Differentiating benign from malignant solid breast lesions: Combined utility of conventional ultrasound and contrast-enhanced ultrasound in comparison with magnetic resonance imaging

Objective

To prospectively evaluate the diagnostic efficacy of conventional ultrasound (US), contrast-enhanced US (CEUS), the combined use of two modalities, and magnetic resonance imaging (MRI) in the differentiation of focal solid breast lesions.

Materials and methods

61 patients with BI-RADS category 3–5 breast lesions detected at conventional US underwent CEUS and MRI. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of conventional US, CEUS, combination of two modalities and MRI for discrimination between benign and malignant breast lesions.

Results

Tissue specimens of 61 breast lesions were obtained either from surgical resection (n = 46) or from needle biopsy (n = 15). Histopathologic diagnosis revealed 28 benign and 33 malignant lesions. The diagnostic performance of conventional US and CEUS in differentiating benign from malignant breast lesions showed no significant difference (P = 0.741). The combination of two modalities significantly improved the diagnostic accuracy compared with either conventional US or CEUS alone (P = 0.031 and P = 0.012, respectively). The area under the ROC curve (A_z) value for the combined use of two modalities for discrimination between benign and malignant breast lesions was 0.94, and that for MRI was 0.91, whereas no statistical difference was found between them (P = 0.296).

Conclusion

The combined use of conventional US and CEUS has a better diagnostic performance than either method alone and displays good agreement with MRI in the differentiation capability for benign and malignant breast lesions.     

Enhancement pattern of hilar cholangiocarcinoma: Contrast-enhanced ultrasound versus contrast-enhanced computed tomography

Objective

To compare the enhancement pattern of hilar cholangiocarcinoma on contrast-enhanced ultrasound (CEUS) with that on contrast-enhanced computed tomography (CECT).

Methods

Thirty-two consecutive patients with pathologically proven hilar cholangiocarcinomas were evaluated by both low mechanical index CEUS and CECT. The enhancement feature of the tumor, portal vein infiltration, and lesion conspicuity on them was investigated.

Results

In the arterial phase, the numbers of the lesions showing hyperenhancement, isoenhancement, and hypoenhancement, were 14 (43.8%), 14 (43.8%), and 4 (12.6%), on CEUS, and 12 (37.5%), 9 (28.1%), and 11 (34.4%), on CECT (P = 0.162). In portal phase, the numbers of the lesions showing hypoenhancement, isoenhancement, and hyperenhancement were 30 (93.8%), 1 (3.1%), and 1 (3.1%), on CEUS, and 23 (71.9%), 8 (25.0%), and 1 (3.1%), on CECT (P = 0.046). The detection rates for portal vein infiltration were 84.2% (16/19) for baseline ultrasound, 89.5% (17/19) for CEUS, and 78.9% (15/19) for CECT (all P > 0.05 between every two groups). CEUS significantly improved the lesion conspicuity in comparison with CECT. CEUS and CECT made correct diagnoses in 30 (93.8%) and 25 (78.1%) lesions prior to pathological examination (P = 0.125).

Conclusion

The enhancement pattern of hilar cholangiocarcinoma on CEUS was similar with that on CECT in arterial phase, whereas in portal phase hilar cholangiocarcinoma shows hypoenhancement more likely on CEUS. CEUS and CECT lead to similar results in evaluating portal vein infiltration and diagnosis of this entity.     

Pancreatic multicenter ultrasound study (PAMUS)

Aim

To describe the typical CEUS pattern of pancreatic lesions and to evaluate the diagnostic accuracy of Contrast-enhanced ultrasound (CEUS) in their characterization.

Materials and methods

All US and CEUS examinations of focal pancreatic masses performed in six centers during a period of five years were reviewed. Inclusion criteria were: focal pancreatic mass pathologically proved, visible at ultrasound (US) and studied with CEUS. All lesions were then evaluated for size, aspect and enhancement pattern. Sensitivity, specificity, positive and negative predictive values with 95% CIs were calculated to define diagnostic accuracy of CEUS in respect to pathology. Diagnostic confidence of US and CEUS, discerning between benign and malignant lesions, were represented by using ROC (receiver operating characteristics) curves. Agreement was evaluated by means of k statistics.

Results

1439 pancreatic lesions were included. At CEUS the lesions were divided into solid (89%) and cystic (12%) masses and classified into six and eight categories, respectively. Among the solid lesions, adenocarcinomas were characterized with an accuracy of 87.8%. Among the cystic lesions, cystic tumors were diagnosed with an accuracy of 97.1%. ROC curve area increased from 0.637 for US to 0.877 for CEUS (p < 0.0001). Inter-observer agreement was slightly higher for solid (k = 0.78) than cystic (k = 0.62) lesions. In none of the centers side effects were reported.

Conclusion

CEUS is accurate in the characterization of pancreatic lesions. CEUS should be considered as a complementary imaging method for pancreatic lesions characterization.     

Indeterminate solid hepatic lesions identified on non-diagnostic contrast-enhanced computed tomography: Assessment of the additional diagnostic value of contrast-enhanced ultrasound in the non-cirrhotic liver

Objective

To assess the additional diagnostic value of contrast-enhanced ultrasound (CEUS) in the characterization of indeterminate solid hepatic lesions identified on non-diagnostic contrast-enhanced computed tomography (CT).

Methods

Fifty-five solid hepatic lesions (1–4 cm in diameter) in 46 non-cirrhotic patients (26 female, 20 male; age ± SD, 55 ± 10 years) underwent CEUS after being detected on contrast-enhanced CT which was considered as non-diagnostic after on-site analysis. Two blinded independent readers assessed CT and CEUS scans and were asked to classify retrospectively each lesion as a malignant or benign based on reference diagnostic criteria for the different hepatic lesion histotypes. Diagnostic accuracy and confidence (area – A_z – under ROC curve) were assessed by using gadobenate dimeglumine-enhanced magnetic resonance (MR) imaging (n = 30 lesions), histology (n = 7 lesions), or US follow-up (n = 18 lesions) as the reference standards.

Results

Final diagnoses included 29 hemangiomas, 3 focal nodular hyperplasias, 1 hepatocellular adenoma, and 22 metastases. The additional review of CEUS after CT images improved significantly (P < .05) the diagnostic accuracy (before vs after CEUS review = 49% [20/55] vs 89% [49/55] – reader 1 and 43% [24/55] vs 92% [51/55] – reader 2) and confidence (A_z, 95% Confidence Intervals before vs after CEUS review = .773 [.652–.895] vs .997 [.987–1] – reader 1 and .831 [.724–.938] vs .998 [.992–1] – reader 2).

Conclusions

CEUS improved the characterization of indeterminate solid hepatic lesions identified on non-diagnostic contrast-enhanced CT by identifying some specific contrast enhancement patterns.     

The application value of contrast-enhanced ultrasound in the differential diagnosis of pancreatic solid-cystic lesions

Objective

To retrospectively determine the accuracy of baseline ultrasound (BUS) and of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of pancreatic solid-cystic lesions.

Methods

Fifty-four pancreatic solid-cystic lesions in 52 patients were examined with BUS and CEUS, two different seniority radiologists read the images independently, Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic value of BUS and CEUS in the diagnosis of benign or malignant pancreatic solid-cystic lesions, the diagnostic consistency between different seniority radiologists was evaluated by Kappa statistics.

Results

Among the 54 lesions, there were pancreatic cyst five cases, pancreatic pseudocyst twenty cases, pancreatic cystadenoma eight cases, pancreatic cystadenocarcinoma seven cases, intraductal papillary mucinous neoplasm of pancreas (IPMN) three cases, pancreatic carcinoma combined liquefied six cases, solid-pseudopallary tumor of pancreas (SPTP) three cases, pancreatic myopericytoma one case, pancreatic lymphangioma one case. After ROC analysis, the areas under the ROC curve (Az) were 0.752 by BUS, 0.928 by CEUS to resident radiologist, and 0.896 by BUS, 0.954 by CEUS to staff radiologist. The correct diagnosis rate of specific disease was 42.6% by BUS, 64.8% by CEUS to staff radiologist (P < 0.05), and 33.3% by BUS, 53.7% by CEUS to resident radiologist (P < 0.05). The interobserver agreement in CEUS is higher than that in BUS, the Kappa value was 0.889 ± 0.062 and 0.428 ± 0.126 respectively.

Conclusion

Compared with BUS, CEUS can significantly enhance the diagnostic rate of pancreatic solid-cystic lesions.     

Small nodules (1-2 cm) in liver cirrhosis: characterization with contrast-enhanced ultrasound

Objective

To determine the diagnostic efficacy of arterial phase contrast-enhanced ultrasound (CEUS) for characterizing small hepatic nodules (1-2 cm) in patients with high-risk for hepatocellular carcinoma (HCC).

Materials and methods

Over 12 months, CEUS was performed in 59 patients at high-risk for HCC with small hepatic nodules (1-2 cm; mean, 1.5 cm). Based only on arterial phase (<45 s) vascular intensity and pattern, lesions were prospectively diagnosed as HCC if there was hypervascularity without known features of hemangioma. The diagnosis of HCC was made regardless of the presence or absence of washout. Verification of diagnosis was made by liver transplantation (n = 13), biopsy (n = 12), resection (n = 3) or clinical and imaging follow-up for at least 12 months (n = 31).

Results

At of the time of CEUS, the 59 nodules were diagnosed as HCC in 26 and benign lesions in 33, including 20 regenerative/dysplastic nodules (RN/DN), 11 hemangiomas, and 2 focal fat sparing. All 26 nodules with arterial phase hypervascularity without hemangioma-like features were HCC. However, CEUS misdiagnosed HCC as RN/DN in 4 cases with arterial iso- (n = 3) or hypovascularity (n = 1). CEUS correctly diagnosed all 11 hemangiomas. The sensitivity, specificity, and accuracy of CEUS for diagnosing HCC were 86.7, 100, and 93.2%.

Conclusions

Arterial phase vascular intensity and pattern of CEUS are highly accurate for the diagnosis of small (1-2 cm) HCC and hemangioma in liver cirrhosis. On CEUS, arterial phase hypervascularity without a hemangioma-pattern alone may be sufficient for diagnosis of small HCC. Infrequent iso/hypovascular HCC may erroneously suggest RN/DN necessitating biopsy or close follow-up.     

Contrast-enhanced ultrasound in the differentiation between phlegmon and abscess in Crohn's disease and other abdominal conditions

Aim

To evaluate the diagnostic accuracy of the contrast-enhanced ultrasound (CEUS) to differentiate between intra-abdominal phlegmon and abscess.

Methods

We retrospectively reviewed all contrast-enhanced ultrasound performed between June 2006 and May 2012 to identify patients with the terms “inflammatory mass”, “phlegmon” or “abscess” on the sonographic report. The initial CEUS report was used for the diagnosis of phlegmon or abscess.

Results

71 inflammatory masses in 50 patients were identified in CEUS examination. 57 masses, 21 phlegmons and 36 abscesses, were confirmed by other imaging techniques, percutaneous drainage or surgery. CEUS specificity for the diagnosis of abscess was 100%. Kappa coefficient between CEUS and other techniques in the diagnosis of phlegmon or abscess was excellent (kappa = 0.972). Only in one patient surgery detected a small abscess (<2 cm) within a phlegmon that not was detected by CEUS. Statistically significant differences were found between the size of the abscesses before and after contrast agent injection. The interobserver agreement in the diagnosis of phlegmon or abscess was excellent (kappa = 0.953).

Conclusions

CEUS is an accurate method for differentiating between intra-abdominal phlegmon and abscess in gastrointestinal conditions, especially in CD. Its use may help to better define the size of the collections and avoid other techniques that use ionizing radiation. CEUS should be used to confirm an inflammatory mass identified at US.     

Contrast-enhanced ultrasound is helpful in the differentiation of malignant and benign breast lesions

Objective

To evaluate the significance of contrast-enhanced ultrasound (CEUS) examination in differential diagnosis of malignant and benign breast lesions.

Methods

Seventy-one patients with seventy-six breast tumors are selected randomly. CEUS examinations were performed before and after bolus injection of the contrast agent SonoVue (Bracco, Milan, Italy). Specific sonographic quantification software, Qontrast, was adopted to determine the morphology of vessels. Wash-in and wash-out parameters of each lesion were assessed for both procedures.

Results

The final histopathological findings distinguished 45 malignant and 31 benign from all of the lesions. Following SonoVue administration different perfusion phases could be identified: early (0-1 min), mid (1-4 min) and late (4-6 min) phases. In the early phase, CEUS identified 91.1% of malignant tumors characterized by a claw-shaped enhancement, while 83.9% of benign tumors had a homogeneous enhancement, with a statistically significant difference between the two enhancement patterns (χ² = 43.16, P < 0.01). Moreover, contrast medium persistence in the late phase was helpful in the identification of benign and malignant tumors (χ² = 46.88, P < 0.01): contrast medium was present in 88.9% of malignant tumors, while in only 9.7% of the benign tumors. The study showed that various parametric imaging color maps for peak intensity and time to peak were mostly suggestive of malignancy, while quite uniform peak intensity and time to peak of color maps were the characteristic of benign tumors. The study also found that malignant lesions presented with a higher maximum intensity signal than benign ones (P < 0.05) on the time-intensity curves.

Conclusions

CEUS cooperating with conventional US shows improved accuracy in differentiating between malignant and benign breast tumors. It could be a reliable diagnostic method of breast lesions.     

Prospective comparative evaluation of quantitative-elastosonography (Q-elastography) and contrast-enhanced ultrasound for the evaluation of thyroid nodules: Preliminary experience

Purpose

To assess the effectiveness of semiquantitative elastosonography (Q-elastography) compared with contrast-enhanced ultrasound (CEUS) in differentiating the nature of thyroid nodules.

Methods and materials

Forty-eight consecutive patients (35 males, 13 females, range: 34–69 years, mean: 49.4 years), candidate to surgery, previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated semiquantitative software (Q-Elastography, Toshiba XG) and CEUS (Technos Mylab 70 Gold X, and Toshiba XG) before surgery. CEUS and elastosonography were evaluated by two investigators in consensus. Comparison between the CEUS pattern and elastonographic strain ratio observed and expected frequencies for the diagnoses was evaluated with χ² test or with Fisher exact test.

Results

Fifty-three nodules (19 papillary carcinoma, 32 hyperplasia, and 2 follicular adenoma) in 48 patients were available for analysis. Regarding echogenicity score, sensitivity, specificity, PPV and NPV of conventional US were 81%, 50%, 56%, 77%; according to Q-elastography, sensitivity, specificity, PPV and NPV were 95%, 88%, 97% and 91% respectively; whereas concerning CEUS, sensitivity specificity PPV and NPV were 79%, 91%, 83% and 89% respectively. Both CEUS and Q-elastography were more specific than US (p < 0.01), with not statistical significant difference with regard to sensitivity.

Conclusions

The results of the present study suggest that Q-elastography is a valuable tool in the characterization of thyroid nodules and it seems to be more sensitive than CEUS.     

Staging accuracy of pancreatic cancer: Comparison between non-contrast-enhanced and contrast-enhanced PET/CT

Purpose

Our aim was to clarify the diagnostic impact of contrast-enhanced (CE) ¹⁸F-fluorodeoxyglucose (FDG)–positron emission tomography (PET)/computed tomography (CT) for staging of pancreatic cancer compared to non-CE PET/CT.

Method and materials

Between April 2006 and November 2009, a total of 95 patients (age range, 36–83 years [mean age, 67]) with primary pancreatic cancer underwent ¹⁸F-FDG PET/CT examinations. Diagnostic accuracy was compared between non-CE PET/CT and CE PET/CT. Images were analyzed visually and quantitatively by two blinded reviewers. Reference standard was histological examination in 48 patients (51%) and/or confirmation of an obvious progression in number and/or size of the lesions on follow-up CT examinations in 47 patients (49%).

Results

For T-staging, invasion of duodenum (n = 20, 21%), mesentery (n = 12, 13%), and retroperitoneum (n = 13, 14%) was correctly diagnosed by both modalities. The ROC analyses revealed that the Az values of celiac artery (CA), common hepatic artery (CHA), splenic artery (SV), and superior mesenteric vein (SMV) invasion were significantly higher in the CE PET/CT group for both readers. Nodal metastasis was correctly diagnosed by CE PET/CT in 38 patients (88%) and by non-CE PET/CT in 45 patients (87%). Diagnostic accuracies of nodal metastasis in two modalities were similar. Using CE PET/CT, distant metastasis, scalene node metastasis, and peritoneal dissemination were correctly assigned in 39 patients (91%), while interpretation based on non-CE PET/CT revealed distant metastasis, scalene node metastasis, and peritoneal dissemination in 42 patients (81%). Diagnostic accuracy of distant metastasis, scalene node metastasis, and peritoneal dissemination with CE PET/CT was significantly higher than that of non-CE PET/CT (p < 0.05).

Conclusion

CE PET/CT allows a more precise assessment of distant metastasis, scalene node metastasis, and peritoneal dissemination in patients with pancreatic cancer.     

Evaluation of renal urothelial carcinoma by contrast-enhanced ultrasonography

Purpose

To observe ultrasonographic features of urothelial carcinoma in renal pelvis and evaluate contrast-enhanced ultrasound (CEUS) in diagnosis.

Materials and methods

Fifty-two patients with urothelial carcinoma underwent preoperative conventional US, colour Doppler flow imaging (CDFI) and CEUS.

Results

Of 52 total lesions, 41 (78.8%) could be clearly identified by US, and 49 (94.2%) were enhanced by CEUS. Among US-imaged lesions, 39 (95.1%) were solid tumours, and two (4.9%) were mixed solid-cystic; 25 (61.0%) were isoechoic, 11 (26.8%) hypoechoic, and five (12.2%) hyperechoic. Analysis of tumour blood flow by CDFI characterised 17 avascular lesions (41.5% of total), 16 hypovascular (39.0%), and 8 hypervascular (19.5%). The resistance index ranged from 0.65 to 0.88 (mean of 0.71). Enhancement was seen in 49 lesions after injection of SonoVue. A slow enhancement pattern was observed in 36 lesions (73.5%) relative to renal cortex, and 13/49 (26.5%) showed simultaneous enhancement. At peak enhancement, 38 lesions (77.6%) were hypo-enhanced, six (12.2%) iso-enhanced, and five (10.2%) hyper-enhanced. There were 12 lesions with intertumoural necrosis or haemorrhage (24.5%) that were heterogeneously enhanced, and 37 (75.5%) were homogeneously enhanced. A fast washout pattern was observed in 46 lesions (93.9%), synchronous washout in two (4.08%), and slow washout in one (2.04%).

Conclusions

Slow-in, fast-out, and hypo-enhancement properties are associated with renal urothelial carcinoma and may thus have diagnostic value. We found that CEUS is able to identify tumours that are ambiguous by conventional US, and it thus significantly improves the confidence of diagnosis.     

Dynamic contrast-enhanced ultrasound for assessment of therapy effects on skeletal muscle microcirculation in peripheral arterial disease: Pilot study

Objective

To assess with dynamic contrast-enhanced ultrasound (CEUS) and transient arterial occlusion whether the muscular micro-perfusion in patients with peripheral arterial disease (PAD) is improved after angioplasty or surgery.

Materials and methods

This study had local institutional review board approval. Written informed consent was obtained from all 20 patients with PAD, Fontaine stage IIb (mean age, 64 years), who participated in the study. Low-MI CEUS (7 MHz; MI, 0.28) was applied to the mainly affected lower leg after start of a continuous automatic intravenous injection of 4.8 mL SonoVue^®. Muscle-perfusion was monitored by CEUS before, during, and after provocation by arterial occlusion at the thigh level lasting for 60 s. CEUS examination was performed a second time within 14 days after angioplasty (n = 15), thrombendarterectomy (n = 2), angioplasty and thrombendarterectomy (n = 1), or bypass (n = 2). Clinical amelioration was re-evaluated within 6 months after the intervention using a 4-point scale.

Results

Ankle-brachial-index (ABI) increased from 0.8 ± 0.2 to 0.9 ± 0.3 after treatment (p = 0.01). Time to maximum CEUS signal (t_max) shortened from 26 ± 14 s to 14 ± 4 s (p = 0.004). The slope to maximum after transient occlusion (m₂) changed to steeper values (6.4 ± 5.8 ∼mL/s versus 10.2 ± 5.0 ∼mL/s; p = 0.04). Shortened t_max predicted improvement in the patients’ intermittent leg pain and therefore successful therapy outcome.

Conclusion

Dynamic CEUS with transient arterial occlusion can visualize the treatment-induced improvement of muscular micro-perfusion in patients with PAD.     

Real-time contrast enhanced ultrasound imaging of focal splenic lesions

Objective

To investigate the imaging features of focal splenic lesions (FSLs) on contrast-enhanced ultrasound (CEUS).

Methods

Thirty two patients with FSLs proved by pathology were retrospectively analyzed. CEUS was performed using intravenous bolus injection of 2.4 ml sulfur hexafluoride-filled microbubble contrast agent and real time scanning. There were hemangioma (n = 7), lymphoma (n = 8), true cyst (n = 3), infarction (n = 4), hematolymphangioma (n = 2), metastasis tumor (n = 2), and one for each of the following entities extramedullary hemopoiesis, hamartoma, tuberculosis, Langerhans’ cell histiocytosis, inflammatory pseudotumor and myxofibrosarcoma.

Results

Among 21 benign lesions, 4 infarctions and 3 cysts presented non-enhancement throughout CEUS scanning, and the other 14 lesions displayed various enhancement levels with 6 (42.9%) hyper-enhancement, 2 (14.3%) iso-enhancement and 6 (42.9%) hypo-enhancement in arterial phase and 11 (78.6%) hypo-enhancement, 1 (7.1%) iso-enhancement and 2 (14.3%) hyper-enhancement in late phase, respectively. The enhancement pattern included 9 (64.3%) homogeneous, 4 (28.6%) heterogeneous and 1 (7.1%) rim-like enhancement. As for the malignant FSLs, all the lesions became completely or extensively hypo-enhancement during the late phase no matter their vascularity during arterial phase.

Conclusions

The CEUS features reported in this series may enrich the knowledge for CEUS characterization of FSLs.     

Dynamic contrast-enhanced ultrasound and transient arterial occlusion for quantification of arterial perfusion reserve in peripheral arterial disease

Objective

To quantify muscular micro-perfusion and arterial perfusion reserve in peripheral arterial disease (PAD) with dynamic contrast-enhanced ultrasound (CEUS) and transient arterial occlusion.

Materials and methods

This study had local institutional review board approval and written informed consent was obtained from all subjects. We examined the dominant lower leg of 40 PAD Fontaine stage IIb patients (mean age, 65 years) and 40 healthy volunteers (mean age, 54 years) with CEUS (7 MHz; MI, 0.28) during continuous intravenous infusion of 4.8 mL microbubbles. Transient arterial occlusion at mid-thigh level simulated physical exercise. With time–CEUS–intensity curves obtained from regions of interest within calf muscles, we derived the maximum CEUS signal after occlusion (max) and its time (t_max), slope to maximum (m), vascular response after occlusion (AUC_post), and analysed accuracy, receiver operating characteristic (ROC) curves, and correlations with ankle-brachial index (ABI) and walking distance.

Results

All parameters differed in PAD and volunteers (p < 0.014). In PAD, t_max was delayed (31.2 ± 13.6 vs. 16.7 ± 8.5 s, p < 0.0001) and negatively correlated with ankle-brachial-index (r = −0.65). m was decreased in PAD (4.3 ± 4.6 mL/s vs. 13.1 ± 8.4 mL/s, p < 0.0001) and had highest diagnostic accuracy (sensitivity/specificity, 75%/93%) for detection of diminished muscular micro-perfusion in PAD (cut-off value, m < 5∼mL/s). Discriminant analysis and ROC curves revealed m, and AUC_post as optimal parameter combination for diagnosing PAD and therefore impaired arterial perfusion reserve.

Conclusions

Dynamic CEUS with transient arterial occlusion quantifies muscular micro-perfusion and arterial perfusion reserve. The technique is accurate to diagnose PAD.     

Contrast enhanced ultrasound of splenic lymphoma involvement

Objective

The aim of this study was to compare the value of contrast-enhanced ultrasonography (CEUS) with standard B-mode ultrasound (US) for diagnosis of splenic lymphoma involvement.

Methods

From 04/2005 to 10/2008 n = 250 lymphoma patients were investigated by standard B-mode US. A homogeneous splenic echotexture was found in 199 patients (79%). To clarify the benefit of CEUS in this group a pilot series was performed with 16 of the 199 lymphoma patients. All patients with an abnormal splenic echotexture on standard B-Mode US (n = 51) including focal hypoechoic splenic lesions (n = 41) and an inhomogeneous splenic texture (n = 10) were studied by CEUS. CEUS data were retrospectively evaluated. The diagnoses included indolent lymphoma (n = 27), aggressive lymphoma (n = 14), and Hodgkin's disease (n = 10). Number and size of lesions were determined by B-mode US and CEUS. The visualisation of splenic lymphoma involvement by CEUS in comparison to B-mode US was classified as worse, equal, or better.

Results

All patients with a homogeneous spleen on B-mode US (n = 16) had no visible focal lesions on CEUS. Study patients with focal lesions (n = 41) had a hypoechoic (n = 22) or isoechoic (n = 19) enhancement during the arterial phase, and a hypoechoic enhancement during the parenchymal phase (n = 41). The visualisation of focal splenic lymphoma was equal (n = 32), better (n = 6), or worse (n = 3). In all study patients with an inhomogeneous spleen on B-mode US (n = 10) no focal lesions were found by CEUS and the value of CEUS therefore was classified as worse.

Conclusion

CEUS has no clear advantage for diagnosis of splenic lymphoma involvement.     

Three-dimensional contrast enhanced ultrasound score and dynamic contrast-enhanced magnetic resonance imaging score in evaluating breast tumor angiogenesis: Correlation with biological factors

Objective

To explore the clinical value of three-dimensional contrast enhanced ultrasound (3D-CEUS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) score systems in evaluating breast tumor angiogenesis by comparing their diagnostic efficacy and correlation with biological factors.

Methods

3D-CEUS was performed in 183 patients with breast tumors by Esaote Mylab90 with SonoVue (Bracco, Italy), DCE-MRI was performed on a dedicated breast magnetic resonance imaging (DBMRI) system (Aurora Dedicated Breast MRI Systems, USA) with a dedicated breast coil. 3D-CEUS and DCE-MRI score systems were created based on tumor perfusion and vascular characteristics. Microvessel density (MVD), vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMP-2, MMP-9) expression were measured by immunohistochemistry.

Results

Pathological results showed 35 benign and 148 malignant breast tumors. MVD (P = 0.000, r = 0.76), VEGF (P = 0.000, r = 0.55), MMP-2 (P = 0.000, r = 0.39) and MMP-9 (P = 0.000, r = 0.41) expression were all significantly different between benignity and malignancy. Regarding 3D-CEUS 4 points as cutoff value, the sensitivity, specificity and accuracy were 85.1%, 94.3% and 86.9%, respectively, and correlated well with MVD (P = 0.000, r = 0.50), VEGF (P = 0.000, r = 0.50), MMP-2 (P = 0.000, r = 0.50) and MMP-9 (P = 0.000, r = 0.66). Taking DCE-MRI 5 points as cutoff value, the sensitivity, specificity and accuracy were 86.5%, 94.3% and 88.0%, respectively and also correlated well with MVD (P = 0.000, r = 0.52), VEGF (P = 0.000, r = 0.44), MMP-2 (P = 0.000, r = 0.42) and MMP-9 (P = 0.000, r = 0.35).

Conclusions

3D-CEUS score system displays inspiring diagnostic performance and good agreement with DCE-MRI scoring. Moreover, both score systems correlate well with MVD, VEGF, MMP-2 and MMP-9 expression, and thus have great potentials in tumor angiogenesis evaluation.     

Enhancement pattern of small hepatocellular carcinoma (HCC) at contrast-enhanced US (CEUS), MDCT, and MRI: intermodality agreement and comparison of diagnostic sensitivity between 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines

Objective

To evaluate agreement between contrast-enhanced ultrasound (CEUS), multi-detector row computed tomography (MDCT) and magnetic resonance imaging (MRI) for the assessment of typical and atypical enhancement patterns of small hepatocellular carcinoma (HCC); and to compare diagnostic sensitivity of 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines.

Materials and methods

Between January 2008 and December 2009, we included cirrhotic patients with newly diagnosed 10–20 mm HCC imaged at two contrast-enhanced imaging techniques among CEUS, MDCT, and MRI. Dynamic studies were reviewed by two radiologists to assess enhancement pattern. Percentage of cases with concordant findings and Cohen coefficient (k) were calculated. McNemar's test was used to compare sensitivity between 2005 and 2010 AASLD guidelines.

Results

There were 91 patients (69 M; 22 F; mean age, 68 years) with 96 HCCs, studied with a combination of CEUS and MDCT (n = 59), CEUS and MRI (n = 26), or MDCT and MRI (n = 11). Intermodality agreement for assessment of tumor enhancement pattern was 67% (k = 0.294, P = 0.001). Typical enhancement pattern was detected coincidentally at two imaging modalities in 50 (52%) HCCs. Sensitivity for the diagnosis of HCC increased significantly using the 2010 AASLD (81/96 (84%) vs. 50/96 (52%), P < 0.001).

Conclusions

Agreement between two imaging modalities for the detection of typical tumor enhancement pattern was reached in 52% of cases. The 2010 AASLD guidelines significantly increased the sensitivity for the diagnosis of HCC.     

Role of contrast-enhanced ultrasound in decision support for diagnosis and treatment of hepatic artery thrombosis after liver transplantation

Objective

To assess role of contrast-enhanced ultrasound (CEUS) in decision support for diagnosis and treatment of hepatic artery thrombosis (HAT) after liver transplantation.

Materials and methods

Between January 2005 and January 2011, 605 patients underwent liver transplantation in our medical center. All the liver transplant recipients received Doppler ultrasound scanning and CEUS examination was performed in 45 patients with suspected HAT on Doppler ultrasound. Sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were determined based on the results from angiography, surgery and clinical follow-up.

Results

Fourteen HATs, including one late HAT, were diagnosed by CEUS. Twelve HAT cases were confirmed by angiographic and/or surgical findings, while the late HAT and other 31 patients with negative CEUS finding were confirmed by the clinical follow-up. There was a false positive HAT diagnosed by CEUS in which angiography revealed a patent hepatic artery. The sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were 100%, 96.9%, 97.8%, 92.9% and 100%, respectively. In our series of 605 liver transplants, the incidence and mortality of HAT was 2.2% (13/605) and 53.8% (7/13), respectively.

Conclusions

Our study demonstrates the important role of CEUS in decision support for diagnosis and treatment of HAT after liver transplantation. When HAT is suspected by Doppler ultrasound, CEUS shall immediately be performed to elucidate its nature. A negative CEUS finding shall avoid invasive angiography. Such as, CEUS may alter the clinical workflow on HAT detection after liver transplantation.     

Clear cell renal cell carcinoma: contrast-enhanced ultrasound features relation to tumor size

Objectives

To analyze the contrast-enhanced ultrasound (CEUS) features of clear cell renal cell carcinoma (CCRCC) in relation to tumor size.

Materials and methods

The CEUS appearance of 92 CCRCCs confirmed pathologically were retrospectively analyzed. Tumor size was stratified into six groups with a 1 cm interval. For each lesion, the degree of enhancement, the homogeneity of enhancement and the presence of pseudocapsule sign were evaluated and compared with the pathologic findings.

Results

The tumors of groups I-VI were counted for 13, 26, 21, 11, 10 and 11, respectively. All the CCRCCs mainly showed a marked enhancement, and there was no statistically significance between the degree of enhancement and tumor size (P > 0.05). However, both homogeneity of enhancement and frequency of pseudocapsule correlated well with the tumor size (P < 0.01). Homogeneous enhancement was shown in 85%, 65%, 19%, 9%, 0% and 0% of the tumors in the six groups, respectively. In tumors ≤3 cm the frequency (72%) of homogeneity was significantly higher than in tumors >3 cm (9%; P < 0.01). The detection rate of pseudocapsule sign in the six group was 23%, 62%, 71%, 64%, 50% and 0%, respectively. The frequency of pseudocapsule sign was significantly higher in tumors 2.1-5 cm than <2 cm and >5 cm (66%, 23%, 24%, respectively; P < 0.01). On the pathologic examinations, the mean MVD was significantly higher in marked enhancement tumors than slight enhancement tumors (46.0 ± 15.9, 27.5 ± 8.3, respectively; P < 0.01). Any tumors with a heterogeneous enhancement pattern were accompanied by intratumoral necrosis or cysts on histologic specimen. A pseudocapsule was seen at pathology in all the 46 cases with perilesional enhancement and 4 of 46 tumors without perilesional enhancement at CEUS.

Conclusion

CEUS features of CCRCCs vary with the size of the tumor, especially in the homogeneity of enhancement and the presence of pseudocapsule sign. CEUS is effective in demonstrating the sonographic visualization of tumoral characteristics.     

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

Objectives

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

Materials and methods

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

Results

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P < 0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

Conclusion

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.