Characterization of focal liver lesions using contrast enhanced ultrasound as a first line method: a large monocentric experience.

AIM: To present a large monocentric experience in the characterization of focal liver lesions (FLLs) using Contrast Enhanced Ultrasound (CEUS). METHOD: A retrospective study was performed in the Gastroenterology and Hepatology Department, Timisoara, including 1100 patients with 1329 FLLs evaluated between September 2009 and January 2013. A CEUS examination was considered conclusive if the FLL respected the typical enhancement pattern as described in the EFSUMB Guidelines. RESULTS: From the 1329 FLLs, CEUS was conclusive for a specific pathology in 1102 cases (82.9%). For the differentiation of benign/malignant lesions, CEUS reached a conclusive diagnosis in 1196 (90%) cases. The percentage of conclusive CEUS examinations was significantly higher in patients without chronic liver disease as compared with those with chronic hepatopathies: 87.3% vs. 74.4% (p<0.0001). CONCLUSION: CEUS patterns of enhancement fell into clear cut specific diagnostic patterns in 83% of the FLLs discovered by US, and into clear cut benign versus malignant patterns in 90% of the cases. For this reason, we can strongly recommend CEUS as a first line imaging method to characterize FLLs found at US, at least in centers with a good experience in CEUS.

Contrast enhanced ultrasound in the pathology of the pancreas - a monocentric experience.

UNLABELLED: The AIM: of this study was to summarize the spectrum of pancreatic pathology assessed by contrast enhanced ultrasound (CEUS) in a single Gastroenterology Center and to emphasize its accuracy in assessing two of the most important pancreatic lesions: solid tumors and necrotic lesions in acute pancreatitis. MATERIAL AND METHODS: Our retrospective study included 197 patients with pancreatic lesions (de novo pancreatic masses; acute, severe pancreatitis; other pathologies) evaluated by CEUS from October 2009 to May 2013, in which a reference method (contrast CT/MRI) was available. RESULTS: A conclusive diagnosis was established according to the EFSUMB Guidelines in 87.8% of the 197 cases. In 87.3% cases there was a perfect concordance between CEUS and the reference method (contrast CT/MRI). 95 examinations were made for pancreatic solid masses: 41.1% (39) were hypoenhanced, 34.7% (33) were hyperenhanced, and 20% (19) were isoenhancing - chronic pancreatitis and autoimmune pancreatitis - while in 4.2% (4) cases CEUS was inconclusive. 60 examinations were made in severe acute pancreatitis and in 50% (30) cases pancreatic necrosis was diagnosed. 42 examinations were performed for other lesions: 64.2% (27) pancreatic pseudocysts, 11.9% (5) cystic tumors, 23.8% (10) other pathologies (abscesses, fibrosis, etc). CEUS accuracy for solid tumors was 92.9%. For necrotic lesions the accuracy was 97.4%. CONCLUSIONS: CEUS has turned to be a good method for the characterization of different pancreatic pathologies and for evaluating acute pancreatitis. CEUS was conclusive in 90% cases and it should be considered as a first line imaging method in clinical practice.

How often hepatocellular carcinoma has a typical pattern in contrast enhanced ultrasound?

OBJECTIVES: Contrast Enhanced Ultrasound is an imaging method that can evaluate imediatelly focal liver lesions discovered by ultrasound.The aim of this study is to demonstrate if Contrast Enhanced Ultrasound can be reliable as a diagnostic method for hepatocellular carcinoma. MATERIAL AND METHODS: We included in our retrospective monocentric study all patients evaluated in our Department during 2 years, which had hepatocellular carcinoma as final diagnosis (using Contrast Enhanced Ultrasound, Contrast Enhanced Computed Tomography, Magnetic Resonance Imaging or biopsy). 91 patients with chronic liver diseases were evaluated, with a total of 114 liver nodules. The enhancement pattern of the nodules was evaluated according to the 2008 guidelines of the European Federation of Societies for Ultrasound in Medicine and Biology. The lesions with arterial enhancement and washout in the portal or late phase were considered hepatocellular carcinoma. The nodules were classified according to their size in ≤3 cm and >3 cm. OUTCOMES: Of all nodules, 103 had hyperenhancing arterial pattern and washout was observed in 79 cases. In our study, this method established the diagnosis of hepatocellular carcinoma in 45 of 55 cases with liver nodules larger than 3 cm (81.8%) vs. 34 of 59 cases with nodules smaller than 3 cm (57.6%) (p<0.001). CONCLUSIONS: 69.3% of all hepatocellular carcinoma had a typical enhancement pattern on Contrast Enhanced Ultrasound, performing better in nodules larger than 3 cm, than in smaller nodules (p<0.001).

The contribution of contrast enhanced ultrasound for the characterization of benign liver lesions in clinical practice - a monocentric experience.

INTRODUCTION: Contrast-enhanced ultrasound (CEUS) uses second generation microbubble contrast agents and is considered to be a useful imaging method for focal liver lesions (FLLs) characterization. AIM: To observe if CEUS increases the diagnostic performance of benign FLLs as compared with standard ultrasonography examination (US). PATIENTS AND METHODS: This is a single centre study developed during September 2009- December 2011 in the Department of Gastroenterology and Hepatology, in Timisoara. We evaluated 386 benign FLLs diagnosed by means of CEUS. Before performing CEUS, all FLLs were examined by US and Power Doppler techniques. At CEUS, the benign nature of a lesion was established by the absence of washout in the portal and late phase. The typical features observed using contrast, allowed their classification in a particular type of pathology, according to the 2008 EFSUMB Guidelines. RESULTS: From 386 benign FLLs, 81 (20.9%) of them were diagnosed in patients with chronic liver disease, while 305 (79.1%) were in patients without chronic hepatopathy. In 355 (92%) cases CEUS established a particular type of pathology. The most frequent lesions were: hemangiomas (37.5%), focal fatty alterations (24.8%), complex cysts (10.7%) and regenerative nodules (11.8%). Based on US we correctly estimated the positive diagnosis in 55.7% cases and using CEUS, the diagnostic performance increased up to 92%. CONCLUSIONS: In our study, by means of US the estimate positive diagnosis was made in 55.7% of cases. CEUS properly characterized 92% of benign FLLs and increased the diagnostic performance of these lesions, as compared with US.

Contrast Enhanced Ultrasound for the evaluation of focal liver lesions in daily practice. A multicentre study.

BACKGROUND AND AIM: Development of contrast specific ultrasound techniques and introduction of the second-generation ultrasound contrast agents have improved the ability of this technique in detecting and characterizing focal liver lesions (FLLs). The purpose of this study was to present the experience of four Romanian centers in the evaluation of FLLs by contrast enhanced ultrasound (CEUS), in daily practice. MATERIALS AND METHODS: We performed a multicentre retrospective study, including 1244 FLLs, evaluated by means of CEUS in four Romanian centers with extensive experience in ultrasound, during September 2009-December 2010. RESULTS: This study included 1244 FLLs, both "de novo" (1056 cases) and pre-existing (such as hepatocellular carcinomas evaluated after percutaneous treatment to assess the treatment results). In 1046/1244 of cases (84.1%), CEUS showed a typical pattern of enhancement (according to the EFSUMB Guidelines 2008), thus being sufficient for a correct and final diagnosis, while in 198/1244 of cases (15.9%), other methods of diagnosis were required, such as contrast CT/MRI or biopsy. In our study, CEUS established the benign or malignant nature of lesions in 1139/1244 of cases (91.5%). CONCLUSION: According to our results, CEUS could be the first imaging method of diagnosis for uncharacteristic FLLs detected by standard ultrasound, providing a correct classification in 84.1% of cases and a correct differentiation between benign/malignant lesions in 91.5% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound, our local strategy is to perform CEUS as a first-line imaging investigation.

Contrast enhanced ultrasound for the diagnosis of liver hemangiomas in clinical practice.

BACKGROUND AND AIM: Contrast enhanced ultrasound (CEUS) has a well established place in the characterization of focal liver lesions (FLL). The aim of this paper was to evaluate the usefulness of CEUS in the assessment of liver hemangiomas. MATERIAL AND METHOD: We included in a prospective study all the CEUS examinations performed during a 13 months period for the evaluation of de novo FLL, using a Siemens Acuson S2000™ Ultrasound System, following an intravenous bolus of 2.4 ml SonoVue® CEUS was considered conclusive for hemangioma if a typical pattern was present following contrast (centripetal fill in during the arterial phase, hyperenhanced lesion during venous and late phases). RESULTS: During September 2009 - October 2010, 413 CEUS examinations were performed in our department for the evaluation of de novo FLL. Out of the 413 cases, based on standard ultrasound, 43 were suspected hemangiomas, 125 were uncharacteristic lesions and 245 were suspected for other types of lesions (metastases, focal nodular hyperplasias, hepatocellular carcinomas etc). Out of the 413 de novo FLL, 64 cases (15.5%) were diagnosed as hemangiomas by CEUS (typical CEUS pattern). MRI diagnosed 7 additional hemangiomas in inconclusive CEUS cases, so 90.1% (64/71) of the hemangiomas were diagnosed by CEUS alone. Out of the 125 uncharacteristic lesions on standard ultrasound, 29 cases were diagnosed after CEUS as hemangiomas. Thus, CEUS diagnosed additional 40.8% (29/71) hemangiomas as compared to standard ultrasound, without the need of more expensive imaging methods. CONCLUSION: CEUS is a reliable method for the diagnosis of hemangiomas, also allowing a precise characterization of FLL. This method diagnosed additional 40% hemangiomas in comparison with standard ultrasound (for atypical ultrasound hemangiomas) and finally, CEUS diagnosed correctly 90% of this type of lesions, all with typical enhancement pattern according to the EFSUMB guidelines.

Contrast enhanced ultrasound for the characterization of hepatocellular carcinoma.

AIM: Contrast-Enhanced Ultrasound (CEUS) is an imaging method that can discriminate between hepatocellular carcinoma (HCC) and other liver lesions. The purpose of this study is to present our experience concerning the use of CEUS in the characterization of HCCs. MATERIAL AND METHOD: We included in our study all the patients evaluated in our Department from September 2009 to October 2010, with focal liver lesions (FLLs) on abdominal ultrasound (US) that were diagnosed as HCCs after CEUS examination, also patients with chronic liver disease with focal liver lesions highly suspected to be HCCs but with an inconclusive pattern on CEUS. One hundred patients with 148 HCCs were included. The enhancement pattern of the nodules was evaluated according to the 2008 EFSUMB Guidelines. Nodules displaying arterial hyperenhancement with "washout" in the portal/venous phase on CEUS were considered diagnostic for HCC. Nodules considered indeterminate after CEUS were evaluated by contrast-enhanced CT or MRI for diagnosis. RESULTS: Among the 100 patients included, 96 were patients with chronic liver disease and 4 were patients without known liver disease. 71 patients had a solitary nodule, 16 patients had two nodules and 13 patients had three or more nodules. 112 HCCs had a typical enhancement pattern and 36 nodules were considered indeterminate after CEUS and were sent to CT/ MRI for diagnosis. CONCLUSIONS: 75.7% of the studied liver nodules were diagnosed by CEUS as HCCs, thus CEUS is an easy method, convenient to perform, avoiding other expensive examinations.

The mean values of liver stiffness assessed by Acoustic Radiation Force Impulse elastography in normal subjects.

UNLABELLED: The AIM of this paper is to establish the values of liver stiffness (LS) assessed by means of ARFI in patients without known liver pathology and considered healthy subjects. MATERIAL AND METHOD: the study group was composed of 82 subjects without known liver pathology, healthy volunteers or patients from other departments of our hospital who did not have altered liver laboratory tests. 76 patients had ARFI valid measurements (47 women and 29 men, mean age 34.5 +/-14.3 years). In each subject abdominal ultrasound was performed (patients with steatosis or any other signs of chronic liver pathology were excluded) as well as ARFI (using Siemens Acuson S2000). The median value of 10 measurements was calculated, expressed in m/s; we considered valid only the measurements with IQR<30%, SR>60%, similar to transient elastography. Mean ARFI values and mean values according to age and gender were evaluated. RESULTS: valid ARFI measurements were obtained in 76/82 patients (92.6%). The mean value of ARFI measurements in normal individuals was 1.15+/-0.21 m/s. There were no significant differences between the mean ARFI values in men vs. women (1.16+/-0.21 vs. 1.14+/-0.22m/s, p=0.67), also among different age groups (p>0.05). CONCLUSION: In our study the mean LS value obtained by ARFI in healthy subjects was 1.15 m/s.

Contrast enhanced ultrasound for the characterization of focal liver lesions.

AIM: to present the practice of two experienced centres concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of focal liver lesions (FLL). MATERIAL AND METHOD: A prospective, bicentric study, between 09.2009-09.2010 was undertaken and 729 FLL (506-Center A, 223-Center B) were evaluated. A CEUS examination was considered conclusive, if the FLL had a typical enhancement pattern according to EFSUMB Guidelines. RESULTS: From the 729 cases with FLL, 389 (53.4%) were patients without known and 340 (46.6%) with known chronic liver disease. CEUS was conclusive for the diagnosis in 597/729 cases (82%) and allowed the positive diagnosis of benign vs. malignant lesion in 662/729 (90.8%) FLL. For each center independently (Center A vs. Center B) the situation was as follows: conclusive for the diagnosis 390/506 (77.1%) vs 207/223 (92.8%) (p<0.0001), conclusive for the differentiation benign/malignant 449/506 (88.7%) vs. 213/223 (95.5%) (p=0.0032). CONCLUSION: In our bicentric study, CEUS was conclusive for diagnosis in 82% of FLL and the benign or malignant character of a lesion was demonstrated in 90.8% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound, our local strategy in both centers was to perform CEUS as a first-line investigation thus avoiding other expensive examinations.

Contrast enhanced ultrasound in focal liver lesions--a cost efficiency study.

UNLABELLED: Contrast enhanced ultrasound (CEUS) has a well established role for the evaluation of focal liver lesions (FLL). The AIM of our paper was to evaluate if CEUS is a cost-efficient method for the first line evaluation of FLL. MATERIAL AND METHOD: We performed a prospective study that included all the CEUS evaluations performed in our Department during a 6 months period (September 2009-March 2010). CEUS evaluation was performed with a Siemens Acuson S2000TM Ultrasound System following an intravenous bolus injection of 2.4 ml SonoVue(R) (Bracco). A CEUS examination was considered conclusive if, following contrast, the FLL had a typical enhancement pattern(after EFSUMB Guidelines 2008), allowing its classification as hemangioma, FNH, adenoma, hepatocellular carcinoma, metastasis, fatty-free area, focal fatty infiltration. We compared the costs of a CEUS positive diagnosis, to the cost of contrast CT and/or contrast MRI positive diagnosis. We also included the additional costs of CT and/or MRI, if CEUS was not conclusive. The cost of CEUS was calculated as the cost of 1/2 vial of SonoVue + the cost of abdominal ultrasound (150 + 30 = 180 RON). The costs of contrast CT scan and MRI were 285 and 650 RON respectively (mean costs practiced in Timisoara). RESULTS: In our study were included 316 FLL: 163 (51.6 %) in patients without hepatitis and 153 (48.4 %) in patients with chronic hepatopathies (in 133 cases liver cirrhosis and in 20 cases chronic hepatitis). CEUS was conclusive in 250 (79.1%) of the 316 cases, the cost for the evaluation of these patients being 45,000 RON. For the other 66 patients, the diagnosis cost will include the cost of CEUS + the cost of contrast CT: 30,690 RON. If contrast MRI was used for the differential diagnosis, the cost would be 54,780 RON. So the total cost of diagnosing 316 FLL would be 75,690 RON or 99,780 RON. If contrast CT would be used as the first line diagnosis for the 316 FLL, the cost would be 90,060 RON, by CEUS saving 14,370 RON, or 45.5 RON/lesion (using contrast CT for the differential diagnosis). If contrast MRI would be used as the first line diagnosis, the cost would be 205,400 RON, by CEUS saving 105,620 RON, or 334.2 RON/lesion (using contrast MRI for the differential diagnosis). CONCLUSION: CEUS is a cost-efficient method as a first line diagnosis of FLL as compared to first line contrast-CT or first-line MRI.

How useful is contrast enhanced ultrasonography for the characterization of focal liver lesions?

AIM: Focal liver lesions (FLLs) are quite frequently discovered in daily practice at routine ultrasound. The aim of our study is to present a single centre experience concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of FLL and to find when one can avoid using other expensive imaging modalities such as contrast enhanced CT or MRI. METHOD: We performed a prospective, single centre study during September 2009 - April 2010, and we evaluated 379 FLLs. A CEUS examination was considered conclusive if the FLL had a typical enhancement pattern according to the EFSUMB guidelines. RESULTS: From the 379 cases with FLL, 198 (52.2%) were patients without known liver disease and 181 (47.8%) with known chronic liver disease (156 had cirrhosis, 25 chronic hepatitis); in 296/379 cases (78.1%) CEUS was conclusive. CEUS allowed the positive diagnosis of benign vs. malignant lesion in 261/294 (88.8%) de novo FLLs (CEUS performed for the first time), while in 33 (11.2%) cases it was inconclusive and could not differentiate between benign or malignant lesions. The CEUS results included 129 (49.4%) benign lesions and 132 (50.6%) malignant. CONCLUSION: CEUS was conclusive in approximately 80% of the FLLs and the benign or malignant character of a lesion was demonstrated in about 90% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound examination, our local strategy is to perform CEUS as a first-line investigation, thus avoiding other expensive examinations.

Contrast enhanced ultrasound (CEUS) in the evaluation of liver metastases.

Liver metastases are the most frequent malignancies of the liver. The grayscale sonographic appearance of metastases varies: they can be hypoechoic, hyperechoic, they can present a peripheral halo, they can have an infiltrative or cystic appearance. On contrast enhanced ultrasound (CEUS), in the arterial phase, liver metastases can be hyperenhancing (hypervascular ones) or hypoenhancing (hypovascular ones). All liver metastases present wash-out in the portal and late phases, a typical enhancement pattern. CEUS sensitivity is superior to standard ultrasound for the diagnosis of liver metastases being similar to the one of contrast CT.

The role of contrast enhanced ultrasound (CEUS) in the assessment of liver nodules in patients with cirrhosis.

Liver cirrhosis is a major risk factor for the development of hepatocellular carcinoma, hence the need to screen those patients by means of liver ultrasound every 6 months. The differential diagnosis between a regenerative nodule, a dysplastic one and hepatocellular carcinoma is made based on a contrast imaging method (CEUS, MRI or CT) as they all have comparative sensitivities.

Colonoscopy and sedation in Romania: early experience using a balanced propofol regimen.

UNLABELLED: The aim of this study was to evaluate if the sedation during colonoscopy is correctly performed in our patients, especially because it is usually performed by residents in anesthesiology. METHODS: we retrospectively evaluated sedation in all the colonoscopies performed in our Endoscopy Department in 2007, by analyzing the sedation scheme that was used. RESULTS: 974 colonoscopies were evaluated. The following sedation schemes were used in the majority of cases: midazolam+propofol+fentanyl-507 patients (52.1%) and diazepam+propofol+fentanyl-258 patients (26.5%). Propofol (in combination with one or more other agents) was used for sedation in 96.9% of cases. The mean doses of drugs were: propofol 125.2+/-67.7 mg, midazolam 2.29+/-0.84 mg (or diazepam 3.4+/-1.4 mg) and fentanyl 59+/-10 microg. The following complications were observed during sedation for colonoscopy: 6 patients (0.6%) developed hypoxemia, which was managed successfully with supplemental oxygen administration or flumazenil injection; 1 patient (0.1%) suffered a cardiac arrest that was successfully managed. There were no deaths or other complications. CONCLUSIONS: Propofol, combined with an opioid and a benzodiazepine, was used in approximately 97% of cases. The rate of significant oxygen desaturation was low (0.6%). No fatal complications occurred. The mean doses of propofol used were higher than those from published data, while the doses of midazolam and fentanyl were similar.