lesions, n=51; low- and intermediate-grade PCa [Gleason grade group 1 and 2], n=22; high-grade PCa [≥ Gleason grade group 3], n=19). RESULTS: In peripheral zone lesions of all tested CEUS parameters only time to peak (TTPCEUS) showed significant differences between benign lesions and PCa (AUC 0.65). Of all tested DCE-MRI parameters, rate constant (Kep) was the best discriminator of high-grade PCa in the whole prostate (AUC 0.83) and in peripheral zone lesions (AUC 0.89). CONCLUSION: DCE-MRI showed a superior performance for detection of PCa and prediction of its aggressiveness. CEUS and DCE-MRI performed better in peripheral zone lesions than in transition zone lesions. KEY POINTS: • DCE-MRI gathers information about vascularization and capillary permeability characteristics of tissues. • DCE-MRI can detect PCa and predict its aggressiveness. • CEUS also gathers information about vascularization of tissues. • For detection of PCa and prediction of aggressiveness DCE-MRI performed superiorly. • Both imaging techniques performed better in peripheral zone lesions.

Percutaneous Treatment of Malignant Liver Lesions: Evaluation of Success Using Contrast- Enhanced Ultrasound (CEUS) and Perfusion Software.

AIM: Using new perfusion software for evaluation of the success of percutaneous treatments of malignant liver tumors with CEUS. MATERIALS AND METHODS: Retrospective analysis of 88 patients (74 male, 14 female; 30 - 84 years) with 165 malignant liver lesions. The lesions were 57 metastases and 108 HCCs. The success of interventional treatment (IRE n = 47; RFA n = 38; MWA n = 44; TACE n = 36) was evaluated by CEUS and perfusion software (VueBox®). CEUS was performed after injection of 1 - 2.4 ml of sulfur hexafluoride microbubbles (SonoVue®) using a 1 - 5 MHz convex probe. DICOM loops up to 1 min. in the ablation area were stored digitally in the PACS. Regions of interest (ROI) were manually placed in the center, the margins of the lesions as well as in the surrounding tissue. Using VueBox® peak, time to peak (TTP), mean transit time (mTT), rise time (RT), the wash-in and wash-out rate were calculated for the regions, in order to evaluate the success of the percutaneous treatment after the ablation in comparison to the ceCT/ceMRI up to 6 months after the treatment. RESULTS: There were significant differences in all cases between the center compared to the margins for the main perfusion parameters (peak, mTT, RT) (p < 0.001). Peak, wash-in and wash-out ratios were further analyzed with the type of lesion and the method of ablation. All parameters were significantly different between lesions treated successfully vs. lesions with recurrence. CONCLUSION: A combination of CEUS with perfusion imaging enables critical assessment of successful treatment after percutaneous interventional procedures for a malignant liver lesion.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version).

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Short Version).

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

Characterization of Focal Liver Lesions using CEUS and MRI with Liver-Specific Contrast Media: Experience of a Single Radiologic Center.

AIM: The purpose of this study was to compare contrast-enhanced ultrasound (CEUS), magnetic resonance imaging (MRI) using liver-specific contrast agent and a combination of both for the characterization of focal liver lesions (FLL). METHODS: 83 patients with both benign and malignant liver lesions were examined using CEUS and MRI after the intravenous administration of liver-specific contrast media. All patients had inconclusive results from prior imaging examinations. Histopathological specimens could be obtained in 53 patients. Ultrasound was performed using a multi-frequency curved probe (1 - 6 MHz) after the injection of 1 - 2.4 ml ultrasound contrast media. The sensitivity, specificity, positive predictive value and negative predictive value of CEUS, MRI and a combination of both (CEUS + MRI) were compared. RESULTS: The sensitivity, specificity, positive and negative predictive values regarding lesion classification were 90.9 %, 70.6 %, 92.3 % and 66.6 %, respectively, for CEUS; 90.9 %, 82.4 %, 95.2 % and 70.0 %, respectively, for MRI; and 96.9 %, 70.6 %, 92.7 % and 85.7 % respectively, for CEUS + MRI. There were no statistically significant differences. 6 malignant lesions were missed using CEUS or MRI alone (false negatives). The use of both modalities combined reduced the false-negative results to 2. CONCLUSION: CEUS and MRI with liver-specific contrast media are very reliable and of equal informative value in the characterization of focal liver lesions. The number of false-negative results can be decreased using a combination of the two methods.