Safe and pivotal approaches using contrast-enhanced ultrasound for the diagnostic workup of non-obstetric conditions during pregnancy, a single-center experience.

PURPOSE: Conventional ultrasound is the main imaging modality in obstetrics for assessing the maternal and fetal status. Up to date, contrast-enhanced ultrasound (CEUS) has not found widespread use in gynecology and obstetrics, but recent studies demonstrate promising results. The aim of the present study is to assess safe and valuable application of CEUS during pregnancy to investigate non-obstetric conditions. METHODS: Five pregnant patients on whom CEUS was performed between 2019 and 2020 were included in this retrospective single-center study. A total of six CEUS examinations were performed including one CEUS-guided biopsy (mean age: 31 years, mean weeks of pregnancy: 18 weeks). CEUS examinations were performed by a consultant radiologist (EFSUMB level 3). RESULTS: All included pregnant women safely underwent CEUS. Neither maternal nor fetal adverse effects were detected. CEUS critically helped in the diagnostic workup of a desmoid tumor of the abdominal wall, hepatic hemangioma, amebic hepatic abscess, uncomplicated renal cyst and post-inflammatory alteration of the renal cortex and for excluding active abdominal bleeding. In addition, CEUS-guided biopsy was performed to prevent intratumoral hemorrhage. Findings from CEUS prompted immediate treatment in two women, whereas in three women regular obstetric monitoring of the women could be conducted. CONCLUSION: Our results demonstrate safe and crucial application of off-label CEUS in pregnant women to assess different non-obstetric conditions allowing to prevent additional ionizing CT or application of (gadolinium-based) contrast agent in MRI. Hence, CEUS might add pivotal value for evaluating obstetric and non-obstetric conditions and thereby directing clinical management of pregnant women in the future.

Comparison of Magnetic Resonance Imaging and Contrast-Enhanced Ultrasound as Diagnostic Options for Unclear Cystic Renal Lesions: A Cost-Effectiveness Analysis.

PURPOSE: Correct differentiation between malignant and benign incidentally found cystic renal lesions has critical implications for patient management. In several studies contrast-enhanced ultrasound (CEUS) showed higher sensitivity with respect to the accurate characterization of these lesions compared to MRI, but the cost-effectiveness of CEUS has yet to be investigated. The aim of this study was to analyze the cost-effectiveness of CEUS as an alternative imaging method to MRI for the characterization of incidentally found cystic renal lesions. MATERIALS AND METHODS: A decision model including the diagnostic modalities MRI and CEUS was created based on Markov simulations estimating lifetime costs and quality-adjusted life years (QALYs). The recent literature was reviewed to obtain model input parameters. The deterministic sensitivity of diagnostic parameters and costs was determined and probabilistic sensitivity analysis using Monte-Carlo Modelling was applied. Willingness-to-pay (WTP) was assumed to be $ 100 000/QALY. RESULTS: In the base-case scenario, the total costs for CEUS were $9654.43, whereas the total costs for MRI were $9675.03. CEUS resulted in an expected effectiveness of 8.06 QALYs versus 8.06 QALYs for MRI. Therefore, from an economic point of view, CEUS was identified as an adequate diagnostic alternative to MRI. Sensitivity analysis showed that results may vary if CEUS costs increase or those of MRI decrease. CONCLUSION: Based on the results of the analysis, the use of CEUS was identified as a cost-effective diagnostic strategy for the characterization of incidentally found cystic renal lesions.

Should We Use Contrast-Enhanced Ultrasound (CEUS) for the Characterization of Nonpalpable Testicular Lesions? An Analysis from a Cost-Effectiveness Perspective.

PURPOSE: Accurate characterization of testicular lesions is crucial to allow for correct treatment of malignant tumors and to avoid unnecessary procedures in benign ones. In recent years, contrast-enhanced ultrasound (CEUS) proved to be superior in specifying the dignity of small, nonpalpable testicular lesions (< 1.5 cm) compared to native B-mode and color Doppler ultrasound which were previously regarded as the primary imaging method. However, the cost-effectiveness of CEUS has not been evaluated yet. The aim of this study was to analyze the cost-effectiveness of CEUS as compared to unenhanced ultrasound for the characterization of nonpalpable testicular lesions. METHODS: A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with unenhanced ultrasound and CEUS. Model input parameters were obtained from recent literature. Deterministic sensitivity analysis of diagnostic parameters and costs was performed. Also, probabilistic sensitivity analysis using Monte-Carlo Modelling was applied. The willingness-to-pay (WTP) was set to $100 000/QALY. RESULTS: In the base-case scenario, unenhanced ultrasound resulted in total costs of $5113.14 and an expected effectiveness of 8.29 QALYs, whereas CEUS resulted in total costs of $4397.77 with 8.35 QALYs. Therefore, the unenhanced ultrasound strategy was dominated by CEUS in the base-case scenario. Sensitivity analysis showed CEUS to be the cost-effective alternative along a broad range of costs. CONCLUSION: Contrast-enhanced ultrasound is a cost-effective imaging method for the characterization of nonpalpable testicular lesions.

Contrast-Enhanced Ultrasound (CEUS) for the Evaluation of Bosniak III Complex Renal Cystic Lesions-A 10-Year Specialized European Single-Center Experience with Histopathological Validation.

Background and objectives: The aim of the present retrospective single-center study is to evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) for assessing Bosniak III complex renal cystic lesions with histopathological validation. Materials and Methods: 49 patients with CEUS-categorized Bosniak III renal cystic lesions were included in this retrospective study. All patients underwent native B-mode, Color Doppler, contrast-enhanced ultrasound (CEUS) between 2010-2020. Eight and five patients underwent computed tomography (CT) and magnetic resonance imaging (MRI), respectively. Twenty-nine underwent (partial) nephrectomy allowing for histopathological analysis. The applied contrast agent for CEUS was a second-generation blood pool agent. Ultrasonography examinations were performed and interpreted by a single experienced radiologist with more than 15 years of experience (EFSUMB Level 3). Results: CEUS examinations were successfully performed in all included patients without registering any adverse effects. The malignancy rate of CEUS-categorized Bosniak III renal lesions accounted for 66%. Initially, cystic complexity was visualized in native B-mode. In none of the renal lesions hypervascularization was detected in Color Doppler. CEUS allowed for detection of contrast enhancement patterns in all included Bosniak III renal lesions. Delayed wash-out could be detected in 6/29 renal lesions. In two cases of histopathologically confirmed clear-cell RCC, appropriate up-grading from Bosniak IIF to III was achieved by CEUS. Conclusions: CEUS depicts a promising imaging modality for the precise diagnostic workup and stratification of renal cystic lesions according to the Bosniak classification system, thereby helping guidance of adequate clinical management in the future.

Structured Reporting of Head and Neck Sonography Achieves Substantial Interrater Reliability.

Purpose Ultrasound examinations are often criticized for having higher examiner dependency compared to other imaging techniques. Compared to free-text reporting, structured reporting (SR) of head and neck sonography (HNS) achieves superior time efficiency as well as report quality. However, there are no findings concerning the influence of SR on the interrater reliability (IRR) of HNS. Materials and Methods Typical pathologies (n=4) in HNS were documented by video/images by two certified head and neck ultrasound instructors. Consequently, structured reports of these videos/images were created by n=9 senior physicians at departments of otolaryngology or maxillofacial surgery with DEGUM instructors on staff. Reports (n=36) were evaluated regarding overall completeness and IRR. Additionally, user satisfaction was assessed by a visual analog scale (VAS). Results SR yielded very high report completeness (91.8%) in all four cases with a substantial IRR (Fleiss' κ 0.73). Interrater agreement was high at 87.2% with very good user satisfaction (VAS 8.6). Conclusion SR has the potential to ensure high-quality examination reports with substantial comparability and very high user satisfaction. Furthermore, big data collection and analysis are facilitated by SR. Therefore, process quality, workflow, and scientific output are potentially enhanced by SR.

Performance variability of radiomics machine learning models for the detection of clinically significant prostate cancer in heterogeneous MRI datasets.

Background: Radiomics promises to enhance the discriminative performance for clinically significant prostate cancer (csPCa), but still lacks validation in real-life scenarios. This study investigates the classification performance and robustness of machine learning radiomics models in heterogeneous MRI datasets to characterize suspicious prostate lesions for non-invasive prediction of prostate cancer (PCa) aggressiveness compared to conventional imaging biomarkers. Methods: A total of 142 patients with clinical suspicion of PCa underwent 1.5T or 3T biparametric MRI (7 scanner types, 14 institutions) and exhibited suspicious lesions [prostate Imaging Reporting and Data System (PI-RADS) score ≥3] in peripheral or transitional zones. Whole-gland and index-lesion segmentations were performed semi-automatically. A total of 1,482 quantitative morphologic, shape, texture, and intensity-based radiomics features were extracted from T2-weighted and apparent diffusion coefficient (ADC)-images and assessed using random forest and logistic regression models. Five-fold cross-validation performance in terms of area under the ROC curve was compared to mean ADC (mADC), PI-RADS and prostate-specific antigen density (PSAD). Bias mitigation techniques targeting the high-dimensional feature space and inherent class imbalance were applied and robustness of results was systematically evaluated. Results: Trained models showed mean area under the curves (AUCs) ranging from 0.78 to 0.83 in csPCa classification. Despite using mitigation techniques, high performance variability of results could be demonstrated. Trained models achieved on average numerically higher classification performance compared to clinical parameters PI-RADS (AUC =0.78), mADC (AUC =0.71) and PSAD (AUC =0.63). Conclusions: Radiomics models' classification performance of csPCa was numerically but not significantly higher than PI-RADS scoring. Overall, clinical applicability in heterogeneous MRI datasets is limited because of high variability of results. Performance variability, robustness and reproducibility of radiomics-based measures should be addressed more transparently in future research to enable broad clinical application.

Benefits of contrast-enhanced ultrasonography for interventional procedures.

For evaluating unclear tumorous lesions, contrast-enhanced ultrasonography (CEUS) is an important imaging modality in addition to contrast-enhanced computed tomography and magnetic resonance imaging, and may provide valuable insights into the microvascularization of tumors in dynamic examinations. In interventional procedures, CEUS can make a valuable contribution in pre-, peri-, and post-interventional settings, reduce radiation exposure and, under certain circumstances, decrease the number of interventions needed for patients.

Cost-Effectiveness Analysis of 68Ga DOTA-TATE PET/CT, 111In-Pentetreotide SPECT/CT and CT for Diagnostic Workup of Neuroendocrine Tumors.

Neuroendocrine tumors (NETs) are relatively rare neoplasms arising from the hormone-producing neuroendocrine system that can occur in various organs such as pancreas, small bowel, stomach and lung. As the majority of these tumors express somatostatin receptors (SSR) on their cell membrane, utilization of SSR analogs in nuclear medicine is a promising, but relatively costly approach for detection and localization. The aim of this study was to analyze the cost-effectiveness of 68Ga-DOTA-TATE PET/CT (Gallium-68 DOTA-TATE Positron emission tomography/computed tomography) compared to 111In-pentetreotide SPECT/CT (Indium-111 pentetreotide Single Photon emission computed tomography/computed tomography) and to CT (computed tomography) alone in detection of NETs. A decision model on the basis of Markov simulations evaluated lifetime costs and quality-adjusted life years (QALYs) related to either a CT, SPECT/CT or PET/CT. Model input parameters were obtained from publicized research projects. The analysis is grounded on the US healthcare system. Deterministic sensitivity analysis of diagnostic parameters and probabilistic sensitivity analysis predicated on a Monte Carlo simulation with 30,000 reiterations was executed. The willingness-to-pay (WTP) was determined to be $ 100,000/QALY. In the base-case investigation, PET/CT ended up with total costs of $88,003.07 with an efficacy of 4.179, whereas CT ended up with total costs of $88,894.71 with an efficacy of 4.165. SPECT/CT ended up with total costs of $89,973.34 with an efficacy of 4.158. Therefore, the strategies CT and SPECT/CT were dominated by PET/CT in the base-case scenario. In the sensitivity analyses, PET/CT remained a cost-effective strategy. This result was due to reduced therapy costs of timely detection. The additional costs of 68Ga-DOTA-TATE PET/CT when compared to CT alone are justified in the light of potential savings in therapy costs and better outcomes.

Contrast-Enhanced Ultrasound (CEUS) for Follow-Up of Bosniak 2F Complex Renal Cystic Lesions-A 12-Year Retrospective Study in a Specialized European Center.

Bosniak 2F renal cystic lesions feature morphologic characteristics between Bosniak I and III categories, the majority of which remain benign. However, a minor part of Bosniak 2F lesions may progress to malignancy. The purpose of this study was to assess Bosniak 2F cystic lesions during follow-up examinations by CEUS. One-hundred-and-twelve out of 364 patients with Bosniak 2F lesions underwent follow-up CEUS examinations between February 2008 and February 2020. Twelve out of 364 patients underwent renal surgery without follow-up CEUS. The progression rate of Bosniak 2F renal lesions detected by CEUS accounted for 7.1% (8/112 patients) after a mean of 12.9 months. The first follow-up CEUS revealed 75% of progressions (6/8), the remaining 25% (2/8) of progressions were detected during second follow-up CEUS. Underlying clear-cell renal cell carcinoma was histopathologically validated in 5/8 progressive complex cystic renal lesions. Stable sonomorphologic features were observed in 92.1% (104/112 patients). CEUS depicts a promising diagnostic imaging modality in the diagnostic work-up and follow-up of complex renal cystic lesions at higher spatial and temporal resolutions than CT or MRI. Its excellent safety profile, its easy and repeatable accessibility, and low financial costs render CEUS an attractive and powerful alternative imaging tool for monitoring complex renal cystic lesions.

Advanced Fusion Imaging and Contrast-Enhanced Imaging (CT/MRI-CEUS) in Oncology.

Fusion imaging depicts an innovative technique that facilitates combining assets and reducing restrictions of advanced ultrasound and cross-sectional imaging. The purpose of the present retrospective study was to evaluate the role of fusion imaging for assessing hepatic and renal lesions. Between 02/2011-08/2020, 92 patients in total were included in the study, of which 32 patients had hepatic lesions, 60 patients had renal lesions. Fusion imaging was technically successful in all patients. No adverse side effects upon intravenous (i.v.) application of SonoVue® (Bracco, Milan, Italy) were registered. Fusion imaging could clarify all 11 (100%) initially as indeterminate described hepatic lesions by computed tomography/magnetic resonance imaging (CT/MRI). Moreover, 5/14 (36%) initially suspicious hepatic lesions could be validated by fusion imaging, whereas in 8/14 (57%), malignant morphology was disproved. Moreover, fusion imaging allowed for the clarification of 29/30 (97%) renal lesions initially characterized as suspicious by CT/MRI, of which 19/30 (63%) underwent renal surgery, histopathology revealed malignancy in 16/19 (84%), and benignity in 3/19 (16%). Indeterminate findings could be elucidated by fusion imaging in 20/20 (100%) renal lesions. Its accessibility and repeatability, even during pregnancy and in childhood, its cost-effectiveness, and its excellent safety profile, make fusion imaging a promising instrument for the thorough evaluation of hepatic and renal lesions in the future.