Contrast-enhanced Ultrasound Guidance Research Articles

The Effect of Contrast-enhanced Ultrasound via Vessels and Surgical Drains Guidance Percutaneous Catheter Drainage in the Treatment of Pyogenic Liver Abscess.

Pyogenic liver abscess (PLA) is a purulent disease caused by microbial contamination of liver parenchyma and includes amoebic liver abscess, fungal liver abscess, and the most common bacterial liver abscess. Explore the efficacy of contrast-enhanced ultrasound (CEUS) via vessels and surgical drain guidance percutaneous catheter drainage (PCD) in the treatment of pyogenic liver abscesses (PLA). A total of 86 PLA patients who underwent PCD treatment in our hospital from May 2018 to February 2023 were retrospectively selected. Of them, 41 patients were treated under intravenous CEUS guidance (Control group), and 45 patients were treated under CEUS via vessels and surgical drain guidance (study group). Perioperative characteristics, treatment effectiveness, and incidence of complications were analyzed and compared between groups. The duration of surgery, drainage, white blood cell recovery, body temperature recovery, and hospitalization in the study group were longer than those in the control group (P<0.05). The total effective rate of the study group (95.56%) was higher than that of the control group (80.49%) (P<0.05). The incidence of complications in the study group (4.44%) was lower than that in the control group (19.51%) (P<0.05). Compared with intravenous CEUS alone, treatment under CEUS via vessels and surgical drains-guided PCD was associated with shorter surgical time, faster recovery, better treatment effect, lower risk of complications, and ensured treatment safety in PLA patients.

Percutaneous biopsy for the diagnosis, risk stratification, and molecular profiling of neuroblastoma: A single-center retrospective study.

To determine whether percutaneous core needle biopsy (PCNB) is adequate for the diagnosis and full molecular characterization of newly diagnosed neuroblastoma. Patients with newly diagnosed neuroblastoma who underwent PCNB in interventional radiology at a single center over a 5-year period were included. Pre-procedure imaging and procedure details were reviewed. Rates of diagnostic success and sufficiency for International Neuroblastoma Pathology Classification (INPC), risk stratification, and evaluation of genomic markers utilized in the Children's Oncology Group risk stratification, and status of the anaplastic lymphoma kinase (ALK) gene were assessed. Thirty-five patients (13 females, median age 2.4years [interquartile range, IQR: 0.9-4.4] and median weight 12.4kg [IQR: 9.6-18]) were included. Most had International Neuroblastoma Risk Group Stage M disease (n=22, 63%). Median longest axis of tumor target was 8.8cm [IQR: 6.1-12]. A 16-gauge biopsy instrument was most often used (n=20, 57%), with a median of 20 cores [IQR: 13-23] obtained. Twenty-five specimens were assessed for adequacy, and 14 procedures utilized contrast-enhanced ultrasound guidance. There were two post-procedure bleeds (5.7%). Thirty-four of 35 procedures (97%) were sufficient for histopathologic diagnosis and risk stratification, 94% (n=32) were sufficient for INPC, and 85% (n=29) were sufficient for complete molecular characterization, including ALK testing. Biologic information was otherwise obtained from bone marrow (4/34, 12%) or surgery (1/34, 2.9%). The number of cores did not differ between patients with sufficient versus insufficient biopsies. In this study, obtaining multiple cores with PCNB resulted in a high rate of diagnosis and successful molecular profiling for neuroblastoma.

Percutaneous ablation of colorectal liver metastases: a comparison between the outcomes of grayscale US guidance and Sonazoid CEUS Kupffer phase guidance using propensity score matching

Purpose To assess the utility of Sonazoid contrast-enhanced ultrasound (CEUS) for guiding percutaneous microwave ablation (MWA) for colorectal liver metastases (CRLMs). Materials and Methods The medical records of patients who had undergone ultrasound (US)-guided percutaneous MWA between July 2020 and June 2022, were reviewed. Propensity score matching (PSM) with a ratio of 1:1 was used to balance the potential bias between the grayscale US-guided and Sonazoid CEUS-guided groups. Local tumor progression (LTP), intrahepatic recurrence (IR), and complication rates were compared between the two groups. Results Of 252 patients enrolled, 247 achieved complete ablation, and the technical effectiveness was 98.0% (247/252). Of these 247 patients, 158 were in the grayscale US-guided group and 89 in the Sonazoid CEUS-guided group. The median follow-up period was 14.6 months. After PSM, there were no significant differences in LTP, IR, or complication rates between the two groups (p = 0.100, p = 0.511, p > 0.99, respectively). Multivariate analysis identified tumor size ≥ 3 cm (hazard ratio [HR], 7.945; 95% CI, 2.591-24.370; p < 0.001), perivascular (HR, 2.331; 95% CI, 1.068-5.087; p = 0.034), and tumor depth > 8 cm (HR, 3.194; 95% CI, 1.439-7.091; p = 0.004) as significant factors associated with LTP. For tumors with poor vision on grayscale US, Sonazoid CEUS-guided ablation achieved a better LTP rate than grayscale US-guided ablation (3.7% vs.14.8%, p = 0.032). Conclusion For tumors with poor vision on grayscale US, Sonazoid CEUS guidance is recommended for better local tumor control.

Contrast-enhanced ultrasound guided core needle biopsy for soft tissue tumors: Accuracy and applicability

ObjectiveTo evaluate the effectiveness of contrast-enhanced ultrasound (CEUS) guided core needle biopsy (CNB) in diagnosing soft tissue tumors (STTs) and to identify the conventional ultrasonography (US) features of STTs that are recommended for CEUS-guided CNB. Materials and methodsA retrospective study was conducted on 123 patients with surgically confirmed STTs. Before surgeries, all subjects underwent CNB under the guidance of US or CEUS. The histopathological results of surgical specimens were considered as the gold standards. A successful biopsy diagnosis was defined as the pathological subtypes obtained by biopsy consistent with the gold standard. The diagnostic yields were compared between the US and CEUS groups, and the diagnostic yields based on various conventional US features of STTs were also compared between the two groups. ResultsSixty-seven cases underwent US-guided CNB and fifty-six cases underwent CEUS-guided CNB. The clinical, biopsy, and conventional US characteristics revealed no significant difference between the two groups. The diagnostic yield of the CEUS group was statistically higher than that of the US group (p = 0.011). In the CEUS group, more STTs with the anechoic areas were identified after CEUS examination (p = 0.031). Furthermore, the diagnostic yields based on the conventional US features of STTs, including deep fascia layer (p = 0.010), a maximum diameter ≥5 cm (p = 0.037), rough margin (p = 0.016), heterogeneous echotexture (p = 0.017), and absence of anechoic area (p = 0.013), were significantly different between the two groups, and the CEUS group exhibited higher diagnostic yields. ConclusionCEUS-guided CNB was found to be an efficient method for STTs diagnosis. It is particularly recommended for STTs with the following conventional US features, including location in deep fascia layer, a maximum diameter ≥5 cm, rough margin, heterogeneous echotexture, or absence of anechoic area.

Comparison of the effects of contrast-enhanced ultrasound and conventional ultrasound-guided radiofrequency ablation on benign thyroid nodules.

To compare the effect of contrast-enhanced ultrasound (CEUS) and conventional ultrasound-guided radiofrequency ablation (RFA) on benign thyroid nodules (BTNs). In this retrospective observational study, the data of 72 patients with BTNs who received RFA treatment in The Fourth Affiliated Hospital of Zhejiang University School of Medicine from January 2020 to December 2021 were retrospectively reviewed and selected. The records showed that 34 patients received RFA under the guidance of conventional ultrasound (conventional ultrasound group) and 38 patients received RFA under the guidance of CEUS (CEUS group). The effect of treatment, complications and recurrence of the two groups were compared and analyzed. There was a smaller volume of thyroid nodules in the two groups immediately post-operation. The incidence of complications was lower in the CEUS group (5.26%) compared to the conventional ultrasound group (23.53%) (P<0.05). The recurrence rate at 6-months (0.00% vs 11.76%) and 12- months (2.63% vs 20.59%) post-operation was lower in the CEUS group compared to the conventional ultrasound group (P<0.05). Compared with conventional ultrasound, CEUS-guided RFA is effective in treating BTNs, with smaller postoperative nodule volume, reduced occurrence of surgical complications, and reduced recurrence rate of thyroid nodules.

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

Photoacoustic/ultrasound-guided gene silencing: Multifunctional microbubbles for treating adjuvant-induced arthritis.

To effectively deliver small interfering RNA (siRNA) to inflammatory tissues for treating rheumatoid arthritis (RA), we developed the multifunctional microbubbles (MBs) to perform photoacoustic/ultrasound-guided gene silencing. Fluorescein amidite (FAM)-labelled tumour necrosis factor-α (TNF-α)-siRNA and cationic MBs were mixed to fabricate FAM-TNF-α-siRNA-cMBs. The cell transfection efficacy of FAM-TNF-α-siRNA-cMBs was evaluated in vitro on RAW264.7 cells. Subsequently, wistar rats with adjuvant-induced arthritis (AIA) were injected intravenously with MBs and simultaneously subjected to low-frequency ultrasound for ultrasound-targeted microbubble destruction (UTMD). Photoacoustic imaging (PAI) was utilized to visualize the distribution of siRNA. And the clinical and pathological changes of AIA rats was estimated. FAM-TNF-α-siRNA-cMBs were evenly distributed within the RAW264.7 cells and significantly reduced TNF-α mRNA levels of the cells. For AIA rats, the entering and collapsing of MBs was visualized by contrast-enhanced ultrasound (CEUS). Photoacoustic imaging showed markedly enhanced signals following injection, indicating localization of the FAM-labelled siRNA. The articular tissues of the AIA rats treated with TNF-α-siRNA-cMBs and UTMD showed decreased TNF-α expression levels. The theranostic MBs exhibited a TNF-α gene silencing effect under the guidance of CEUS and PAI. The theranostic MBs served as vehicles for delivering siRNA as well as contrast agents for CEUS and PAI.

Effects of lauromacrogol injection under contrast-enhanced ultrasound guidance on cesarean scar pregnancy: a prospective cohort study.

Compared with the current commonly used pretreatment approaches, the therapeutic effect of contrast-enhanced ultrasound-guided sclerotherapy with lauromacrogol injection (CEUSL) on cesarean scar pregnancy (CSP) is not clear. This study aimed to investigate the clinical efficacy and safety of CEUSL compared with gelatin sponge uterine artery embolization (UAE) and UAE combined with methotrexate (UAEM) in the pretreatment of CSP to prevent massive bleeding during subsequent curettage. Sixty-four patients were divided into the CEUSL (n=20), UAE (n=22), and UAEM (n=22) groups. All patients with CSP underwent curettage and hysteroscopy after CEUSL, UAE, or UAEM pretreatment. The efficacy and safety indicators after pretreatment were analyzed. Time for pretreatment [95% confidence interval (CI): 31.92-39.28] and hospitalization cost (95% CI: 7,852.32-9,063.23) were significantly decreased in the CEUSL group compared with that in the UAE (95% CI: 53.55-59.99% and 95% CI: 12,901.42-15,166.63, respectively) and the UAEM group (95% CI: 52.90-58.83 and 95% CI: 11,324.66-13,302.69, respectively; P<0.001). The beta human chorionic gonadotropin (β-hCG) percentage decrease 24 hours later and the hospital stay were significantly decreased in the CEUSL group (95% CI: 0.65-0.70 and 95% CI: 3.32-4.58 days, respectively) compared with those in the UAE (95% CI: 0.67-0.74 and 95% CI: 4.06-5.84, respectively) or UAEM (95% CI: 0.62-0.68 and 95% CI: 4.12-5.88, respectively) groups (P<0.05). After pretreatment, there were significantly fewer patients (P<0.05) with fever (95% CI: -0.52 to -0.093), pelvic pain (95% CI: -0.427 to -0.018), increased white blood cell count (95% CI: -0.359 to 0.040), and hypersensitive C-reactive protein (hs-CRP) elevation (95% CI: -0.572 to -0.118) in the CEUSL group than in the UAE or UAEM groups. At follow-up, all patients resumed normal menstruation, with no residual gestational sac on ultrasound imaging or sequel. The pretreatment procedures were all technically successful, with good outcomes in different pretreatment procedures. Compared with UAE with or without methotrexate, CEUSL may be as effective and safe for pretreatment of CSP, with fewer adverse effects and shorter pretreatment time and hospital stay.

Abstract 15543: Fibrin-Targeted Phase Shift Microbubbles Outperform Fibrin-Targeted Microbubbles for the Treatment of Microvascular Obstruction

Introduction: Mortality from AMI has decreased in recent years; however, microvascular obstruction (MVO) occurs frequently, and is associated with rising post-AMI CHF, and has no definitive therapy. To address this urgent unmet need, we have developed an image-guided acute therapy, termed ‘sonoreperfusion’ (SRP), that resolves MVO via ultrasound-targeted microbubble cavitation (UTMC). We previously used standard-size, fibrin-targeted MBs and demonstrated enhanced reperfusion compared to standard-size, non-targeted MBs. However, phase shift microbubbles may allow greater clot penetration and perhaps more effective SRP, owing to their much smaller size Vs. standard MBs (~200 nm vs. 3 μm). Thus, we compared the SRP efficacies of fibrin-targeted phase shift microbubbles (FTPSMBs) (Microvascular Therapeutics, Inc), to standard-size fibrin-targeted microbubbles (FTMBs) for the treatment of MVO Methods: MVO of the rat hindlimb ( n=6 ) was created by injecting porcine microthrombi into the left femoral artery under contrast-enhanced ultrasound (CEUS) guidance. DEFINITY ® MBs (Lantheus Medical Imaging) were infused (2 mL/hr) through the right external jugular vein for CEUS. Following 10 min of stable MVO, a transducer was positioned vertically above the hindlimb to deliver therapeutic US pulses during concomitant administration of FTMBs/FTPSMBs (3 mL/hr). CEUS cine loops with burst replenishment were obtained at baseline (BL), 10 min post-MVO, and after each of the two SRP treatment sessions (TX1, TX2) and video intensities were analyzed (MATLAB_R2021a) Results: FTPSMBs treatment resulted in a greater increase in the blood volume (dB) and flow rate (dB/sec) than FTMB after each 10-minute treatment session (Figure 1) Conclusions: US-guided FTPSMB cavitation causes more rapid and complete reperfusion of MVO than FTMB, likely owing to their small size and more effective thrombus penetration. Studies to explore the underlying mechanisms are underway

Fibrin-targeted phase shift microbubbles outperform fibrin-targeted microbubbles for the treatment of microvascular obstruction

Introduction: Mortality from AMI has decreased in recent years; however, microvascular obstruction (MVO) occurs frequently, ultimately limits myocardial salvage, is associated with rising post-AMI CHF, and has no definitive therapy. To address this urgent unmet need, we have developed an image-guided acute therapy, termed “sonoreperfusion” (SRP), that resolves MVO via ultrasound-targeted microbubble cavitation (UTMC). We previously used standard MBs with fibrin-targeting and demonstrated enhanced reperfusion compared to standard MBs with non-targeting. However, phase shift microbubbles are much smaller than standard MBs. Thus, we compared the SRP efficacies of fibrin-targeted phase shift microbubbles (FTPSMB) to standard size fibrin-targeted microbubbles (FTMBs). Methods: MVO of the rat hindlimb was created by injecting microthrombi into the left femoral artery under contrast-enhanced ultrasound (CEUS) guidance. DEFINITY® MBs were infused (2 ml/h) through the right external jugular vein for CEUS. Following 10 min of stable MVO, a transducer was positioned vertically above the hindlimb to deliver therapeutic US pulses during concomitant administration of FTMBs/FTPSMBs (3 ml/h). Results and conclusion: FTPSMB treatment resulted in a greater increase in the blood volume (dB) and flow rate (dB/sec) than FTMB after each 10-minute treatment session owing to their small size and more effective thrombus penetration. Studies to explore the underlying molecular mechanisms associated with SRP treatments are underway

The benefit of contrast-enhanced ultrasound in biopsies for focal liver lesions: a retrospective study of 820 cases.

This study compared the performance between ultrasound (US)- and contrast-enhanced US (CEUS)-guided liver biopsies and evaluated the benefit of CEUS in percutaneous biopsy for focal liver lesions (FLLs). We performed a retrospective study of 820 patients with FLLs, who underwent percutaneous liver biopsy in our center between 2017 and 2019. The patients were divided into two groups based on whether US (n = 362) or CEUS (n = 458) used before a biopsy. The two groups were compared based on specimen adequacy for pathological diagnosis and diagnostic accuracy of liver biopsy. Stratification analysis was performed based on lesion and protocol characteristics to provide detailed information for selecting the imaging guidance for biopsy. Compared with the US group, the CEUS group yielded more acceptable samples (97.6% vs. 99.4%, p < 0.05) and improved diagnostic accuracy (92.6% vs. 96.4%, p < 0.05), and achieved better sensitivity (92.5% vs. 96.2%, p < 0.05) for liver biopsies, especially in FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary. The CEUS group showed significantly higher accuracy compared with the US group pertaining to single-puncture biopsies (100% vs. 92.7%, p < 0.05) or biopsies with punctures ≤ 2 (97.6% vs. 94.3%, p < 0.05). CEUS achieved an enhanced success rate for sampling and diagnostic accuracy of liver biopsies, especially in FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary. CEUS can be used to decrease the number of punctures needed, which might increase the safety of liver biopsy. • CEUS can help confirm an adequate biopsy site, increasing the sampling success rate and diagnostic accuracy of the liver biopsy. • CEUS can be used to decrease the number of punctures needed to improve the safety of liver biopsy. • It is recommended to use CEUS guidance for liver biopsies, especially with FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary.

The Application of Dual-Pathway Contrast-Enhanced Ultrasound (CEUS) in the Treatment of Periappendiceal Abscesses.

To explore the value of an ultrasound contrast agent (Sonovue) as an interventional treatment for periappendiceal abscesses. From January 2019 to December 2020, 30 patients were recruited who were admitted to Jinan Central Hospital due to periappendiceal abscesses. Before the operation, 2.5ml of SonoVue® contrast agent was injected intravenously to determine the non-enhanced area of liquefaction and necrosis in the abscess cavity. The puncture sites were selected. Percutaneous catheterization and drainage (PCD) were performed under contrast-enhanced ultrasound guidance. After the operation, 1ml of diluted SonoVue® suspension was injected through the drainage tube to observe the position of the drainage tube, the degree of drainage and the development of the abscess. An ultrasound contrast agent was used preoperatively to assess the extent of the abscess. Liquefaction and necrosis were observed in the abscess cavity. CEUS showed hyperenhancement in the wall of the abscess in the arterial phase and the liquefied necrotic area in the abscess cavity was not enhanced before PCD. CEUS allowed operators to confidently identify the puncture site. Amongst the 30 cases of PCD, 27 cases showed the clear positioning of the drainage tube. The head of the drainage tube was placed in the ideal position and development could be seen in the abscess cavity. The diffusion effect of the contrast agent was good with no spillover and the drainage was unobstructed. Abscess development was observed in 3 patients after puncture injection of the contrast agent but the head of the drainage tube was not in the predetermined position. After adjusting the position of the drainage tube, CEUS was repeated and showed a strong diffusion effect of the contrast agent. Intravenous injection of Sonovue before PCD of periappendiceal abscesses can evaluate the extent of the abscess, liquefaction and necrosis in the abscess cavity. The approach can also provide guidance for the placement of the drainage tube. After the operation, a diluted contrast agent was injected through the drainage tube. The position of the drainage tube and the flow direction of the contrast agent could be seen. This approach has good value for clinical applications to accurately judge the position of the drainage tube.

Quantitative analysis of in-vivo microbubble distribution in the human brain

Microbubbles (MB) are widely used as contrast agents to perform contrast-enhanced ultrasound (CEUS) imaging and as acoustic amplifiers of mechanical bioeffects incited by therapeutic-level ultrasound. The distribution of MBs in the brain is not yet fully understood, thereby limiting intra-operative CEUS guidance or MB-based FUS treatments. In this paper we describe a robust platform for quantification of MB distribution in the human brain, allowing to quantitatively discriminate between tumoral and normal brain tissues and we provide new information regarding real-time cerebral MBs distribution. Intraoperative CEUS imaging was performed during surgical tumor resection using an ultrasound machine (MyLab Twice, Esaote, Italy) equipped with a multifrequency (3–11 MHz) linear array probe (LA332) and a specific low mechanical index (MI < 0.4) CEUS algorithm (CnTi, Esaote, Italy; section thickness, 0.245 cm) for non-destructive continuous MBs imaging. CEUS acquisition is started by enabling the CnTI PEN-M algorithm automatically setting the MI at 0.4 with a center frequency of 2.94 MHz–10 Hz frame rate at 80 mm—allowing for continuous non-destructive MBs imaging. 19 ultrasound image sets of adequate length were selected and retrospectively analyzed using a custom image processing software for quantitative analysis of echo power. Regions of interest (ROIs) were drawn on key structures (artery–tumor–white matter) by a blinded neurosurgeon, following which peak enhancement and time intensity curves (TICs) were quantified. CEUS images revealed clear qualitative differences in MB distribution: arteries showed the earliest and highest enhancement among all structures, followed by tumor and white matter regions, respectively. The custom software built for quantitative analysis effectively captured these differences. Quantified peak intensities showed regions containing artery, tumor or white matter structures having an average MB intensity of 0.584, 0.436 and 0.175 units, respectively. Moreover, the normalized area under TICs revealed the time of flight for MB to be significantly lower in brain tissue as compared with tumor tissue. Significant heterogeneities in TICs were also observed within different regions of the same brain lesion. In this study, we provide the most comprehensive strategy for accurate quantitative analysis of MBs distribution in the human brain by means of CEUS intraoperative imaging. Furthermore our results demonstrate that CEUS imaging quantitative analysis enables discernment between different types of brain tumors as well as regions and structures within the brain. Similar considerations will be important for the planning and implementation of MB-based imaging or treatments in the future.

Contrast-Enhanced Ultrasound Assisted Surgery of Intramedullary Spinal Cord Tumors: Analysis of Technical Benefits and Intra-operative Microbubble Distribution Characteristics

Intra-operative contrast-enhanced ultrasound (CEUS) is a relatively standardized procedure in brain neurosurgery, but it is still underused in spinal cord and intramedullary tumor evaluation. We reviewed and analyzed the intra-operative data from a surgical series of patients harboring intramedullary spinal cord tumors who underwent surgery under CEUS guidance. CEUS was performed in 12 patients (age range: 13–55 y); all lesions had ill-defined boundaries or peritumoral cysts at preliminary intra-operative B-mode ultrasound. CEUS highlighted the tumors in all cases. The contrast agent's spinal distribution revealed different phases (arterial, peak, washout), as observed in the brain, but these appeared to be slower and less intense. In our experience, intra-operative CEUS allows surgeons to assess spinal cord perfusion and highlight intramedullary tumors in real time. As for other imaging modalities, ultrasound contrast agents add valuable information over baseline imaging, and their use should be fostered to better understand microbubble distribution dynamics.

Ultrasound-guided percutaneous needle biopsy skill for peripheral lung lesions and complications prevention

BackgroundTo investigate puncture skills and complications prevention in ultrasound-guided percutaneous needle biopsy for peripheral lung lesions.MethodsNinety-two peripheral lung lesions in 92 patients, detected via computed tomography (CT) and also visible on ultrasound, were retrospectively analyzed. All patients underwent percutaneous peripheral lung lesion needle biopsy under traditional ultrasound or contrast enhanced ultrasound (CEUS) guidance paying attention to avoiding necrotic areas and large blood vessels. All the specimens were examined histopathologically. Preprocedure all 92 lesions were performed by traditional ultrasonography to evaluate the size, the echogenecity, liquefaction areas and blood flow on color Doppler imaging, some of which were performed by CEUS for evaluating non-enhanced necrosis areas, contrast agent arrival time (AT) and characteristics of blood perfusion.ResultsThe histopathologic results of all 92 lesions were as follows: 67 malignant tumors (including 28 adenocarcinomas, 19 squamous cell carcinomas, 6 bronchoalveolar carcinomas, 5 small cell carcinomas, 5 metastatic cancers, 3 poorly differentiated cancers and 1 malignant mesothelioma), 20 benign lesions (including 9 pneumonia, 6 inflammatory pseudotumors and 5 tuberculomas), 5 undetermined lesions. Of 52 lesions by CEUS guidance, 7 lesions showed enhancement in the pulmonary arterial-phase (including 6 pneumonia and 1 malignant tumors), 45 lesions showed enhancement in the bronchial artery phase (including 37 malignant tumors, 3 inflammatory pseudotumors, 4 tuberculomas and 1 undetermined lesion). According to needle insertion angle along linear path, a total of 92 lesions were divided into two groups, 49 lesions at an angle of 70°–80° needle insertion and 43 lesions at an angle of 80°–90° needle insertion. In the study, linear and non-linear two puncture paths were used, we first tried to puncture along linear path in all lesions, if an attempt to insert into the lesions failed due to be blocked by the ribs and then changed to puncture along non-linear path instead. The success rate of biopsy procedure along linear puncture was significantly higher at an angle of 80°–90°group (93.0% vs. 20.4%, P<0.01), and the adoption rate of non-linear path biopsy for solving the puncture needle blocked by the ribs was significantly higher at angle of 70°–80°group (79.6% vs. 7.0%, P<0.01). Of 52 lesions by CEUS guidance, 27 (51.9%) showed non enhanced necrosis areas on CEUS, only 5 showed liquefaction necrosis areas on gray-scale ultrasound. Of 40 lesions by traditional ultrasound guidance, 4 showed necrosis areas on gray-scale ultrasound. There were no significant differences in lesion size, the average number of biopsy attempts and complication rates between CEUS guidance group and traditional ultrasound guidance group (P>0.05), the pathological confirmation rate in CEUS guidance group was higher than that in traditional ultrasound guidance group, but without significant difference (98.1% vs. 90.0%, P>0.05). Of all 92 cases, 3 cases (3.3%) had mild pneumothorax and 4 cases (4.3%) had hemoptysis.ConclusionsIn ultrasound-guided needle biopsy for peripheral lung lesions, using a combination of linear and non-linear puncture techniques and keeping away from necrotic areas and large blood vessels, may help to increase the success rate and reduce the incidence of complications further.

Role of contrast-enhanced ultrasound guidance in core-needle biopsy for diagnosis of cervical tuberculous lymphadenitis.

To investigate the diagnostic value of core-needle biopsy (CNB) guided by contrast-enhanced ultrasound (CEUS) in cervical tuberculous lymphadenitis (CTL). 178 patients with pathological confirmation of CTL were retrospectively enrolled. All of them had undergone CNB prior to the final surgery. According to the different ways of puncture guidance, they were divided into two groups: conventional ultrasound (US) group (n = 81) and CEUS group (n = 97). The comparison of diagnostic efficacy between two groups was compared and analyzed. Among the 178 patients, 146 were directly diagnosed as CTL by CNB, including 59 patients in CEUS group and 87 patients in US group. The diagnostic accuracy were 89.7% (87/97) and 72.8% (59/81), respectively (P < 0.01). For subgroup analyses, differences among diagnostic efficacy ascribed to the different guiding methods were significant in medium size group (>2.0 cm and ≤3.0 cm) and large size group (>3.0 cm), 91.7% for CEUS group vs. 69.0% for US group (P < 0.05) and 84.4% for CEUS group vs. 57.7% for US group (P < 0.05), respectively. In the diagnosis of CTL, compared with the US-guided CNB, CEUS-guided CNB have certain advantages, especially for larger lymph nodes.

Anatomy and clinical application of anterior and posterior terminal perforators of peroneal artery

To investigate the anatomy of anterior and posterior terminal perforators of the peroneal artery and its clinical applications. Six lower limb specimens were obtained from 3 fresh cadavers. The anterior and posterior terminal perforators and the perforator of terminal peroneal artery were exposed under surgical microscope, and the distances from the beginning of each perforator branch to the lateral malleolus tip and the external diameter of each perforator were measured. With these anatomical knowledge and contrast-enhanced ultrasound (CEUS) guidance, the pedicle flaps with above-mentioned perforators were rationally selected and precisely designed for 18 patients with skin defects in the ankle and foot region between October 2016 and December 2018. Among the patients, there were 14 males and 4 females, aged 28-62 years, with an average age of 40 years. The area of wound ranged from 4 cm×3 cm to 13 cm×10 cm and the area of skin flap ranged from 5 cm×4 cm to 14 cm×10 cm. The anterior peroneal artery terminal perforator flap were applied in 13 cases and the posterior peroneal artery terminal perforator flap in 5 cases. The donor sites were closed directly in 7 cases and repaired with full thickness skin graft in 11 cases. The distance from the beginning of the anterior terminal perforator to the lateral malleolus tip was (5.1±0.5) cm, the external diameter of the anterior terminal perforator was (1.51±0.05) mm. The distance from the beginning of the posterior terminal perforator to the lateral malleolus tip was (4.9±0.9) cm, the external diameter was (1.78±0.17) mm; the distance from the beginning of the perforator of terminal peroneal artery to the lateral malleolus tip was (1.7±0.7) cm, the external diameter was (0.58±0.12) mm. Clinical application results: The edge of the flap was dark in 2 cases after operation and healed after surgical dressing, and 1 case of wound infection healed gradually after debridement. The other flaps survived and healed by first intention. Three patients underwent plastic surgery at 3 months after operation due to flap swelling. All patients were followed up 3-18 months. During the follow-up period, the flaps had good texture and appearance, and partial recovery of sensation. All cases were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) score at last follow-up. The results were excellent in 9 cases, good in 6 cases, fair in 2 cases, and poor in 1 case, with the excellent and good rate of 83.3%. Further classification of peroneal artery perforators in the lateral malleolus region can improve clinical understanding and be helpful to selection and application of perforator flaps in the lateral malleolus.

Management of sub-centimeter recurrent hepatocellular carcinoma after curative treatment: Current status and future

Hepatocellular carcinomas (HCCs) frequently recur despite initial successful surgical resection or local ablation therapy. Diagnostic methods for small HCCs have improved with the introduction of gadoxetic acid-enhanced liver magnetic resonance imaging and diffusion-weighted imaging (DWI). Currently, sub-centimeter recurrent nodules showing typical hallmark imaging findings of HCC are frequently detected in patients with a treatment history for HCC. With five typical magnetic resonance findings, including arterial enhancement, washout on portal or transitional phase, high signal intensity on both T2-weighted image and DWI, and low signal intensity on hepatobiliary phase, sub-centimeter recurrent HCC can be diagnosed with high accuracy. Although more information is needed to determine the treatment of choice, local ablation therapy under fusion imaging and/or contrast-enhanced ultrasound guidance or cone-beam computed tomography-guided chemoembolization seem to be promising as they are effective and safe for the management of sub-centimeter recurrent HCCs.

Ablation treatment of primary and secondary liver tumors under contrast-enhanced ultrasound guidance in field practice of interventional ultrasound centers. A multicenter study

The present retrospective study was aimed at characterizing the clinical impact of contrast-enhanced ultrasound (CEUS) as a guidance technique for ablation of primary and secondary liver tumors at six interventional ultrasound centers. 148 patients (103M/45F, median age 74 yrs.) with 151 liver target lesions (median size 15 mm, 86.7% Hepatocellular Carcinomas) in whom CEUS guidance was used for Percutaneous Ethanol Injection (35.2%), Radiofrequency (46.3%) and Microwave (18.5%) were selected during the period 2008–2016. CEUS-guided ablations represented 7.3% (range 2.5%–13.8%) of 2015 ablative sessions performed at the participating centers. Indications to CEUS-guided ablation were: improvement of conspicuity of the target (28.5%), a target lesion undetectable on B-mode ultrasound (29.8%), detection of viable areas in nodules with either incomplete ablation or local tumor progression (41.7%). Overall, complete radiological ablation was obtained in 113/151 tumors (74.8%), with heat-based techniques (RF and MW) achieving higher rate of successful ablation (86.7%) than PEI (51%). Neither deaths nor major complications occurred after ablations.CEUS guidance demonstrates improved visibility and effectiveness in aiding ablation procedures that are otherwise technically difficult using only B-Mode US guidance.

Ultrasound assisted gene and photodynamic synergistic therapy with multifunctional FOXA1-siRNA loaded porphyrin microbubbles for enhancing therapeutic efficacy for breast cancer

To improve the non-invasive therapeutic efficacy for ER positive breast cancer (ER+ BC), we fabricated a multifunctional FOXA1 loaded porphyrin microbubble to combine photodynamic therapy (PDT) and gene therapy of FOXA1 knockdown (KD) with ultrasound targeted microbubble destruction (UTMD) technology under the guidance of contrast enhanced ultrasound (CEUS). Cationic porphyrin microbubbles (CpMBs) were firstly fabricated from a porphyrin grafted lipid with two cationic amino groups (PGL-NH2) and fluorocarbon inert gas of C3F8. Porphyrin group in the CpMBs monolayer could be used as a photosensitizer for PDT, while amino groups could adsorb siRNA through electrostatic interaction for FOXA1 KD, which could inhibit the proliferation of estrogen-dependent ER+ BC. This system showed high photosensitizer and gene loading content. Moreover, CpMBs/siRNA can be converted into nanoparticles with low-frequency pulsed ultrasound (LFUS) exposure, which increase the transfection efficiency of siRNA (∼4 fold) and the porphyrin uptake (∼8 fold) in MCF-7 (a human breast cancer cell line, ER+) by sonoporation effect. In vivo, UTMD was performed under the guidance of CEUS, and the fluorescence intensity of CpMBs/siRNA at the tumour site reached a peak value at 6 h after injection and it was retained in the following 24 h. Furthermore, there was no tumour recurrence during the observation period (21 days) in the group of PDT combined with FXOA1 KD. Compared to the PDT or FOXA1 KD alone group, the combination of these two methods was much more efficient in inhibiting ER+ breast cancer, showing a good synergistic effect. CpMBs/siRNA combined with UTMD dramatically increased the local accumulation of porphyrin and siRNA through ultrasound-induced sonoporation effect under the guidance of CEUS, showing excellent therapeutic effect for estrogen-dependent ER+ breast cancer.