Contrast-enhanced Ultrasound Enhancement Patterns Research Articles

8402 The Usefulness Of The Contrast-Enhanced Ultrasound (CEUS) In Preoperative Localization Of Parathyroid Gland Adenomas

Abstract Disclosure: A. Żyłka: None. K. Dobruch-Sobczak: None. H. Piotrzkowska-Wróblewska: None. P. Góralski: None. J. Gałczyński: None. E. Bakuła-Zalewska: None. M. Dedecjus: None. Objectives: Preoperative localization of parathyroid gland adenomas in patients diagnosed with primary hyperparathyroidism (pHPT) is challenging process. The aim of the study was to assessed the usefulness of contrast-enhanced ultrasound (CEUS) as complimentary diagnostic modality to conventional ultrasonography for detection of hyperfunctioning parathyroid gland lesions. Methods: Between the years 2021 and 2022, 36 adult patients (33 women and 3 men, aged 37-76) diagnosed with pHPT, underwent high-resolution ultrasound (US) and CEUS of parathyroid gland adenomas, suspected after fine-needle aspiration biopsy with positive parathormone (PTH) wash-out results and/or avid in 99mTechnetium -sestamibi scintigraphy. During CEUS examination 1.5 ml of SonoVue contrast has been injected and followed by analysing of qualitative CEUS enhancement features. All patients were qualified to surgical treatment according to clinical symptoms, laboratory and imaging findings and underwent parathyroidectomy with histopathologic results confirming parathyroid gland adenomas. Analysis of the B-mode features and visual CEUS enhancement patterns was performed retrospectively. Ten CEUS qualitative parameters of lesions were assessed including: homo- or heterogenous enhancement; hyper- or hypoenhancement; distribution of contrast in wash-in phase as: centripetal, centrifugal or combined and in wash-out phase as: centrally, peripherally or combined. Then the model was extended using the results based on US B-mode imaging which involved size, echogenicity, calcifications, cystic components and vascularity patterns assessed in Color Doppler (CD) and superb microvascular imaging (SMI). Results: Histopathologic results included 36 parathyroid adenomas (in 33 women and 3 men), the medium size 18.8mm (±11.1) and volume 3.7mm3 (±8.2). In B-mode US examination the majority of lesions were assessed as hypoechoic (n=36; 100%) with dominant inhomogenous echostructure (n=20; 55.5%), mixed vascularity (n=24; 66.6%) and polar vessel observed in 14 lesions (38.8%). There were no adenomas with calcifications, cystic components were observed only in 4 nodules (11.1%). In the CEUS study, dominated qualitative features were homogenous (n=22; 61,1%) and hyperenhancement (n=27; 75%), with centripetal distribution of contrast in wash-in phase (n=24; 66,6%) and dominant centrally wash-out of the contrast (n=20; 55,5%). Conclusions: Preliminary results indicate ultrasonographic patterns characteristic for parathyroid gland adenomas in multiparametric ultrasound involved CEUS examination, which seemed to be valuable tool for localization hyperfunctional parathyroid glands. Further multicenter studies should be performed to standardize qualitative CEUS features in order to diagnose primary hyperparathyroidism preoperatively. Presentation: 6/1/2024

8402 The Usefulness of the Contrast-Enhanced Ultrasound (CEUS) in Preoperative Localization of Parathyroid Gland Adenomas

Abstract Disclosure: A. Żyłka: None. K. Dobruch-Sobczak: None. H. Piotrzkowska-Wróblewska: None. P. Góralski: None. J. Gałczyński: None. E. Bakuła-Zalewska: None. M. Dedecjus: None. Objectives: Preoperative localization of parathyroid gland adenomas in patients diagnosed with primary hyperparathyroidism (pHPT) is challenging process. The aim of the study was to assessed the usefulness of contrast-enhanced ultrasound (CEUS) as complimentary diagnostic modality to conventional ultrasonography for detection of hyperfunctioning parathyroid gland lesions. Methods: Between the years 2021 and 2022, 36 adult patients (33 women and 3 men, aged 37-76) diagnosed with pHPT, underwent high-resolution ultrasound (US) and CEUS of parathyroid gland adenomas, suspected after fine-needle aspiration biopsy with positive parathormone (PTH) wash-out results and/or avid in 99mTechnetium -sestamibi scintigraphy. During CEUS examination 1.5 ml of SonoVue contrast has been injected and followed by analysing of qualitative CEUS enhancement features. All patients were qualified to surgical treatment according to clinical symptoms, laboratory and imaging findings and underwent parathyroidectomy with histopathologic results confirming parathyroid gland adenomas. Analysis of the B-mode features and visual CEUS enhancement patterns was performed retrospectively. Ten CEUS qualitative parameters of lesions were assessed including: homo- or heterogenous enhancement; hyper- or hypoenhancement; distribution of contrast in wash-in phase as: centripetal, centrifugal or combined and in wash-out phase as: centrally, peripherally or combined. Then the model was extended using the results based on US B-mode imaging which involved size, echogenicity, calcifications, cystic components and vascularity patterns assessed in Color Doppler (CD) and superb microvascular imaging (SMI). Results: Histopathologic results included 36 parathyroid adenomas (in 33 women and 3 men), the medium size 18.8mm (±11.1) and volume 3.7mm3 (±8.2). In B-mode US examination the majority of lesions were assessed as hypoechoic (n=36; 100%) with dominant inhomogenous echostructure (n=20; 55.5%), mixed vascularity (n=24; 66.6%) and polar vessel observed in 14 lesions (38.8%). There were no adenomas with calcifications, cystic components were observed only in 4 nodules (11.1%). In the CEUS study, dominated qualitative features were homogenous (n=22; 61,1%) and hyperenhancement (n=27; 75%), with centripetal distribution of contrast in wash-in phase (n=24; 66,6%) and dominant centrally wash-out of the contrast (n=20; 55,5%). Conclusions: Preliminary results indicate ultrasonographic patterns characteristic for parathyroid gland adenomas in multiparametric ultrasound involved CEUS examination, which seemed to be valuable tool for localization hyperfunctional parathyroid glands. Further multicenter studies should be performed to standardize qualitative CEUS features in order to diagnose primary hyperparathyroidism preoperatively. Presentation: 6/1/2024

Classification of Neoadjuvant Therapy Response in Patients With Colorectal Liver Metastases Using Contrast-Enhanced Ultrasound—With Histological Pathology as the Gold Standard

ObjectiveTo evaluate the response to neoadjuvant therapy in patients with colorectal liver metastases (CRLMs) using ultrasound(US) and contrast-enhanced ultrasound(CEUS), with correction to the tumor regression grade (TRG) of pathological results. MethodsThis study included patients with resectable CRLMs admitted from February to December 2022. After at least 4 cycles neoadjuvant therapy, all the patients received US and CEUS examinations within two weeks before hepatectomy. CEUS clips were postprocessed with color parameter imaging (CPI) and microflow imaging (MFI) analysis. Logistic regression analyses were used to develop an evaluation Nomogram. Ultrasound-based model was constructed to discriminate between the response (TRG1/2/3) and nonresponse (TRG4/5) groups at the lesion level. The model's predictive ability was evaluated using the C index and calibration curve, with decision curve analysis assessing the Nomogram's added value. ResultsThe study analyzed 105 CRLM lesions (the lesion with the highest diameter analyzed for each patient), with 43.8% showing a response to therapy. Univariate analysis identified calcification on US (p = 0.039), CEUS enhancement degree (p < 0.001), CEUS enhancement pattern (p<0.001), CEUS washout type (p < 0.001), CEUS necrosis (p < 0.001), CPI feeding artery (p = 0.003) and MFI pattern (p < 0.001) were significantly associated with TRG. The multivariate analysis showed CEUS enhancement pattern (p = 0.026), CEUS washout type (p = 0.018) and CEUS necrosis (p = 0.005) were independently associated with the neoadjuvant therapy response. A Nomogram with the three independent predictors was developed, with an AUC of 0.898. ConclusionThe ultrasound-based model provided accurate evaluation of pathological tumor response to preoperative chemotherapy in patients with CRLM, and may help to decide the individualized treatment strategy.

Quantitative analysis of contrast-enhanced ultrasound and superb microvascular imaging for the evaluation of disease activity in inflammatory bowel disease.

To evaluate the effectiveness of conventional US (ultrasound), SMI (superb microvascular imaging), and CEUS (contrast-enhanced ultrasound) features for the assessment of the activity of inflammatory bowel disease. Conventional US, CEUS and SMI features of 76 patients were retrospectively analyzed. Patients were categorized into two groups: active group (n = 57) and inactive group (n = 19), with endoscopic results as reference standard. Results in the active group and inactive group were compared using an independent t-test, Mann-Whitney U test, chi-square test, and receiver operating characteristic curve (ROC) analysis. Cut-off values were determined using ROC analysis, and sensitivity and specificity were calculated. US quantitative and TIC-based quantitative parameters were analyzed, and each patient was scored based on the parameters that are statistically significant and immediately available in the clinic to evaluate the diagnostic ability of conventional US, SMI, and CEUS features for active IBD patients. Qualitative parameters such as CEUS enhancement pattern I/II, LimbergIII/IV, and lost bowel stratification were reliable indicators of active patients. Quantitative parameters such as bowel thickness and VI of mSMI were reliable indicators of active patients. Patients scored based on these statistically significant parameters with a score ≥3, were highly suspected to be active patients. For TIC-based quantitative parameters, PE, WiAUC, WoAUC, WiWoAUC, WiR, WiPI, and WoR were statistically significant in the differentiation of active IBD from inactive IBD. Conventional US, SMI, and CEUS features may help in the differentiation of active IBD from inactive IBD and have potential application value in the choice of treatment options.

The Utility of Contrast-Enhanced Ultrasound (CEUS) in Assessing the Risk of Malignancy in Thyroid Nodules.

Ultrasonography is a primary method used in the evaluation of thyroid nodules, but no single feature of this method predicts malignancy with high accuracy. Therefore, this paper aims to assess the utility of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of thyroid nodules. The study group comprised 188 adult patients (155 women and 33 men) who preoperatively underwent CEUS of a thyroid nodule classified as Bethesda categories II-VI after fine-needle aspiration biopsy. During the CEUS examination, 1.5 mL of SonoVue contrast was injected intravenously, after which 15 qualitative CEUS enhancement patterns were analysed. The histopathologic results comprised 65 benign thyroid nodules and 123 thyroid carcinomas. The dominant malignant CEUS features, such as hypo- and heterogeneous enhancement and slow wash-in phase, were evaluated, whereas high enhancement, ring enhancement, and a slow wash-out phase were assessed as predictors of benign lesions. Two significant combinations of B-mode and CEUS patterns were noted, namely, hypoechogenicity with heterogeneous enhancement and non-smooth margins with hypo- or iso-enhancement. The preliminary results indicate that CEUS is a useful tool in assessing the risk of malignancy of thyroid lesions. The combination of the qualitative enhancement parameters and B-mode sonographic features significantly increases the method's usefulness.

Colorectal liver metastases: Correlations of contrast-enhanced ultrasound features with tumor clinicopathological factors and clinical outcomes following conversion therapy.

To explore the prognostic impact of contrast-enhanced ultrasound (CEUS) features for initially unresectable colorectal liver metastases (CLMs) in a clinical setting of conversion therapy. Between March 2015 and November 2020, consecutive patients with CLMs who received conversion treatment were prospectively enrolled. All participants underwent liver CEUS at baseline. The primary endpoint was conversion resection rate (R0 and overall resection). Secondary endpoints were objective response rate (ORR), overall survival (OS), and progression-free survival (PFS). 104 participants who completed conversion treatment were included. CEUS enhancement pattern was correlated with index lesion (size and echogenicity), primary (site, differentiation, perineural invasion, and RAS genotype) and serum (CA19-9 level) characteristics (P = <0.001-0.016). CEUS enhancement pattern was significantly associated with R0 resection rate, ORR, PFS, and OS (P = 0.001-0.049), whereas enhancement degree was associated with PFS and OS (P = 0.043 and 0.045). Multivariate analysis showed that heterogeneous enhancement independently predicted R0 and overall resection (P = 0.028 and 0.024) while rim-like enhancement independently predicted ORR and OS (P = 0.009 and 0.026). CEUS enhancement pattern was significantly associated with tumor characteristics and clinical outcomes following conversion therapy, and thus might be of prognosis impact for initially unresectable CLMs.

Application of Dynamic Contrast-Enhanced Ultrasound in Evaluation the Activity of Crohn's Disease.

The dynamic assessment of disease activity during the follow-up of patients with Crohn's disease (CD) remains a significant challenge. In this study, we aimed to identify the role of dynamic contrast-enhanced ultrasound (DCE-US) in the evaluation of activity of CD. In the retrospective study, patients diagnosed with CD in our hospital were included. All the diagnoses were confirmed by clinical symptoms and ileocolonoscopical results. All patients underwent intestinal ultrasound and contrast-enhanced ultrasound (CEUS) examinations within 1 week of the ileocolonoscopy examinations. Acuson Sequoia (Siemens Healthineers, Mountain View, CA, USA) and Resona R9 Elite (Mindray Medical Systems, China) with curved array and Line array transducers were used. The CEUS examination was performed with SonoVue (Bracco SpA, Milan, Italy). DCE-US analysis was performed by UltraOffice (version: 0.3-2010, Mindray Medical Systems, China) software. Two regions of interest (ROIs) were set in the anterior section of the infected bowel wall and its surrounding normal bowel wall 2 cm distant from the inflamed area. Time-intensity curves (TICs) were generated and quantitative perfusion parameters were obtained after curve fittings. The Simple Endoscopic Score for Crohn's disease (SES-CD) was regarded as the reference standard to evaluate the activity of CD. The receiver operating characteristic curve (ROC) analyses were used to determine the diagnostic efficiency of DCE-US quantitative parameters. From March 2023 to November 2023, 52 CD patients were included. According to SES-CD score, all patients were divided into active group with the SES-CD score > 5 (n = 39) and inactive group SES-CD score < 5 (n = 13). Most of the active CD patients showed bowel wall thickness (BWT) > 4.2 mm (97.4%, 38/39) or mesenteric fat hypertrophy (MFH) on intestinal ultrasound (US) scan (69.2%, 27/39). Color Doppler signal of the bowel wall mostly showed spotty or short striped blood flow signal in active CD patients (56.4%, 22/39). According to CEUS enhancement patterns, most active CD patients showed a complete hyperenhancement of the entire intestinal wall (61.5%, 24/39). The TICs of active CD showed an earlier enhancement, higher peak intensity, and faster decline. Among all CEUS quantitative parameters, amplitude-derived parameters peak enhancement (PE), wash-in area under the curve (WiAUC), wash-in rate (WiR), wash-in perfusion index (WiPI), and wash-out rate (WoR) were significantly higher in active CD than in inactive CD (p < 0.05). The combined AUROC of intestinal ultrasound features and DCE-US quantitative perfusion parameters in the diagnosis of active CD was 0.987, with 97.4% sensitivity, 100% specificity, and 98.1% accuracy. DCE-US with quantitative perfusion parameters is a potential useful noninvasive imaging method to evaluate the activity of Crohn's disease.

Differential diagnosis between pancreatic solid pseudopapillary tumors and pancreatic neuroendocrine tumors based on contrast enhanced ultrasound imaging features.

To evaluate the application of contrast enhanced ultrasound (CEUS) in preoperatively differential diagnosis between pancreatic solid pseudopapillary tumors (SPTs) and pancreatic neuroendocrine tumors (pNETs). This retrospective study was approved by Institutional Review Board. Patients with surgical resection and histopathological diagnosis as SPTs and pNETs were included. All patients underwent B mode ultrasound (BMUS) and CEUS examinations within one week before surgical operation. On BMUS, the size, location, echogenicity, calcification, and margin of lesions were observed and recorded. On CEUS imaging, enhancement patterns, and enhancement degrees were recorded and analyzed. An independent t-test or Mann-Whitney U test was used for comparison between continuous variables. Chi-square test was used to compare the CEUS patterns. From February 2017 to Dec 2022, patients diagnosed as SPTs (n = 39) and pNETs (n = 48) were retrospectively included. On BMUS, anechoic cystic changes (19/39, 48.72%) and hyperechoic calcification (14/39, 35.90%) are more commonly detected in SPTs (P = 0.000). On CEUS imaging, the majority of SPTs (27/39, 69.23%) showed hypo-enhancement in the arterial phase, while most of the pNETs (36/48, 75.00%) showed hyper- or iso-enhancement in the arterial phase (P = 0.000). In the venous phase, most of the SPTs (32/39, 82.05%) showed hypo-enhancement, while over half of pNETs (29/48, 60.42%) showed hyper- or iso-enhancement compared to pancreatic parenchyma (P = 0.001). CEUS is a valuable and non-invasive imaging method to make preoperatively differential diagnoses between SPTs and pNETs.

Pancreatic ductal adenocarcinoma: CEUS characteristics are correlated with pathological findings and help predict early recurrence after resection.

To identify characteristics of preoperative contrast-enhanced ultrasound (CEUS) that could predict early recurrence after curative resection of pancreatic ductal adenocarcinoma (PDAC). From January 2017 to September 2022, a total of 110 patients with PDAC (all confirmed by samples obtained via operation) who underwent CEUS within 1 month before surgery were enrolled. We proposed five CEUS enhancement patterns (Pattern I, homogeneous enhancement; Pattern II, heterogeneous enhancement without cystic components; pattern III, ring enhancement; Pattern IV, starry enhancement; Pattern V, heterogeneous enhancement with cystic components) of PDAC. Clinical-pathologic and CEUS characteristics for predicting early recurrence (recurrence within 1 year after curative resection) were analyzed. Important CEUS characteristics were compared with the pathological findings. Tumor size and TNM stage were closely associated with early recurrence. Incomplete-enhancement and enhancement pattern III, IV and V at CEUS imaging were more prone to early recurrence. Incomplete-enhancement lesions had higher histological tumor grades, less frequent remaining acini, and more frequent necrosis within the tumor. PDACs with pattern I and II had lower histological tumor grades, and pattern III, IV and V had higher histological tumor grades. PDACs with pattern I, II and IV had less frequent intratumoral necrosis than PDACs with pattern III and V, and PDACs with pattern IV had lower MVD values. PDACs with incomplete enhancement and enhancement pattern III, IV and V were more prone to early recurrence after attempted curative resection, and these important CEUS characteristics were closely related to the pathological findings of PDAC.

OR32-04 The Usefulness Of The Contrast-enhanced Ultrasound (CEUS) In Evaluating The Risk Of Malignancy In Thyroid Nodules

Abstract Disclosure: A. Zylka: None. K. Dobruch-Sobczak: None. M. Jedrzejczyk: None. H. Piotrzkowska-Wroblewska: None. P. Goralski: None. J. Galczynski: None. E. Bakula-Zalewska: None. M. Dedecjus: None. Objectives Ultrasonography (US) is a primary method used in the evaluation of the thyroid nodules, but there is no single feature predicting malignancy preoperatively with high accuracy. Contrast-enhanced ultrasound (CEUS) provides information about the vascular perfusion and hemodynamics in the thyroid nodules. Therefore, the aim of this paper was to evaluate the usefulness of CEUS in the differential diagnosis of thyroid nodules. Methods Between the years 2021 and 2022, 182 adult patients (149 women and 33 men, aged 18-85) underwent CEUS of a thyroid nodule classified after fine-needle aspiration biopsy with II-VI Bethesda category. During CEUS examination 1.5 ml of SonoVue contrast has been injected and followed by analysing of qualitative CEUS enhancement patterns. All patients subsequently underwent thyroid operation and histopathologic results were used to confirm or exclude the risk of malignancy. Analysis of the visual CEUS enhancement patterns was performed by two experienced specialists in thyroid ultrasonography. Fifteen CEUS qualitative parameters of nodules were estimated and compared with normal thyroid parenchyma including: ring enhancement; low-, iso- and high enhancement; homo- or heterogenous enhancement; slow, fast or equal wash-in and wash-out and centripetal, centrifugal or diffuse enhancement. The statistical analysis of the obtained results was performed using the logistic regression. First sensitivity, specificity and AUC were calculated only for CEUS qualitative features. Then the model was extended using the results based on US B-mode imaging which involved three suspicious features: irregular margins, microcalcifications and marked hypoechogenicity. Results Histopathologic results included 61 benign thyroid nodules (in 51 women and 10 men) and 121 thyroid carcinomas (in 99 women and 22 men). The analysis has pointed five CEUS parameters statistically significant in differential diagnosis between benign and malignant thyroid nodules: low, homogenous and centrifugal enhancement, ring enhancement and slow-wash-out of the contrast. The model, using the above parameters evaluated the risk of malignancy of thyroid nodules with sensitivity of 85.12% and specificity of 45.90% with 0.75 AUC. Including the B-mode features, the sensitivity, specificity and AUC were 85.95%, 62.30% and 0.86, respectively. Conclusions Preliminary results indicate that CEUS is an useful tool in the evaluation of the risk of malignancy in thyroid nodules. The combination of the qualitative enhancement parameters and US B-mode sonographic features increases the usefulness of the method in differential diagnosis between benign and malignant nodules. However, further multicenter studies should be performed in order to standardize qualitative and quantitative CEUS features. Presentation: Sunday, June 18, 2023

Impact of Hepatocellular Carcinoma Tumor Size on Sonazoid Contrast-Enhanced Ultrasound Enhancement Features

The aim of the work described here was to evaluate the impact of hepatocellular carcinoma (HCC) tumor size on Sonazoid contrast-enhanced ultrasound (CEUS) enhancement features, especially in tumors with diameters ≤30 mm and <10 mm. In this retrospective study, we included patients with histopathologically confirmed HCC lesions and divided them into three groups on the basis of tumor size. All patients underwent Sonazoid-enhanced CEUS examinations before surgery. B-mode ultrasound (BMUS) features and CEUS enhancement patterns were evaluated according to current World Federation for Ultrasound in Medicine and Biology Guidelines criteria. The χ2- and Student t-tests were used to compare differences between groups. We included 132 patients with histopathologically confirmed HCC lesions from November 2020 to September 2022. On the basis of tumor size, patients were divided into group 1 (<10 mm, n=5), group 2 (10-30 mm, n=54) and group 3 (>30 mm, n=73). On BMUS, most HCCs appeared heterogeneous but predominantly hypo-echoic (61.4%, 81/132) with ill-defined margins and irregular shapes. Meanwhile, iso-echoic features were more common in small HCCs ≤30 mm (15.3%, 9/59), but a mixed hyper- and hypo-echoic appearance was more common in HCCs >30 mm (17.8%, 13/73) (p=0.003). On Sonazoid-enhanced CEUS, all HCCs presented arterial phase hyperenhancement (APHE) (100.0%, 132/132). Most HCCs >30 mm exhibited heterogeneous hyperenhancement (86.3%, 63/73), whereas nearly one-third of small HCCs ≤30 mm exhibited homogeneous hyperenhancement (35.6%, 21/59) (p=0.003). In the portal venous phase, there was a significantly higher proportion of washout in HCCs >30 mm (84.9%, 62/73) than in small HCCs ≤30 mm (64.4%, 38/59) (p=0.006). During the Kupffer phase, 11 additional hypo-enhanced lesions (mean size: 14.1 ± 4.1 mm, iso-echoic on BMUS), which were also suspected to be HCC lesions, were detected in 5 patients with small HCCs ≤30 mm and 4 patients with HCCs >30 mm. All 5 cases of HCCs <10 mm exhibited APHE and late washout (>60 s). The majority (3/5, 60%) exhibited washout in the portal venous phase (70, 74 and 75 s), one case did so in the late phase (125 s) and another in the Kupffer phase (420 s). Tumor size had a significant impact on the washout features of HCC lesions on Sonazoid-enhanced CEUS. Small HCC lesions ≤30 mm had a higher proportion of relatively late washout in comparison to larger lesions. Sonazoid-enhanced CEUS might be helpful in the detection and characterization of HCC lesions <10 mm.

The Role of Contrast-Enhanced Ultrasound Plus Color Parametric Imaging in the Differential Diagnosis of Subpleural Pulmonary Lesions.

To distinguish benign and malignant subpleural pulmonary lesions (SPLs) with contrast-enhanced ultrasound (CEUS) and color parametric imaging (CPI), and evaluate the role of CEUS plus CPI in the differential diagnosis of pathological types of SPLs. One hundred and thirty-six patients underwent CEUS with a Logiq E9 XD Clear ultrasonic machine equipped with a 3.5- to 5.0-MHz C5-1 transducer in our center were enrolled in our study, including 27 cases of benign lesions and 109 cases of malignant lesions. The ultrasound contrast agent used in this study was SonoVue. CEUS images and CPI of all cases were reviewed and analyzed by the resident and staff radiologist groups separately. With CEUS alone, by both the two groups, the main enhancement pattern of benign SPLs was arborization (P < .001), while centripetal enhancement pattern occurred more frequently in malignant SPLs (P < .001). With CEUS plus CPI, by both the two groups, the main enhancement pattern of benign SPLs was arborization (P < .001), while those of malignant SPLs were centripetal (P < .001) and eccentric (P < .05). The diagnosis performance of CEUS plus CPI was significantly higher than that of CEUS alone in both the resident (area under the curve [AUC] = 0.857 vs 0.677, P < .001) and staff (AUC = 0.866 vs 0.681, P < .001) groups. Moreover, CPI offered remarkable inter-consistency improvements in the enhancement pattern determination between the two groups. The CEUS enhancement patterns would provide information of blood perfusion patterns in the differential diagnosis of benign and malignant SPLs. The diagnosis performance could be significantly improved by CEUS plus CPI compared with CEUS alone.

Value of Multimodal Data From Clinical and Sonographic Parameters in Predicting Recurrence of Hepatocellular Carcinoma After Curative Treatment.

The objective of the work described here was to assess the value of the combination of pre-operative multimodal data-including clinical data, contrast-enhanced ultrasound (CEUS) information and liver stiffness measurement (LSM) based on 2-D shear wave elastography (SWE)-in predicting early (within 1 y) and late (after 1 y) recurrence of hepatocellular carcinoma (HCC) after curative treatment. We retrospectively included 101 patients with HCC who met the Milan criteria and received curative treatment. The multimodel data from clinical parameters, LSM by 2-D SWE and CEUS enhancement patterns were collected. The association between different variables in HCC recurrence was accessed using a Cox proportional hazard model. On the basis of the independent factors of early recurrence, models with differentsource variables were established (Clinical Model, CEUS-Clinical Model, SWE-Clinical Model, CEUS-SWE-Clinical Model). The goodness-of-fit of models was evaluated and the performance trends of different models were calculated by time-dependent area under the curve (AUC). Two-dimensional SWE, CEUS enhancement patterns and clinical parameters (spleen length, multiple tumors, α-fetoprotein, albumin and prothrombin time) were independently associated with early recurrence (all p values <0.05). Multiple tumors and a decrease in albumin independently contributed to the late recurrence. The model fit of CEUS-SWE-Clinical Model was superior to other models in predicting early recurrence (all p values <0.05). The AUCs of the CEUS-Clinical Model were higher from 2 mo to 7 mo, while the SWE-Clinical Model had higher AUCs from 9 mo to 12 mo. CEUS enhancement patterns and 2-D SWE were independent predictors of HCC early recurrence as the two factors contributed to the predictive performance at different times. The multimodal model, which included diverse data in predicting early HCC recurrence, had the best goodness-of-fit.

Applications of Dynamic Contrast-Enhanced Ultrasound in Differential Diagnosis of Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma in Non-cirrhotic Liver.

The aim of the work described here was to investigate the value of dynamic contrast enhanced ultrasound (DCE-US) and quantitative analysis in pre-operative differential diagnosis of intrahepatic cholangiocarcinoma (ICC) and hepatocellular carcinoma (HCC) in non-cirrhotic liver. In this retrospective study, patients with histopathologically proven ICC and HCC lesions in non-cirrhotic liver were included. All patients underwent contrast-enhanced ultrasound (CEUS) examinations with an Acuson Sequoia unit (Siemens Healthineers, Mountain View, CA, USA) unit or LOGIQ E20 (GE Healthcare, Milwaukee, WI, USA) within 1 wk before surgery. SonoVue (Bracco, Milan, Italy) was used as the contrast agent. B-mode ultrasound (BMUS) features and CEUS enhancement patterns were analyzed. DCE-US analysis was performed by VueBox software (Bracco). Two regions of interest (ROIs) were set in the center of the focal liver lesions and their surrounding liver parenchyma. Time-intensity curves (TICs) were generated, and quantitative perfusion parameters were obtained and compared between the ICC and HCC groups using the Student t-test or Mann-Whitney U-test. From November 2020 to February 2022, patients with histopathologically confirmed ICC (n=30) and HCC (n=24) lesions in non-cirrhotic liver were included. During the arterial phase (AP) of CEUS, ICC lesions exhibited heterogeneous hyperenhancement (13/30, 43.3%), heterogeneous hypo-enhancement (2/30, 6.7 %) and rim-like hyperenhancement (15/30, 50.0%), whereas all HCC lesions exhibited heterogeneous hyperenhancement (24/24, 100.0%) (p < 0.05). Subsequently, most of the ICC lesions exhibited AP wash-out (83.3%, 25/30), whereas a few cases exhibited wash-out in the portal venous phase (PVP) (15.7%, 5/30). In contrast, HCC lesions exhibited AP wash-out (41.7%, 10/24), PVP wash-out (41.7%, 10/24) and a small part of late phase wash-out (16.7%, 4/24) (p < 0.05). Compared with those of HCC lesions, TICs of ICCs revealed earlier and lower enhancement during the AP, faster decline during the PVP and reduced area under the curve. The combined area under the receiver operating characteristic curve (AUROC) of all significant parameters was 0.946, with 86.7% sensitivity, 95.8% specificity and 90.7% accuracy in differential diagnosis between ICC and HCC lesions in non-cirrhotic liver, which improved the diagnostic efficacy of CEUS (58.3% sensitivity, 90.0% specificity and 75.9% accuracy). ICC and HCC lesions in non-cirrhotic liver might exhibit some overlap of CEUS features in diagnosis. DCE-US with quantitative analysis would be helpful in pre-operative differential diagnosis.

The use of modified TI-RADS using contrast-enhanced ultrasound features for classification purposes in the differential diagnosis of benign and malignant thyroid nodules: A prospective and multi-center study.

To evaluate the diagnostic efficacy of a modified thyroid imaging reporting and data system (TI-RADS) in combination with contrast-enhanced ultrasound (CEUS) for differentiating between benign and malignant thyroid nodules and to assess inter-observer concordance between different observers. This study included 3353 patients who underwent thyroid ultrasound (US) and CEUS in ten multi-centers between September 2018 and March 2020. Based on a modified TI-RADS classification using the CEUS enhancement pattern of thyroid lesions, ten radiologists analyzed all US and CEUS examinations independently and assigned a TI-RADS category to each thyroid nodule. Pathology was the reference standard for determining the diagnostic performance (accuracy (ACC), sensitivity (SEN), specificity (SPN), positive predictive value (PPV), and negative predictive value (NPV)) of the modified TI-RADS for predicting malignant thyroid nodules. The risk of malignancy was stratified for each TI-RADS category-based on the total number of benign and malignant lesions in that category. ROC curve was used to determine the cut-off value and the area under the curve (AUC). Cohen's Kappa statistic was applied to assess the inter-observer agreement of each sonological feature and TI-RADS category for thyroid nodules. The calculated malignancy risk in the modified TI-RADS categories 5, 4b, 4a, 3 and 2 nodules was 95.4%, 86.0%, 12.0%, 4.1% and 0%, respectively. The malignancy risk for the five categories was in agreement with the suggested malignancy risk. The ROC curve showed that the AUC under the ROC curve was 0.936, and the cutoff value of the modified TI-RADS classification was >TI-RADS 4a, whose SEN, ACC, PPV, NPV and SPN were 93.6%, 91.9%, 90.4%, 93.7% and 88.5% respectively. The Kappa value for taller than wide, microcalcification, marked hypoechoic, solid composition, irregular margins and enhancement pattern of CEUS was 0.94, 0.93, 0.75, 0.89, 0.86 and 0.81, respectively. There was also good agreement between the observers with regards to the modified TI-RADS classification, the Kappa value was 0.80. The actual risk of malignancy according to the modified TI-RADS concurred with the suggested risk of malignancy. Inter-observer agreement for the modified TI-RADS category was good, thus suggesting that this classification was very suitable for clinical application.

Contrast-enhanced ultrasound in detection and follow-up of focal renal infections in children.

Focal renal infections in children have to be diagnosed early in order to enable an appropriate antibiotic treatment. The purpose of this paper was to investigate the efficacy and clinical utility of intravenous renal contrast-enhanced ultrasound (CEUS) as an alternative imaging method for the diagnosis and follow-up of focal renal infections in children. Fourteen children aged from 6 months to 17 years (mean 6.5 years) in whom focal renal infection was suspected were included in this retrospective study. All data were obtained from medical and imaging records of the patients. CEUS was performed for the diagnosis in all 14 children and then also for follow-up in seven children with renal abscess. In three children enhancement pattern was concordant with focal nephritis and in four children CEUS excluded focal renal infection and the diagnosis of pseudolesion was confirmed. Renal CEUS was proven to be an efficient and self-sufficient imaging in diagnosis and further follow-up of focal renal infections in children. CEUS patterns of focal renal infections are described as well as relevant CEUS enhancement patterns important for differential diagnosis. Renal abscess follow-up algorithm with CEUS is suggested. All clinically relevant imaging data was obtained by CEUS and no other imaging was necessary for the diagnosis and follow-up.

Clinical Value of Contrast-Enhanced Ultrasound in Breast Cancer Diagnosis.

Breast cancer (BC) ranks first in morbidity and mortality among female malignant tumors worldwide. This study is aimed at clarifying clinical value of contrast-enhanced ultrasound (CEUS) in the diagnosis and differentiation of BC. A total of 108 BC patients admitted to our hospital from January 2019 to December 2021 were enrolled. All patients underwent conventional color Doppler ultrasound and CEUS imaging examination. All ultrasound images were analyzed by a senior (5+ years) sonographer. The lesion location, echo, size, and color Doppler flow imaging (CDFI) blood flow distribution of benign and malignant BC were assessed. The transverse and longitudinal diameters of malignant BC presented significant elevation compared with the control group (P < 0.05). CEUS is more reliable than conventional ultrasound in the differentiation of benign and malignant breast lesions, and CEUS has the best reliability. The comparison of CEUS observation indicators between benign and malignant groups demonstrated that CEUS enhancement patterns (time and intensity) and morphological features (lesion boundary, shape, range, homogeneity, and filling defect) presented statistical significance (P < 0.01). Irregular shape and range expansion were high-specificity indicators (all >90.00%); fast-forward, high enhancement, clear boundary, and range expansion were high-sensitivity (all >90.00%); and fast-forward, high enhancement, and clear boundary were low-specificity indicators (all <50.00%); moderate sensitivity is as follows: homogeneous enhancement and range expansion (all >80.00%). The area under curve of CEUS (0.735 ± 0.053) presented elevation relative to conventional ultrasound (0.901 ± 0.024), with statistical significance (Z1 = 2.462, P < 0.05). Relative to conventional ultrasound, the specificity and positive predictive value of CEUS presented elevation (P < 0.05). In conclusion, in the differentiation of benign and malignant breast lesions, CEUS has better diagnostic accuracy and reliability than conventional ultrasound. The diagnostic advantages of CEUS are to elevate the diagnostic specificity and positive predictive value and reduce the misdiagnosis rate.

Prediction Model and Nomogram of Early Recurrence of Hepatocellular Carcinoma after Radiofrequency Ablation Based on Logistic Regression Analysis.

The purpose of this study was to screen for high-risk factors leading to the early recurrence of hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) and to construct a prediction model and nomogram. This retrospective study included 108 patients with primary HCC who underwent RFA treatment at the Harbin Medical University Cancer Hospital between January 2018 and June 2019. Four risk factors were screened for using univariate and multivariate logistic regression analyses: number of tumors (hazard ratio [HR]=14.684, 95% confidence interval [CI]: 1.099-196.215, p=0.042), neutrophil-to-lymphocyte ratio (NLR) (HR=2.178, 95% CI: 1.003-4.730, p=0.049), contrast-enhanced ultrasound (CEUS) performance (HR=6.482, 95% CI: 1.161-36.184, p=0.033) and α-fetoprotein (AFP) level (HR=1.001, 95% CI: 1.000-1.003, p=0.040). We established a prediction model: Logit(p)=-3.096+2.827×(number of tumors >1=1)+1.851×(CEUS revealing rapid enhancement of blood flow signal in the arterial phase and clearance in the portal phase=1)+1.941×(NLR >1.55=1)+0.257×(AFP >32.545=1). Through clinical decision curve analysis, the model's threshold was 0.043-0.873, indicating a high clinical value. Patients with a high AFP level, typical CEUS enhancement pattern, multiple tumors and elevated NLR are more likely to relapse early.

Contrast-Enhanced Ultrasound Features of Histopathologically Proven Hepatocellular Carcinoma in the Non-cirrhotic Liver: A Multicenter Study.

Current literature on the role of contrast-enhanced ultrasound (CEUS) in the diagnosis of hepatocellular carcinoma (HCC) in non-cirrhotic patients is limited. The aim of this retrospective multicenter study was to analyze CEUS features of histologically proven HCC in patients with non-cirrhotic liver. In this multicenter study, 96 patients from eight medical institutions with histologically proven HCC lesions in non-cirrhotic liver were retrospectively reviewed regarding SonoVue-enhanced CEUS features. Two ultrasound experts assessed the CEUS enhancement pattern and came to a consensus using the World Federation of Societies for Ultrasound in Medicine and Biology guideline criteria. The mean size of HCC lesions included was 60.3 ± 37.8 mm (mean ± standard deviation). Most of the lesions were heterogeneous but predominantly hypo-echoic on B-mode ultrasound (64.5%, 62/96), with ill-defined margins and irregular shapes. During the arterial phase of CEUS, most of the HCC lesions in non-cirrhotic liver exhibited heterogeneous hyperenhancement (78.1%, 75/96) compared with the surrounding liver parenchyma. Almost 30% of HCC lesions (28.1%, 27/96) exhibited early wash-out (<60 s). All lesions exhibited wash-out and hypo-enhancement in the late phase. CEUS features of HCC lesions in non-cirrhotic patients typically include hyperenhancement in the arterial phase and relatively rapid wash-out in the portal venous phase, which is different from HCC in cirrhotic livers and more similar to liver metastasis.

Application of dynamic contrast enhanced ultrasound in distinguishing focal-type autoimmune pancreatitis from pancreatic ductal adenocarcinoma.

To explore the value of dynamic contrast enhanced ultrasound (DCE-US) in preoperative differential diagnosis of focal-type autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC). From May 2016 to March 2020, patients with biopsy and histopathologically confirmed focal-type AIP (n = 9) were retrospectively included. All patients received contrast enhanced ultrasound (CEUS) examinations one week before surgery/biopsy. Dynamic analysis was performed by VueBox® software (Bracco, Italy). Eighteen cases of resection and histopathologically proved PDAC lesions were also included as control group. B mode ultrasound (BMUS) features, CEUS enhancement patterns, time intensity curves (TICs) and CEUS quantitative parameters were obtained and compared between AIP and PDAC lesions. After injection of ultrasound contrast agents, most focal-type AIP lesions displayed hyper-enhancement (2/9, 22.2%) or iso-enhancement (6/9, 66.7%) during arterial phase of CEUS, while most of PDAC lesions showed hypo-enhancement (88.9%) (P < 0.01). During late phase, most of AIP lesions showed iso-enhancement (8/9, 88.9%), while most of PDAC lesions showed hypo-enhancement (94.4%) (P < 0.001). Compared with PDAC lesions, TICs of AIP lesions showed delayed and higher enhancement. Among all CEUS perfusion parameters, ratio of PE (peak enhancement), WiAUC (wash-in area under the curve), WiR (wash-in rate), WiPI (wash-in perfusion index, WiPI = WiAUC/ rise time), WoAUC (wash-out area under the curve), WiWoAUC (wash-in and wash-out area under the curve) and WoR (wash-out rate) between pancreatic lesion and surrounding normal pancreatic tissue were significantly higher in AIP lesions than PDAC lesions (P < 0.05). DCE-US with quantitative analysis has the potential to make preoperative differential diagnosis between focal-type AIP and PDAC non-invasively.